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Digestive Diseases and Sciences, Vol. 49, No. 3 (March 2004), pp.

509513 ( C 2004)

Safety of Push Enteroscopy After Recent Myocardial Infarction


MITCHELL S. CAPPELL, MD, PhD, FACG

Although the safety and efcacy of esophagogastroduodenoscopy (EGD) after myocardial infarction (MI) are fairly well characterized, the safety of enteroscopy after recent MI is unstudied and unknown. Enteroscopy could potentially be particularly valuable to evaluate recurrent obscure gastrointestinal (GI) bleeding after MI because ongoing GI bleeding could induce recurrent myocardial ischemia. The safety of push enteroscopy is analyzed in a study of 4 cases among 8900 patients with acute MIs during an 8-year period at a tertiary care medical center. Four patients underwent enteroscopy at 1, 4, 28, and 45 days after MI, of whom three were prospectively monitored for enteroscopic complications. The patients were 82, 63, 72, and 76 years old. Three were male. The mean serum creatinine kinase level was 601 162 U/L, with an MB fraction of 15.9 13.2%. All MIs were subendocardial. Enteroscopy indications included recurrent fecal occult blood and anemia requiring multiple packed erythrocyte transfusions with no signicant lesions identied by EGD and colonoscopy in two patients, maroon stools with no lesions identied by colonoscopy and only anastomotic erosions identied by EGD in one patient status post-Billroth I gastrectomy, and dark red blood per rectum in one patient with prior aortic graft revision for an aortoenteric stula after failure to visualize the distal duodenum by EGD. The patients received a mean of 4.0 1.3 U of packed erythrocytes before enteroscopy. At enteroscopy the mean hematocrit was 32.7 1.6. The patients received a mean of 18.8 12.5 mg of meperidine and 2.6 2.2 mg of midazolam during enteroscopy. Enteroscopy was uniformly uncomplicated. Vital signs and arterial oxygen saturation remained stable during and following enteroscopy. Enteroscopy revealed no new lesions in two patients and distal duodenitis in one patient and ruled out an aortoenteric stual in one patient at high risk for this lesion. These four cases suggest that enteroscopy is not absolutely contraindicated and might be considered after recent MI for strong indications in relatively clinically stable patients.
KEY WORDS: enteroscopy; push enteroscopy; esophagogastroduodenoscopy (EGD); gastrointestinal endoscopy; fecal occult blood; chronic gastrointestinal bleeding; obscure gastrointestinal bleeding; iron deciency anemia; myocardial infarction; angina.

Although enteroscopy is safe, well tolerated, and useful in the general population, the safety of enteroscopy after recent myocardial infarction (MI) is currently unstudied and unknown. While susceptible to all the complications of enteroscopy (1, 2), patients status post-MI may
Manuscript received August 15, 2003; accepted November 11, 2003. From the Division of Gastroenterology, St. Barnabas Medical Center, The Bronx, New York, USA. Address for reprint requests: Mitchell S. Cappell, MD, PhD, Chief, Division of Gastroenterology, Department of Medicine, St. Barnabas Hospital, Third Avenue & 183rd Street, The Bronx, New York 104572594, USA. Digestive Diseases and Sciences, Vol. 49, No. 3 (March 2004)
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be particularly susceptible to cardiopulmonary complications, including myocardial ischemia from discomfort, hypoxia, or anxiety during enteroscopy (3, 4); hypotension or hypertension from medications or anxiety (5); cardiac arrhythmias due to medications, hypoxia, or anxiety (4); and respiratory compromise from endoscopic medications, vagally mediated bronchospasm, laryngeal impingement during esophageal intubation, or pulmonary aspiration (3, 6). Contrariwise, enteroscopy could be particularly valuable after MI to diagnose the cause and to initiate specic treatment for recurrent obscure gastrointestinal (GI) bleeding to prevent consequent myocardial

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ischemia from profound anemia (79); this is becoming ever more valuable due to the increasing use of anticoagulation (10), thrombolysis (11), and antiplatelet agents after MI (12). Although the safety and efcacy of esophagogastroduodenoscopy (EGD) after MI are fairly well characterized (13, 14), the safety and efcacy of enteroscopy must be directly analyzed and not extrapolated from these prior studies. First, enteroscopy could cause greater cardiopulmonary stress than EGD due to a longer procedure time and greater depth of intubation. Second, enteroscopy is generally performed in patients already evaluated by

EGD and colonoscopy. Successful prior performance of colonoscopy and EGD without complications might preselect for patients also able to tolerate enteroscopy after MI. Third, enteroscopy has a much lower diagnostic yield than EGD, partly because it is typically performed after a nondiagnostic EGD (15,16). Fourth, enteroscopy has much narrower indications than EGD in that enteroscopy is usually performed to investigate signicant chronic recurrent GI bleeding (17). Fifth, enteroscopy, unlike EGD, tends to be performed mostly at referral centers by highly trained endoscopists. As part of an ongoing study of the safety of GI endoscopy after MI (13, 14, 1821) (Table 1), the

TABLE 1. SAFETY AND EFFICACY OF DIFFERENT TYPES OF UPPER GASTROINTESTINAL ENDOSCOPY AFTER RECENT MYOCARDIAL INFARCTION Reference No. of patients No. (%) & type of complications Benets of exam Recommendations

Esophagogastroduodenoscopy (EGD) Cappell MS, 1993 (13) Wilcox et al., 1993 (4) 34 19 with severe CAD 3 (9%); 2 major, 1 minor 0 79% diagnostic rate Not discussed Benets may exceed risks of EGD in medically stable patients with GI bleeding. EGD rarely results in myocardial ischemia or arrhythmias in patients with stable CAD. None Benets may exceed risks in medically stable patients. EGD appears to be relatively safe in patients with signicant CAD. EGD relatively safe & benecial when indicated after MI. PEG relatively safe & benecial when indicated after MI.

Rourk et al., 1994 (28) Montalvo & Lee, 1996 (29) Lee et al., 1995 (3) Cappell & Iacovone, 1999 (14)

1 8 39 with severe CAD 200

0 2 (25%); 1 major, 1 minor 4 (10%); 1 major, 3 minor 15 (7.5%); 2 major, 13 minor

Diagnosed gastric angiodysplasia 88% diagnostic rate 79% diagnostic rate 85% diagnostic rate

Percutaneous endoscopic gastrostomy (PEG) Cappell & Iacovone, 1996 (21) 28 3 (10%); all minor All PEGs successfully used for enteral feeding

Wilcox et al., 1993 (4) Rahmin et al., 1995 (30) Cappell, 1996 (18)

Endoscopic retrograde cholangiopancreatography (ERCP) 4 with severe CAD 0 Not discussed 1 4 0 1 (minor) Papillotomy & stone extraction All had successful papillotomy & stone extraction

Too small a study population for rm conclusions Therapeutic ERCP may be an alternative to surgery after MI. ERCP & sphincterotomy are not contraindicated after MI and may be preferable to surgery. Not contraindicated after MI. Can be done for strong & relatively urgent indicatings.

Current report

Enteroscopy 0

Distal duodenitis in 1; excluded aortoenteric stula in 1; no new lesions diagnosed in 2

Note. CAD, coronary artery disease; MI, myocardial infarction.

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safety of push enteroscopy is analyzed in 4 patients among 8900 patients hospitalized for MI at a tertiary cardiac care medical center. METHODS
The author managed three patients undergoing enteroscopy after recent MI, all of whom were prospectively monitored for endoscopic complications. Computerized analysis of the medical record primary or secondary disease codes for MI and procedure codes for EGD or enteroscopy (International Classication of Diseases, Ninth Revision [ICD-9]) revealed one additional patient undergoing enteroscopy after recent MI at Maimonides Medical Center, Brooklyn, New York, from 1994 through 2001. All endoscopic reports at Maimonides Medical Center during the study period were reviewed to conrm that no enteroscopies performed after MI were omitted. Maimonides Medical Center is a tertiary referral center for patients with myocardial infarction because of active interventional cardiology and cardiothoracic surgery services. This study was approved by the Institutional Review Board. Vital signs before, during, and after enteroscopy were obtained from the nurses notes. MI was dened as a serum level of creatinine kinase (CK) >225 U/L (lab normal, 25 225 U/L) and a musclebrain (MB) fraction >5% (lab normal, 05%), with a conrmatory attending cardiology consultation note. Fecal occult blood was determined by digital rectal examination using a guaiac-impregnated slide (Hemoccult; Smith Kline Diagnostics, Sunnyvale, CA). Depth of enteroscope intubation was conrmed uoroscopically in two patients.

RESULTS Incidence. Among circa 8900 patients hospitalized for acute MI at the study site, 4 patients (0.04%) underwent enteroscopy within 60 days of MI. Case 1. An 82-year-old white male status post-aortic graft surgery 1 year earlier for an aortic aneurysm and with aortic graft revision 2 months earlier for an aortic stula to the fourth portion of the duodenum was referred for enteroscopy to exclude recurrent aortoenteric stula 1 day after presenting with dark-red blood per rectum and substernal chest pain from an acute MI; the patient had undergone emergency EGD on admission that had revealed only supercial, linear longitudinal erosions in the gastric body attributed to nasogastric tube trauma, but the distal duodenum had not been visualized by the EGD. The prior aortoenteric stula had presented with an upper GI bleed. The patient was taking 165 mg of aspirin daily but denied alcoholism, chronic fevers, night sweats, or antecedent (herald) bleed before this admission. On admission the patient was afebrile with normal vital signs and with no difference in the blood pressures recorded in different limbs. The abdomen was soft and nontender, with normoactive bowel sounds and no expansile, pulsatile abdominal mass. Nasogastric aspiration revealed no blood. The electrocardiogram revealed 2-mm ST depressions in the anterior
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precordial leads. The peak serum CK level was 632, with an MB fraction of 35.8%. Chest roentgenogram did not reveal widening of the mediastinum. Abdominal ultrasound did not reveal an abdominal aortic aneurysm. The initial hematocrit was 20.1 (lab normal, 3951 in males). The patient was transfused 5 U of packed erythrocytes. At enteroscopy, the blood pressure was 149/57 mm Hg, the pulse was 82 beats/min, and the arterial oxygen saturation was 99%, while the patient was receiving supplemental oxygen at 2 L/min by nasal cannulae. The hematocrit was 29.5. The platelet count, INR (international normalized ratio of prothrombin time), and partial thromboplastin time were within normal limits. Enteroscopy beyond the ligament of Treitz, with intubation 85 cm beyond the pylorus, did not reveal an aortoenteric stula. The patient received intravenous antibiotic prophylaxis before and after enteroscopy and meperidine, 25 mg, and midazolam, 0.5 mg, during enteroscopy. The vital signs remained stable during enteroscopy. The arterial oxygen saturation was 94% or higher throughout enteroscopy. Continuous electrocardiography did not reveal any cardiac arrhythmias. Sigmoidoscopy performed immediately after enteroscopy revealed some dark blood coming from the more proximal colon and small, incidental internal hemorrhoids. Colonoscopy 10 days after MI revealed no lesions aside from the incidental hemorrhoids. The patient was discharged 15 days after MI without further bleeding. Case 2. A 76-year-old Chinese female was referred for enteroscopy 45 days after presenting with an acute MI because of recurrent occult GI bleeding. The patient had no history of GI disease, abdominal pain, or gross GI bleeding. The patient was not drinking alcohol or taking aspirin or nonsteroidal antiinammatory drugs (NSAIDs). Nasogastric aspiration revealed no blood. On admission the hematocrit was 24.9 (lab normal, 3747 in females). The electrocardiogram revealed inverted T waves in the inferior cardiac leads. The peak serum CK level was 818 U/L, with an MB fraction of 10.0%. The patient was transfused 2 U of packed erytrocytes during the rst 2 hospital days. EGD performed 3 days later revealed no lesions. Cardiac catheterization revealed signicant occlusion of all three main coronary arteries and the patient underwent successful coronary artery bypass surgery and was discharged. Colonoscopy performed 28 days after MI revealed no signicant lesions. At enteroscopy the blood pressure was 155/67 mm Hg, the pulse was 97 beats/min, and the arterial oxygen saturation was 95%, while the patient was receiving supplemental oxygen at 2 L/min by nasal cannulae. The hematocrit was 31.4. The platelet count, INR, and partial thromboplastin time were within normal limits. Enteroscopy revealed a whitish exudate in the distal

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descending duodenum. The patient received meperidine, 25 mg, and midazolam, 1.5 mg, during enteroscopy. The vital signs remained stable during enteroscopy. The arterial oxygen saturation was 95% or higher throughout enteroscopy. Continuous electrocardiography did not reveal any cardiac arrhythmias. Pathologic examination of an endoscopic biopsy and of a duodenal aspirate revealed mucosal inammation compatible with duodenitis and no enteric parasites. The patient had no complications during 1 month of follow-up. Case 3. A 72-year-old white male status post-Billroth I partial gastrectomy 30 years earlier for a bleeding duodenal ulcer was referred for enteroscopy 4 days after an uncomplicated MI. The patient had developed melena 1 day before presenting with chest pain. The patient was not drinking alcohol or taking aspirin or NSAIDs. Nasogasatric aspiration revealed no blood. On admission the hematocrit was 25.3. The electrocardiogram revealed 2-mm ST elevations in the anterior precordial leads. The peak CK level was 480 U/L, with an MB fraction of 9.0%. The patient was transfused 2 U of packed erythrocytes during the rst 2 days. EGD, performed 1 day after admission, revealed only anastomotic erosions. Sigmoidoscopy, performed 4 days after admission, did not reveal any lesions. At enteroscopy, the blood pressure was 122/76 mm Hg, the pulse was 92 beats/min, and the arterial oxygen saturation was 97%, while the patient was receiving supplemental oxygen at 2 L/min by nasal cannulae. The hematocrit was 34.6. The platelet count, INR, and partial thromboplastin time were within normal limits. Endoscopy with intubation 65 cm beyond the anastomosis revealed only erosions on the gastric side of the Billroth I anastomosis. The patient received midazolam, 4 mg, during enteroscopy. The vital signs remained stable during enteroscopy. The arterial oxygen saturation was 96% or higher throughout enteroscopy. Continuous electrocardiography did not reveal any cardiac arrhythmias. The patient experienced no endoscopic complications and was discharged 1 day after enteroscopy. Case 4. A 63-year-old hypertensive and diabetic black male status post-coronary artery bypass surgery 6 months earlier was referred for enteroscopy 28 days after admission for uncomplicated MI because of fecal occult blood and severe iron deciency anemia. The patient had been admitted 28 days earlier for substernal chest pain, dyspnea, dizziness, and severe anemia. The patient had been taking aspirin, 325 mg daily. The patient denied alcohol abuse. Nasogastric aspiration revealed no blood. On admission the hematocrit was 22.3. The electrocardiogram revealed inverted T waves in the inferior leads. The peak CK level was 475 U/L, with an MB fraction of 9.0%. The patient was transfused 4 U of packed erythrocytes.

EGD performed 2 days after admission revealed no lesions. Colonoscopy performed 5 days after admission revealed only incidental internal hemorrhoids. At enteroscopy the blood pressure was 167/92 mm Hg, the pulse was 84 beats/min, and the arterial oxygen saturation was 97%, while the patient was receiving supplemental oxygen at 2 L/min by nasal cannulae. The abdomen was soft and nontender, with normoactive bowel sounds. The hematocrit was 30.5. The platelet count, INR, and partial thromboplastin time were within normal limits. Enteroscopy with intubation 20 cm beyond the ligament of Treitz, as conrmed by uoroscopy, revealed no lesions. The patient received meperidine 25, mg, and midazolam, 5 mg, during enteroscopy. The vital signs remained stable during enteroscopy. The arterial oxygen saturation was 97% or higher throughout enteroscopy. Continuous electrocardiography did not reveal any cardiac arrhythmias. The patient experienced no endoscopic complications and was doing well 1 month later. DISCUSSION The currently reported ndings of no complications in four patients undergoing enteroscopy after recent MI is reasonable. Aside from rare complications associated with use of an overtube (22, 23), the complications of enteroscopy are similar to those of EGD in the general population (24). A previous large study showed that EGD is reasonably safe after a recent MI in relatively stable patients (14) (Table 1). The complication rate of EGD was 7.5%, but most complications were minor, without clinical sequelae, and most complications occurred in clinically unstable patients. The current work demonstrates that enteroscopy is not absolutely contraindicated after MI. Enteroscopy (or upper endoscopy to the fourth portion of the duodenum) should be strongly considered after MI to exclude suspected aortoenteric stula or to evaluate a distal duodenal lesion identied on upper GI series (25). Enteroscopy may be considered after recent MI for signicant GI bleeding of undetermined etiology after nondiagnostic EGD and colonoscopy provided that the patient is relatively stable. A physician may, however, reasonably defer an enteroscopy for this indication for at least several weeks after an MI. The risks of enteroscopy after MI and the relatively low diagnostic yield should be weighed against the potential benets of preventing rebleeding, myocardial hypoperfusion, and recurrent angina by endoscopically identifying and treating the bleeding lesion. A large, randomized, controlled study is needed to dene the risks versus benets of enteroscopy after MI. Although wireless capsule endoscopy may replace many indications for
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diagnostic enteroscopy because of higher sensitivity, less procedure invasiveness, and greater patient safety (26) considerations of particular import in patients with recent MIenteroscopy still has a role because of more widespread procedure availability and therapeutic capabilities (27). REFERENCES
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