Severe Cardiogenic Pulmonary Edema Precipitated by a Therapeutic ERCP

I read with great interest the recent article by Johnston et al. [1] on silent myocardial ischemia during endoscopic retrograde cholangiopancreatography (ERCP). Another paper by Christensen et al. [2] also emphasized that ERCP can reduce myocardial blood flow. However, although this appears to be more common than was previously thought, clinical events caused by it appear to be rare.

I would like to report here a case of severe cardiogenic pulmonary edema that took place several hours after a therapeutic ERCP. I believe this complication can be explained by our increasing understanding of myocardial blood flow reduction during the procedure.

A 76-year-old man underwent ERCP due to cholangitis. He had a history of atrial fibrillation and a stable ischemic heart disease. Transcutaneous ultrasonography showed cholecystolithiasis and bile duct dilation. He was receiving treatment with warfarin, amiodarone and omeprazole, and was also using dermal nitrates daily. The anticoagulant medication was interrupted to allow a biliary sphincterotomy to be carried out. At ERCP, the common bile duct was found to be slightly dilated, but no choledocholithiasis was seen. The bile duct stones were therefore thought to have migrated. As the patient was not a good candidate for surgery, a sphincterotomy was performed to facilitate biliary drainage. After the sphincterotomy, oozing bleeding was seen, and a dilute epinephrine injection and argon plasma coagulation were applied. The procedure lasted for 45 min. During the ERCP, continuous pulse oximetry was carried out, oxygen was supplied, and episodes of hypoxemia or tachycardia were not observed.

The procedure ended at 2 p. m., and the patient remained well during the evening, with normal hematocrit, leukocyte, and amylase values. During the night, however (about 14 h after ERCP), he began to experience dyspnea. A chest radiograph showed bilateral lung edema. The patient did not respond to diuretics and oxygen, and admission to the intensive-care unit was required, with endotracheal intubation and positive-pressure ventilation. Finally, after 11 days he recovered and was discharged.

Cardiopulmonary complications of ERCP are rare (< 1 %) and may arise due to cardiac arrhythmia, hypoventilation, or aspiration [3]. It is important and interesting that recent papers such as that by Johnston et al. [1] have suggested that cardiac ischemia may be the mechanism underlying such events. In the case reported above, myocardial contractility may have deteriorated due to a reduction in cardiac blood flow, leading to pulmonary edema. The clinical symptoms appeared several hours after the end of the procedure. One possible explanation might be that from the moment at which ischemia started during the ERCP, water progressively accumulated in the interstices and alveoli before dyspnea appeared.

As Johnston et al. [1] state, the clinical significance of ischemia during ERCP is unclear, as they reported a 22 % rate in patients undergoing the procedure without any relevant complications. In the case reported above, the patient obviously had a clear history of cardiac disease. Nevertheless, ERCP is often performed safely in older patients [4], many of whom have various degrees of heart disease. It is thought that perhaps a quarter of patients in whom short and unremarkable phases of tachycardia and hypoxemia arise also have silent ischemia during the procedure, but severe consequences as in the case reported here are rare. In a recent review of ERCP complications at my center, only the one case reported here was found out of 507 ERCPs, the majority of which were therapeutic. The deterioration in myocardial contractility caused by the endoscopic procedure can therefore be regarded as rare.

The article by Johnston et al. and others on the same subject are welcome, as they can help improve the care provided for patients undergoing a procedure as complex as ERCP.

References

• 1 Johnston S D, McKenna A, Tham T CK. Silent myocardial ischaemia during endoscopic retrograde cholangiopancreatography.  Endoscopy. 2003;  35 1039-1042
• 2 Christensen M, Hendel H W, Rasmussen V. et al . Endoscopic retrograde cholangiopancreatography causes reduced myocardial blood flow.  Endoscopy. 2002;  34 797-800
• 3 Mallery J S, Baron T H, Dominitz J A. et al . Complications of ERCP. Standards of Practice Committee, American Society for Gastrointestinal Endoscopy.  Gastrointest Endosc. 2003;  57 633-638
• 4 García-Cano J. Endoscopic retrograde cholangiopancreatography in patients 90 years of age and older: increasing experience on its effectiveness and safety.  J Clin Gastroenterol. 2003;  37 348-349