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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 efficacy of esophagogastroduodenoscopy (EGD) after myocardial infarction(MI) arefairly well characterized, thesafety of enteroscopyafter recentMI is unstudied andunknown.Enteroscopy could potentially be particularly valuable to evaluate recurrent obscure gastrointestinal(GI) bleeding after MI because ongoing GI bleeding could induce recurrentmyocardial ischemia.The

safetyof push enteroscopyis analyzed in a study of 4 cases among 8900 patients with acute MIsduringan 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 kinaselevel 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 packederythrocyte transfusions with no significant lesions identified by EGD and colonoscopy in twopatients, maroon stools with no lesions identified by colonoscopy and only anastomotic erosionsidentified by EGD in one patient status post-Billroth I gastrectomy, and dark red blood per rectumin one patient with prior aortic graft revision for an aortoenteric fistula after failure to visualize thedistal duodenum by EGD. The patients received a mean of 4.0 1.3 U of packed erythrocytes beforeenteroscopy. At enteroscopy the mean hematocrit was 32.7 1.6. The patients received a mean of18.8 12.5 mg of meperidine and 2.6 2.2 mg of midazolam during enteroscopy. Enteroscopywas uniformly uncomplicated. Vital signs and arterial oxygen saturation remained stable during and

following enteroscopy. Enteroscopy revealed no new lesions in two patients and distal duodenitisin one patient and ruled out an aortoenteric fistual in one patient at high risk for this lesion. Thesefour cases suggest that enteroscopy is not absolutely contraindicated and might be considered afterrecent MI for strong indications in relatively clinically stable patients.

KEY WORDS: enteroscopy; push enteroscopy; esophagogastroduodenoscopy (EGD); gastrointestinal endoscopy; fecal oc-cult blood; chronic gastrointestinal bleeding;obscure gastrointestinal bleeding;iron deficiency anemia; myocardial infarction;angina.

Although enteroscopy is safe, well tolerated, and useful

in the general population, the safety of enteroscopy af-

ter recent myocardial infarction (MI) is currently unstud-

ied and unknown. While susceptible to all the complica-

tions 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. BarnabasHospital, Third Avenue & 183rd Street, The Bronx, New York 10457-2594, USA.

be particularly susceptible to cardiopulmonary compli-

cations, including myocardial ischemia from discomfort,

hypoxia, or anxiety during enteroscopy (3, 4); hypoten-

sion or hypertension from medications or anxiety (5); car-

diac arrhythmias due to medications, hypoxia, or anxiety

(4); and respiratory compromise from endoscopic med-

ications, vagally mediated bronchospasm, laryngeal im-

pingement during esophageal intubation, or pulmonary

aspiration (3, 6). Contrariwise, enteroscopy could be par-

ticularly valuable after MI to diagnose the cause and to

initiate specific treatment for recurrent obscure gastroin-

testinal (GI) bleeding to prevent consequent myocardial

Digestive Diseases and Sciences, Vol. 49, No. 3 (March 2004) 5090163-2116/04/0300-0509/0 C 2004 Plenum Publishing Corporation


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CAPPELL

ischemia from profound anemia (79); this is becoming

ever more valuable due to the increasing use of antico-

agulation (10), thrombolysis (11), and antiplatelet agents

after MI (12).

Although the safety and efficacy of esophagogastro-

duodenoscopy (EGD) after MI are fairly well charac-

terized (13, 14), the safety and efficacy of enteroscopy

must be directly analyzed and not extrapolated from these

prior studies. First, enteroscopy could cause greater car-

diopulmonary stress than EGD due to a longer procedure

time and greater depth of intubation. Second, enteroscopy

is generally performed in patients already evaluated by

TABLE 1. SAFETY AND EFFICACY OF DIFFERENT TYPES OF UPPER GASTROINTESTINAL ENDOSCOPY AFTER RECENT MYOCARDIAL INFARCTION

No. (%) & typeReference No. of patients of complications Benefits of exam Recommendations

Esophagogastroduodenoscopy (EGD)

Cappell MS, 1993 (13) 34 3 (9%); 2 major, 1 minor 79% diagnostic rate Benefits may exceed risks of EGD in medically stablepatients with GI bleeding.

Wilcox et al., 1993 (4) 19 with severe CAD 0 Not discussed EGD rarely results inmyocardial ischemia orarrhythmias in patientswith stable CAD.

Rourket al., 1994 (28) 1 0 Diagnosed gastricangiodysplasia

None

Montalvo & Lee, 1996 (29) 8 2 (25%); 1 major, 1 minor 88% diagnostic rate Benefits may exceed risks inmedically stable patients.

Lee et al., 1995 (3) 39 with severe CAD 4 (10%); 1 major, 3 minor 79% diagnostic rate EGD appears to berelatively safe in patientswith significant CAD.

Cappell & Iacovone, 1999 (14) 200 15 (7.5%); 2 major, 13 minor 85% diagnostic rate EGD relatively safe &beneficial when indicatedafter MI.

Percutaneous endoscopic gastrostomy (PEG)

Cappell & Iacovone, 1996 (21) 28 3 (10%); all minor All PEGssuccessfully usedfor enteralfeeding

PEG relatively safe &beneficial when indicatedafter MI.

Endoscopic retrograde cholangiopancreatography (ERCP)

Wilcox et al., 1993 (4) 4 with severe CAD 0 Not discussed Too small a studypopulation for firmconclusions

Rahmin et al., 1995 (30) 1 0 Papillotomy & stoneextraction

Therapeutic ERCP may bean alternative to surgeryafter MI.

Cappell, 1996 (18) 4 1 (minor) All had successfulpapillotomy &stone extraction

ERCP & sphincterotomyare not contraindicatedafter MI and may bepreferable to surgery.

Enteroscopy

Current report 4 0 Distal duodenitis in1; excludedaortoentericfistula in 1; nonew lesionsdiagnosed in 2

Not contraindicated afterMI. Can be done forstrong & relatively urgentindicatings.

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

EGD and colonoscopy. Successful prior performance of

colonoscopy and EGD without complications might pres-

elect forpatientsalso able to tolerate enteroscopy after MI.

Third, enteroscopy has a much lower diagnostic yield than

EGD, partly because it is typically performed after a non-

diagnostic EGD (15,16). Fourth, enteroscopy has much

narrower indications than EGD in that enteroscopy is usu-

ally performed to investigate significant 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

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


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ENTEROSCOPY AFTER MI

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 enteroscopyafter recent MI, all of whom were prospectively monitored forendoscopic complications. Computerized analysis of the medi-cal record primary or secondary disease codes for MI and proce-dure codes for EGD or enteroscopy (International Classificationof Diseases, Ninth Revision [ICD-9]) revealed one additionalpatient undergoing enteroscopy after recent MI at MaimonidesMedical Center, Brooklyn, New York, from 1994 through 2001.All endoscopic reports at Maimonides Medical Center duringthe study period were reviewed to confirm that no enteroscopiesperformed afterMI wereomitted. MaimonidesMedical Center isa tertiary referral center for patients with myocardial infarctionbecause of active interventional cardiology and cardiothoracicsurgery services. This study was approved by the InstitutionalReview Board. Vital signs before, during, and after enteroscopy

were obtained from the nurses notes. MI was defined as a serumlevel of creatinine kinase (CK) >225 U/L (lab normal, 25225 U/L) and a musclebrain (MB) fraction >5% (lab normal,05%), with a confirmatory attending cardiology consultationnote. Fecal occult blood was determined by digital rectal ex-amination using a guaiac-impregnated slide (Hemoccult; SmithKline Diagnostics, Sunnyvale, CA). Depth of enteroscope intu-bation was confirmed fluoroscopically 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-aorticgraft surgery 1 year earlier for an aortic aneurysm and

with aortic graft revision 2 months earlier for an aortic

fistula to the fourth portion of the duodenum was referred

for enteroscopy to exclude recurrent aortoenteric fistula 1

day after presenting with dark-red blood per rectum and

substernal chest pain from an acute MI; the patient had un-

dergone emergency EGD on admission that had revealed

only superficial, 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 fistula 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 pa-

tient was afebrile with normal vital signs and with no dif-

ference 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 electrocar-

diogram revealed 2-mm ST depressions in the anterior

precordial leads. The peak serum CK level was 632, with

an MB fraction of 35.8%. Chest roentgenogram didnot re-

veal 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 satura-

tion was 99%, while the patient was receiving supplemen-

tal oxygen at 2 L/min by nasal cannulae. The hematocrit

was 29.5. The platelet count, INR (international normal-

ized ratio of prothrombin time), and partial thromboplas-

tin time were within normal limits. Enteroscopy beyond

the ligament of Treitz, with intubation 85 cm beyond the

pylorus, did not reveal an aortoenteric fistula. The pa-

tient received intravenous antibiotic prophylaxis before

and after enteroscopy and meperidine, 25 mg, and mi-

dazolam, 0.5 mg, during enteroscopy. The vital signs re-

mained stable during enteroscopy. The arterial oxygen sat-uration was 94% or higher throughout enteroscopy. Con-

tinuous electrocardiography did not reveal any cardiac ar-

rhythmias. Sigmoidoscopy performed immediately after

enteroscopy revealed some dark blood coming from the

more proximal colon and small, incidental internal hemor-

rhoids. 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 be-

cause of recurrent occult GI bleeding. The patient had no

history of GI disease, abdominal pain, or gross GI bleed-

ing. The patient was not drinking alcohol or taking aspirinor nonsteroidal antiinflammatory drugs (NSAIDs). Naso-

gastric aspiration revealed no blood. On admission the

hematocrit was 24.9 (lab normal, 3747 in females). The

electrocardiogram revealed inverted T waves in the infe-

rior 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 first 2 hospital days.

EGD performed 3 days later revealed no lesions. Cardiac

catheterization revealed significant occlusion of all three

main coronary arteries and the patient underwent success-

ful coronary artery bypass surgery and was discharged.

Colonoscopy performed 28 days after MI revealed no sig-

nificant 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

Digestive Diseases and Sciences, Vol. 49, No. 3 (March 2004) 511


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CAPPELL

descending duodenum. The patient received meperidine,

25 mg, and midazolam, 1.5 mg, during enteroscopy. The

vital signs remained stable during enteroscopy. The ar-

terial oxygen saturation was 95% or higher throughout

enteroscopy. Continuous electrocardiography did not re-

veal any cardiac arrhythmias. Pathologic examination of

an endoscopic biopsy and of a duodenal aspirate revealed

mucosal inflammation 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 duo-

denal 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. Na-

sogasatric aspiration revealed no blood. On admission

the hematocrit was 25.3. The electrocardiogram revealed

2-mm ST elevations in the anterior precordial leads. Thepeak CK level was 480 U/L, with an MB fraction of 9.0%.

Thepatient wastransfused 2 U of packederythrocytes dur-

ingthe first 2 days. EGD, performed1 dayafter admission,

revealed only anastomotic erosions. Sigmoidoscopy, per-

formed 4 days after admission, did not reveal any lesions.

At enteroscopy, the blood pressure was 122/76 mm Hg,



tal oxygen at 2 L/min by nasal cannulae. The hematocrit

was 34.6. The platelet count, INR, and partial thrombo-

plastin timewere within normal limits. Endoscopy within-

tubation 65 cm beyond the anastomosis revealed only ero-

sions on the gastric side of the Billroth I anastomosis. Thepatient 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 re-

veal 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 admis-

sion for uncomplicated MI because of fecal occult blood

and severe iron deficiency anemia. The patient had been

admitted 28 days earlier for substernal chest pain, dysp-

nea, dizziness, and severe anemia. The patient had been

taking aspirin, 325 mg daily. The patient denied alcohol

abuse. Nasogastric aspiration revealed no blood. On ad-

mission 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 le-

sions. Colonoscopy performed 5 days after admission re-

vealed only incidental internal hemorrhoids.

At enteroscopy the blood pressure was 167/92 mm Hg,



tal 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 par-

tial thromboplastin time were within normal limits. En-

teroscopy with intubation 20 cm beyond the ligament of

Treitz, as confirmed by fluoroscopy, 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 elec-

trocardiography did not reveal any cardiac arrhythmias.

The patient experienced no endoscopic complications and

was doing well 1 month later.

DISCUSSION

The currently reported findings 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 pa-

tients (14) (Table 1). The complication rate of EGD was

7.5%,but most complications were minor, without clinical

sequelae, and most complications occurred in clinicallyunstable patients.

The current work demonstrates that enteroscopy is not

absolutely contraindicated after MI. Enteroscopy (or up-

per endoscopy to the fourth portion of the duodenum)

should be strongly considered after MI to exclude sus-

pected aortoenteric fistula or to evaluate a distal duodenal

lesionidentified on upper GI series (25). Enteroscopy may

be considered after recent MI for significant GI bleeding

of undetermined etiology after nondiagnostic EGD and

colonoscopy provided that the patient is relatively sta-

ble. A physician may, however, reasonably defer an en-

teroscopy 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 benefits of preventing rebleeding, myocar-

dial hypoperfusion, and recurrent angina by endoscopi-

cally identifying and treating the bleeding lesion. A large,

randomized, controlled study is needed to define the risks

versus benefits of enteroscopy after MI. Although wire-

less capsule endoscopy may replace many indications for

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


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ENTEROSCOPY AFTER MI

diagnostic enteroscopy because of higher sensitivity, less

procedure invasiveness, and greater patient safety (26)

considerations of particular import in patients with re-

cent MIenteroscopy still has a role because of more

widespread procedure availability and therapeutic capa-

bilities (27).

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