Category Archives: Endoscopic retrograde cholangiopancreatography

Electrocardiographic changes during cholangiopancreatography: CONCLUSIONS

Therefore, it seems that the ST segment changes of the 16 patients were related to both hypoxaemia and sinus tachycardia. It has been suggested 41 that the development of myocardial ischemia during ERCP, manifesting an ST segment deviation, is related to increase cardiac oxygen demand caused by tachycardia rather than decreased oxygen supply caused by hypoxaemia. Our data cannot support this suggestion. We did not use beta-blockade in order to reduce the tachycardia in our patients because this was not the aim of this study. Beta-blockers reduce heart rate, increase cardiac diastolic filling and improve blood oxygen supply to myocardium. Therefore, beta-blockers have been used to prevent tachycardia during endoscopy. Metoprolol is a beta-blocker which has been used in a double blind randomized controlled trial during ERCP in peripheral vascular surgery and after cardiac operations, with positive effect on myocardial oxygen supply and incidence of myocardial ischemia. Beta-blockers have also a strong anxiolytic effect comparable with benzodiazepimes but without concurrent sedation. Continue reading

Electrocardiographic changes during cholangiopancreatography: DISCUSSION (Part 3)

BuscopanBuscopan increases heart rate because it has anticholinergic properties. Premedication with anticholinergic drugs tends to shift the balance of the autonomous nervous system towards sympathetic dominance which increases the cardiac work and heart rate. It has been suggested that patients with cardiac disease, anticholinergic drugs may increase the risk of cardiac complications during endoscopic examination and they should be avoided in shuch patients. These authors state that withholding anticholinergic premedication does not seriously affect the endoscopic examination. To confirm whether psychological stress could alter the cardiac vulnerability, the investigators compared the heart rate in patients who had never undergone endoscopy with those who had. They found that the heart rate increased during endoscopy, but did not increased significantly in those who had previous endoscopy, indicating that psychological factors play an important role in the electrocardiographic changes during endoscopy. Continue reading

Electrocardiographic changes during cholangiopancreatography: DISCUSSION (Part 2)

In one patient asymptomatic supraventricular tachycardia and in another patient a burst of ventricular tachycardia developed but these two patients had ischemic heart disease. The patient who developed sinus bradycardia during ERCP had suffered a previous myocardial infraction and had been diagnosed as having sick sinus syndrome. All patients had diminished blood oxygen saturation and 16 developed ST segment changes compatible with ischemic heart disease.

The mechanisms by which the cardiorespiratory and electrocardiographic changes occur during ERCP remain speculative. During upper gastrointestinal endoscopy airway obstruction, gastric or salivary aspiration, direct pressure on the diaphragm, air insufflation and stress and anxiety triggering catecholamine release may contribute. During ERCP several factors tend to increase sympathetic activity. Continue reading

Electrocardiographic changes during cholangiopancreatography: DISCUSSION (Part 1)

arrhythmias of all kindsThe present study shows that arrhythmias of all kinds, conduction disturbances, electrocardiographic changes compatible with myocardial ischemia and oxygen desaturation are encountered in elderly patients undergoing ERCP. There are previous studies using hemodynamic monitoring (heart rate, blood pressure, rate pressure product), pulse oxymetry and electrocardiographic monitoring during gastrointestinal endoscopic procedures which associate cardiac risk with changes observed in heart rate, asymptomatic arrhythmias, ST segment changes, oxygen desaturation and changes in blood pressure. Some studies have suggested that patients with heart disease were at an increased risk during the above procedures. Continue reading

Electrocardiographic changes during cholangiopancreatography: ST segment

The existence of normal or abnormal pre-ERCP electrocardiogram had little prognostic value in predicting the change of electrocardiographic changes developing during the procedure (Table 4). Of the 22 patients who had clinical, radiological and echocardiographic evidence of heart disease, unifocal ventricular extrasystoles developed in eight, multifocal ventricular extrasystoles developed in three, atrial extrasystoles developed in six and sinus tachycardia in 20.

ST segment changes (depression or elevation) during ERCP, in comparison with the baseline electrocardiogram, were considered as sign of myocardial ischemia. Sixteen (53%) patients developed ST segment changes (15 ST depression and one ST elevation) during the procedure. In all patients the changes were asymptomatic. In all instances the ST segment changes disappeared when the endoscope was withdrawn. There were no significant ST segment changes in the control group during chest, bone, abdomen and small bowel through studies. Continue reading

Electrocardiographic changes during cholangiopancreatography: Cardiac rhythm

The electrocardiograms before the procedure showed no cardiac rhythm disturbances in 20 (67%) patients. However, two (7%) patients had pre-existing atrial fibrillation, five (16 %) patients had premature atrial complexes and three (10%) patients had premature ventricular complexes. During the procedure, premature atrial complexes appeared in 19 (63%) patients, premature ventricular complexes appeared in nine (30%) patients, a burst of supraventricular tachycardia developed in one (3%) patient, a short run of ventricular tachycardia appeared in one (3%) patient and transient left bundle branch block (LBBB) in one (3%) patient. The patient with the LBBB was hypertensive, had cardiomegaly in the chest radiograph and developed premature complexes. Significant differences were found upon comparing the absolute number of atrial and ventricular premature complexes during ERCP and the baseline period (Table 3). In comparing the arrhythmias appearing in the control group during chest, bone, abdomen and upper gastrointestinal small bowel follow-through with the baseline period, significant differences were not found. Continue reading

Electrocardiographic changes during cholangiopancreatography: Heart rate

increased heart rateTwenty nine patients (96%) had increased heart rate during and immediately after ERCP compared with the rate before the endoscopy (P<0.05), but the increased heart rate in the two patients receiving therapeutic P-blockers for ischemic heart disease and in the patient receiving digoxin was not statistically significant. However, the patients who underwent ERCP had a higher mean heart rate (98.3 beats/min; 95 % CI 92.1 to 103.3), than the control subjects (70.1 beats/min; 95 % CI 63.2 to 73.6); statistical significance at P<0.05 for patients and control subjects during and after the procedure (Figure 1). Continue reading

Electrocardiographic changes during cholangiopancreatography: Control subjects

Thirty elderly age- and disease matched patients not receiving any premedication, served as controls. They were undergoing chest, abdomen, bone or upper gastrointestinal small bowel follow-up studies and they had 8 h of electrocardiographic monitoring covering the period before, during and after the examination. The clinical characteristics of the control subjects are shown in Table 2.

Statistical analysis Continue reading

Electrocardiographic changes during cholangiopancreatography: Methods

rate-pressure productAfter the usual skin preparation, modified V2 and V5 electrocardiographic leads were recorded on two channel Circadian Recorders (Circadian Inc, USA). The lead of most significance (V5) was analyzed in detail. The positive electrode was placed in the V5 position and the negative electrode was placed in the right intraclavicular fossa. Because the procedure was elective, electrocardiographic recording usually was initiated 4 h before the procedure and was continued during the examination and 4 h after it. All patients were advised to record in a diary any symptoms of palpitations, shortness of breath or chest pain. Immediately before ERCP, a 12-lead electrocardiogram and resting rhythm strip was available during Valsalva maneuver and during its recovery time. Continuous arterial blood pressure and oximetry monitoring data were recorded throughout the procedure. When it was necessary, arterial blood pressure also was measured by cuff sphygmomanometer in supine position. Continue reading

Electrocardiographic changes during cholangiopancreatography: Subjects

Thirty patients scheduled to undergo ERCP were recruited to the study and were monitored elecrocardiographically with Holter tape recorders. Written informed consent was obtained for data correction and storage on magnetic media. The patients included 18 women and 12 men of mean age 73 years (SD 2, range 71 to 79 years). Their mean weight was 66.5 kg (SD 18.3, range 44 to 100). All current medications were continued to the time of the procedure. No oxygen was administered in the observation period. Premedication was not given until few minutes before ERCP. Diazepam and Buscopan (Boehringer Ingelheim, Canada) were given for sedation and duodenal relaxation. Continue reading

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