Changes in Cardiopulmonary Parameters During Upper Gastrointestinal Endoscopy in Patients with Heart Disease: Towards Safer Endoscopy

Background and Study Aims: Gastrointestinal endoscopy is an invasive examination. The aims of this study were to elucidate the effects and risks of upper gastrointestinal endoscopy with regard to cardiopulmonary functions in patients with heart disease, and to establish safety guidelines for use during endoscopy in this particular group of patients.

Patients and Methods: The patients involved were 53 inpatients in whom upper gastrointestinal endoscopy was carried out before cardiac surgery. Their cardiac functions had been evaluated previously. Electrocardiography with two leads (II, V5) was used, and blood pressure and peripheral oxygen saturation (SpO₂) were monitored throughout the procedure. The relationship between the changes in cardiopulmonary parameters during endoscopy and the cardiac functions was analyzed.

Results: Heart rate increased immediately after insertion of the endoscope (P < 0.01). There was a significantly higher incidence of ventricular and supraventricular extrasystoles during observation of the second portion of the duodenum (P < 0.05). A lower cardiac index (P < 0.05) and a higher New York Heart Association (NYHA) functional classification (P < 0.05) were found in patients with oxygen desaturation than in patients without it. Two patients with severe coronary artery lesions showed marked ST-T depression, and these ischemic changes were thought to be due to increase in cardiac work during endoscopy.

Conclusions: Upper gastrointestinal endoscopy has many adverse effects on cardiopulmonary functions in patients with heart disease. In our study, the clinical value of very close monitoring and administration of oxygen for patients with heart disease was confirmed by objective data.

References

• 1 Segawa K, Nakazawa S, Yamao K, et al. Cardiac response to upper gastrointestinal endoscopy.  Am J Gastroenterol. 1989;  84 13-16
• 2 Palmer E D, Wirts C W. Survey of gastroscopic and esophagoscopic accidents: report of committee on accidents of The American Gastroscopic Society.  J Am Med Ass. 1957;  164 2012-2015
• 3 Silvis S E, Nebel O, Rogers G, et al. Endoscopic complications: results of the 1974 American Society for Gastrointestinal Endoscopy Survey.  J Am Med Ass. 1976;  235 928-930
• 4 Davis R E, Graham D Y. Endoscopic complications: the Texas experience.  Gastrointest Endosc. 1979;  25 146-149
• 5 Katon R M. Complications of upper gastrointestinal endoscopy in the gastrointestinal bleeder.  Dig Dis Sci. 1981;  26 47
• 6 Mandelstam P, Sugawa C, Silvis S E, et al. Complications associated with esophagogastroduodenoscopy and with esophageal dilatation.  Gastrointest Endosc. 1976;  23 16-19
• 7 Smith L E. Fiberoptic colonoscopy: complications of colonoscopy and polypectomy.  Dis Colon Rectum. 1976;  19 407-412
• 8 Gupta S C, Gopalswamy N, Sarkar A, et al. Cardiac arrhythmias and electrocardiographic changes during upper and lower gastrointestinal endoscopy.  Mil Med. 1990;  155 9-11
• 9 Katz D, Selesnick S. Cardiac arrest during gastroscopy.  Gastroenterology. 1957;  33 650-654
• 10 Switz D M, Clarke A M, Longacher J W. Electrical malfunction at endoscopy: possible cause of arrhythmia and death.  J Am Med Ass. 1976;  235 273-275
• 11 McAlpine J K, Martin B J, Devine B L. Cardiac arrhythmias associated with upper gastrointestinal endoscopy in elderly subjects.  Scot Med J. 1990;  35 102-104
• 12 Keeffe E B, O'Connor K W. 1989 ASGE survey of endoscopic sedation and monitoring practices.  Gastrointest Endosc. 1990;  36 18
• 13 Bell G D, McCloy R F, Charlton J E, et al. Recommendations for standards of sedation and patient monitoring during gastrointestinal endoscopy.  Gut. 1991;  32 823-827
• 14 Little W C, Braunwald E. Assessment of cardiac function. In: Braunwald E (ed). Heart disease: a textbook of cardiovascular medicine. Volume 1. 5th edn.  Philadelphia; WB Saunders Co., 1997: 421-444
• 15 Ellestad M H. Stress testing: principles and practice. 4th edn.  Philadelphia; FA Davis Co., 1995
• 16 Habr-Gama A, Waye J D. Complications and hazards of gastrointestinal endoscopy.  World J Surg. 1989;  13 193-201
• 17 Lieberman D A, Wuerker C K, Katon R M. Cardiopulmonary risk of esophagogastroduodenoscopy, role of endoscope diameter and systemic sedation.  Gastroenterology. 1985;  88 468-472
• 18 Mathew P K, Ona F V, Damevski K, et al. Arrhythmias during upper gastrointestinal endoscopy.  Angiology. 1979;  30 834-840
• 19 DiSario J A, Waring J P, Talbert G, et al. Monitoring of blood pressure and heart rate during routine endoscopy: a prospective, randomized, controlled study.  Am J Gastroenterol. 1991;  86 956-960
• 20 Jurell K R, O'Connor K W, Slack J, et al. Effect of supplement oxygen on cardiopulmonary changes during gastrointestinal endoscopy.  Gastrointest Endosc. 1994;  40 665-670
• 21 Grandjean J G, Boonstra P W, den Heyer P, et al. Arterial revascularization with the right gastroepiploic artery and internal mammary arteries in 300 patients.  J Thorac Cardiovasc Surg. 1994;  107 1309-1316
• 22 Antona C, Zanobini M, Pompilio G, et al. Role of right gastroepiploic artery in myocardial revascularization with arterial grafts.  Cardiovasc Surg. 1996;  4 217-221
• 23 Holm C, Rosenberg J. Pulse oximetry and supplemental oxygen during gastrointestinal endoscopy: a critial review.  Endoscopy. 1996;  28 703-711
• 24 Bough E W, Meyers S. Cardiovascular responses to upper gastrointestinal endoscopy.  Am J Gastroenterol. 1978;  69 655-661
• 25 Carrey W D. Indication, contraindications, and complications of upper gastrointestinal endoscopy. In: Sivak MV, Jr (ed). Gastroenterologic endoscopy.  Philadelphia; WB Saunders, 1987: 296-306
• 26 Palmer E D. The abnormal upper gastrointestinal vagovagal reflexes that affect the heart.  Am J Gastroenterol. 1976;  66 513-522
• 27 Rostykus P S, McDonald G B, Albert R K. Upper intestinal endoscopy induces hypoxemia in patients with obstructive pulmonary disease.  Gastroenterology. 1980;  78 488-491
• 28 Morrison L M, Swalm W A. Role of the gastrointestinal tract in production of cardiac symptoms: experimental and clinical observations.  J Am Med Ass. 1940;  114 217-223
• 29 Iwao T, Toyonaga A, Harada H, et al. Arterial oxygen desaturation during non-sedated diagnostic upper gastrointestinal endoscopy.  Gastrointest Endosc. 1994;  40 277-280
• 30 Nakazawa S, Asaka M, Ogoshi K, et al. Report of the Committee of the Japan Gastroenterological Endoscopy Society: cardiorespiratory changes during gastrointestinal endoscopy (Japanese).  Gastroenterol Endosc. 1997;  39 1644-1649
• 31 Alcain G, Guillen P, Escolar A, et al. Predictive factors of oxygen desaturation during upper gastrointestinal endoscopy in nonsedated patients.  Gastrointest Endosc. 1998;  48 143-147
• 32 Blackburn H, Katigbak R. What electrocardiographic leads to take after exercise?.  Am Heart J. 1964;  67 184-185
• 33 Murray A W, Morran C G, Kenny G N, et al. Examination of cardiorespiratory changes during upper gastrointestinal endoscopy. Comparison of monitoring of arterial oxygen saturation, arterial pressure and the electrocardiogram.  Anaesthesia. 1991;  46 181-184
• 34 Rosenberg J, Stausholm K, Andersen I B, et al. No effect of oxygen therapy on myocardial ischaemia during gastroscopy.  Scand J Gastroenterol. 1996;  31 200-205
• 35 Fujita R, Kumura F. Arrhythmias and ischemic changes of the heart induced by gastric endoscopic procedures.  Am J Gastroenterol. 1975;  64 44-48
• 36 Rosenberg J, Overgaard H, Andersen M, et al. Double blind randomised controlled trial of effect of metoprolol on myocardial ischaemia during endoscopic cholangiopancreatography.  Br Med J. 1996;  313 258-261
• 37 Daneshmed T K, Bell G D, Logan R F. Sedation for upper gastrointestinal endoscopy: results of a nationwide survey.  Gut. 1991;  32 12-15
• 38 Arrowsmith J B, Gerstman B B, Fleischer D E, et al. Results from the American Society for Gastrointestinal Endoscopy/U.S. Food and Drug Administration collaborative study on complication rates and drug use during gastrointestinal endoscopy.  Gastrointest Endosc. 1991;  37 421-427
• 39 Froehlich F, Schwizer W, Thorens J, et al. Conscious sedation for gastroscopy: patient tolerance and cardiorespiratory parameters.  Gastroenterology. 1995;  108 697-704
• 40 Froehlich F, Thorens J, Schwizer W, et al. Sedation and analgesia for colonoscopy: patient tolerance, pain, and cardiorespiratory parameters.  Gastrointest Endosc. 1997;  45 1-9
• 41 al-Atrakchi H A. Upper gastrointestinal endoscopy without sedation: a prospective study of 2000 examinations.  Gastrointest Endosc. 1989;  35 79-81
• 42 Hart R, Classen M. Complications of diagnostic gastrointestinal endoscopy.  Endoscopy. 1990;  22 229-233
• 43 Froehlich F, Gonvers J J, Fried M. Conscious sedation, clinically relevant complications and monitoring of endoscopy: results of a nationwide survey in Switzerland.  Endoscopy. 1994;  26 231-234
• 44 Peri V, Amuso M, Gatto G, et al. Monitoring during endoscopy. Italian data support upper gastrointestinal endoscopy without sedation.  Br Med J. 1995;  310 886-887