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Lab/X-ray/ECG Rounds

Lab/X-ray/ECG Rounds. James Huffman January 15, 2009. 67y.o. Female. Epigastric aching/burning for ~ 4 hours Radiates to LUQ/Left chest, ?back Associate N/V, diaphoresis Onset while walking to car after bingo (she won $50) History of HTN, ++smoking, EtOH abuse. Case: Continued.

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Lab/X-ray/ECG Rounds

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  1. Lab/X-ray/ECG Rounds James Huffman January 15, 2009

  2. 67y.o. Female Epigastric aching/burning for ~ 4 hours Radiates to LUQ/Left chest, ?back Associate N/V, diaphoresis Onset while walking to car after bingo (she won $50) History of HTN, ++smoking, EtOH abuse

  3. Case: Continued 36.9°C, 106/63, 62, 20, 96% 3L Chemstrip: 7.3 CVS: unremarkable Resp: fine crackles throughout bases Abdo: Tenderness in the epigastrum (non-peritoneal)

  4. Cath Lab • Normal coronary arteries • No wall motion abnormalities • Now what? • Vitals unchanged • Pain moderately better post morphine • Labs: • Lipase: 2445 U/L • Minor elevations in other LFT’s • TnT <0.03 ng/mL

  5. ECG Manifestations of Gastrointestinal Disease

  6. Objectives • Review the electrocardiographic manifestations of gastrointestinal disease: • ST Elevation • T-wave inversion • Bradycardia • QT prolongation • Understand the basic pathophysiology and significance of these changes

  7. ContextChan, T.C. et al. ECG in Emergency Medicine and Acute Care. CH68 • ECG is often obtained in initial w/u of abdo pain: • Anginal variant (especially women, diabetics) • BUT • Several GI processes are assoc. with ecg changes: • Pancreatitis, Cholecystitis, PUD, Appendicitis, IBD, Cirrhosis, electrolyte abnormalities • Certain GI processes seem to be assoc. with increased risk for concurrent cardiac ischemia or infarction

  8. ST Elevation • STE in the setting of abdominal pain should always raise concern for ACS • Two scenarios: • Certain GI diseases may present with ECG consistent with pseudoinfarction • e.g. acute pancreatitis, cholecystic disease • Certain GI diseases and treatments increase the propensity for coronary thrombosis and true ACS • e.g. IBD

  9. ST Elevation – PseudoinfarctionRubio-Tapia A, et al. Electrocardiographic abnormalities in patients with acute pancreatitis. J Clin Gastroenterol. 2005;39:815-818. • Pancreatitis • Many case reports/series of anatomic STE with no evidence of CAD on angio/autopsy • Abnormal ECG is common (~50%) • “pseudoinfarction” pattern (~1-3%) • Usually inferior, but anterior patterns also reported • Theories: • Vagal stimulation • Proteolytic enzymes damaging myocytes • Enzymatic mediated changes in platelet adhesion • Electrolyte abnormalities • Coronary vasospasm

  10. ST ElevationChan, T.C. et al. ECG in Emergency Medicine and Acute Care. CH68.Ryan, E.T. et al. Myocardial infarction mimicked by acute cholecystitis. Ann Int Med 1992; 116:218. • Acute Cholecystitis • May present with anterior ischemic patterns on their ECGs that often resolve after GB removal • The cardio-biliary reflex commonly cited as cause: • GB distension may lead to vagal response producing intermittent coronary vasospasm • Others: • Splenic rupture • Demand ischemia 2° to catecholamine release

  11. ST Elevation – True diseaseEfremidis, M. et al. Acute myocardial infarction in a young patient during an exacerbation of ulcerative colitis. Int J Cardiol 1999; 70:211. • Inflammatory Bowel Disease • Acute vascular thrombosis is a known complication of both UC and Crohn’s disease • Myopericarditis: • Rare but reported complication of both IBD and an adverse drug reaction to mesalamine (5-ASA agent)

  12. T-Wave InversionChan, T.C. et al. ECG in Emergency Medicine and Acute Care. CH68. Duodenal perforation Acute pancreatitis Cholecystitis ALL occur infrequently

  13. BradycardiaChan, T.C. et al. ECG in Emergency Medicine and Acute Care. CH68. • As a result of vagal response to primary GI disorder or pain • Specific diseases are associated with bradycardia • Ulcerative Colitis • Several cases of 2nd Degree and complete AV block • Jaundice/Bile-acid accumulation • Historically listed in causes of bradycardia • Has not borne out in literature/animal studies

  14. QT ProlongationChan, T.C. et al. ECG in Emergency Medicine and Acute Care. CH68. • Cirrhosis • Historically thought only to occur in pts with EtOH cirrhosis • Now reported in almost every cirrhotic etiology • Growing body of evidence that QT-prolongation is associated with a poorer clinical outcome • One case series has shown a significant reduction in QT interval post transplant • Malnutrition/electrolyte disorders • Celiac disease • One study found 1/3 of all adult pts had QT prolongation

  15. PEARLS ST/T wave changes associated with GI disease may represent true ACS or a pseudoischemic pattern Pts with IBD are at increased risk for thrombotic events, including MI Biliary-cardiac reflex is a known phenomenon which may explain the ST  seen in acute cholecystitis Cirrhosis and celiac disease can be a cause of QT prolongation

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