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  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)

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

ECG Manifestations of Gastrointestinal Disease

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

Context Chan, 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

ST Elevation  STE in the setting of abdominal pain should always raise concern for ACS  Two scenarios: 1.Certain GI diseases may present with ECG consistent with pseudoinfarction  e.g. acute pancreatitis, cholecystic disease 2.Certain GI diseases and treatments increase the propensity for coronary thrombosis and true ACS  e.g. IBD

ST Elevation – Pseudoinfarction Rubio-Tapia A, et al. Electrocardiographic abnormalities in patients with acute pancreatitis. J Clin Gastroenterol. 2005;39:  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

ST Elevation Chan, 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

ST Elevation – True disease Efremidis, 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)

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

Bradycardia Chan, T.C. et al. ECG in Emergency Medicine and Acute Care. CH68. 1.As a result of vagal response to primary GI disorder or pain 2.Specific diseases are associated with bradycardia  Ulcerative Colitis  Several cases of 2 nd Degree and complete AV block  Jaundice/Bile-acid accumulation  Historically listed in causes of bradycardia  Has not borne out in literature/animal studies

QT Prolongation Chan, 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

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

Pancreatitis ST  Non specific ST/T Δ’s T – wave inversion Acute Cholecystitis ST  Bradycardia Non specific ST/T Δ’s Inflammatory Bowel Disease ST  Signs of myopericarditis Heart block Duodenal Perforation T-wave inversion Cirrhosis/Celiac QT Prolongation