Recent MI and EGD

[Intrathecal]

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I was reviewing charts for tomorrow's cases, and one of the scheduled EGD's is on a patient who we took care of 2 weeks ago for a bleeding duodenal ulcer. He had no known cardiac disease at the time, but because of the bleeding ulcer his Hgb dropped to 6 and required 5 units of blood.

His hospitalization was complicated by a diagnosis of non Q wave MI diagnosed by elevated troponin levels. THe MI was presumably caused by the acute blood loss anemia.

Patient was followed up by Cardiologist last week. Recommended medical management for the time being since patient also has chronic renal failure so they did not want to subject him to a contrast dye load for a cardiac cath. THey put him on beta blocker.

We are asked to give him MAC again to take a 2nd look at the ulcer to make sure it's not still bleeding. Is it safe to proceed?

 

[militarymd]

I was reviewing charts for tomorrow's cases, and one of the scheduled EGD's is on a patient who we took care of 2 weeks ago for a bleeding duodenal ulcer. He had no known cardiac disease at the time, but because of the bleeding ulcer his Hgb dropped to 6 and required 5 units of blood.

His hospitalization was complicated by a diagnosis of non Q wave MI diagnosed by elevated troponin levels. THe MI was presumably caused by the acute blood loss anemia.

Patient was followed up by Cardiologist last week. Recommended medical management for the time being since patient also has chronic renal failure so they did not want to subject him to a contrast dye load for a cardiac cath. THey put him on beta blocker.

We are asked to give him MAC again to take a 2nd look at the ulcer to make sure it's not still bleeding. Is it safe to proceed?

nope......




but neither is letting him bleed again because you don't scope him.

 

[Noyac]

why do they think he is still bleeding?

 

[Intrathecal]

why do they think he is still bleeding?

From what I was able to gather from the GI guy's office note, the patient is still having symptoms of heartburn and he is already on a PPI but not on the optimal dose because his insurance won't pay for it.

He probably suspects an occult bleed, otherwise the patient would become symptomatic and present in the ED again. I talked to him about the usual recommendation of waiting 3-6 months after an MI before proceeding to elective surgery, but his argument was that an EGD is not really a surgery.

I replied that an EGD is not a completely benign procedure, with wide hemodynamic alterations at times even though the patient doesn't remember a thing. His rebuttal was exactly what mil said, that if we don't scope him and he is still bleeding he is at risk for further myocardial insult.

I did a quick search, apparently a recent article (July 2008) came out stating that it's ok to scope patients with acute GI bleed even with acute MI. I don't have subscription to the source so I couldn't download the full article, but the abstract basically said that special precautions are needed.

So I think I am stuck doing this case, but just have to be extremely careful to have esmolol, nitro, and neo ready to go.

 

[huktonfonix]

have him document the need (benefit>risk) for procedure. Then topicalize well, and sedate carefully with drugs of choice (dex, midaz, fentanyl, propofol, ketamine, whatever works for you.)

 

[periopdoc]

Just do a technetium-99m-tagged red blood cell scan or a capsule endoscopy

-jpp

 

[proman]

Why don't the GI guys just do fentanyl/midaz like the other 100 million endoscopies?

 

[radslooking]

From what I was able to gather from the GI guy's office note, the patient is still having symptoms of heartburn and he is already on a PPI but not on the optimal dose because his insurance won't pay for it.

He probably suspects an occult bleed, otherwise the patient would become symptomatic and present in the ED again. I talked to him about the usual recommendation of waiting 3-6 months after an MI before proceeding to elective surgery, but his argument was that an EGD is not really a surgery.

I replied that an EGD is not a completely benign procedure, with wide hemodynamic alterations at times even though the patient doesn't remember a thing. His rebuttal was exactly what mil said, that if we don't scope him and he is still bleeding he is at risk for further myocardial insult.

I did a quick search, apparently a recent article (July 2008) came out stating that it's ok to scope patients with acute GI bleed even with acute MI. I don't have subscription to the source so I couldn't download the full article, but the abstract basically said that special precautions are needed.

So I think I am stuck doing this case, but just have to be extremely careful to have esmolol, nitro, and neo ready to go.

holy christ prilosec is 30 dollars for a months supply at Winn-Dixie. I would think somebody could scratch up 30 bucks to maybe help him stay alive. (if it were actually that important) Thats the weakest excuse ever.

 

[urge]

Just bite the bullet and do the case. His original problem was the bleeding, not the heart. Fix the original problem. However, I wouldn't do the case in a ASC. I would do it in the hospital in case he decompensates.

 

[Noyac]

We all do cases that we feel are risky but the surgeon, GI, cardiologist, etc. Get accustom to it. This is probably the easiest one you will see or do. In my opinion, the risk occurs post-op in these pts as the inflamatory mediators start doing their thing. As their Hct drops, as their pain kicks in, etc. This case will avoid all of these. Therefore, the risk is very very low. And the cause of the MI was the bleeding in the first place.

Do the case and move on.