Heart and git interaction

By
Ahmed Abudeif Abdelaal
Assistant Lecturer of Tropical Medicine & Gastroenterology
Sohag Faculty of Medicine
May, 2015
Heart and GIT Interaction

Effect of Heart on GIT
1) Heart failure
- Heart failure is a complex syndrome that can result from any
structural or functional cardiac disorder that impairs the ability
of the heart to function as a pump to support a physiological
circulation.
- Heart failure leads to bowel wall edema.
- Bowel wall edema may lead to early satiety (a common
symptom in heart failure), nausea, diffuse abdominal
discomfort, malabsorption, and a rare form of protein-losing
enteropathy.

2) Ischaemic heart disease (IHD)
- IHD is most commonly caused by obstruction or stenosis of
one or more of the coronary arteries by atheromatus plaque.
Obstruction can result in myocardial ischaemia and infarction.
- Anginal pain is the typical presentation of IHD. However, IHD
can cause symptoms other than anginal pain, including
abdominal manifestations which may be:
• Mid-epigastric burning sensation, often postprandially.
• Sharp abdominal pain (atypical, but more common in women).

• Right-upper quadrant discomfort (may mimic gallbladder disease or
pancreatitis).
• Nausea and/or vomiting (often associated with increased vagal tone
secondary to inferior myocardial ischemia or infarction).

3) Acute coronary syndrome (ACS)
- The term acute coronary syndrome (ACS) is used to describe
the continuum of myocardial ischemia (unstable angina) or
infarction (with or without concomitant ST segment elevation).
- Patients with ACS typically presents with :
• Patients with unstable angina has cardiac chest pain that is new,
worsening (i.e., more severe, prolonged, or frequent than previous
episodes of angina), or occurring at rest, without serologic evidence
of myocyte necrosis (i.e., no elevation of serum concentrations of
troponin or the MB isoenzyme of creatine kinase [CK-MB]).

• The patient with cardiac chest pain with serologic evidence of
myonecrosis and without ST segment elevation is said to have a
non-ST segment elevation myocardial infarction (NSTEMI).
• The patient with acute-onset cardiac chest pain, serologic evidence
of myonecrosis, and persistent (>20 minutes) ST segment elevation
is said to have an ST segment elevation myocardial infarction
(STEMI).
- Atypical presentations of ACS are common and may include
aching or vague chest discomfort, epigastric pain, acute-onset
indigestion, nausea, vomiting, unexplained fatigue, or dyspnea.

- Such atypical complaints are often observed in younger (25 to
40 years of age) and older (>75 years of age) patients, women,
and patients with diabetes mellitus, chronic renal insufficiency,
or dementia.

4) Aortic aneurysm
- An aortic aneurysm is pathologic dilatation of the aorta.
- The large majority of abdominal and thoracic aortic
aneurysms are asymptomatic and are discovered incidentally
on routine physical examination or imaging study.
- When patients with abdominal aortic aneurysms experience
symptoms, pain in the epigastrium radiating to the back is the
most frequent complaint, some patients presents with a
pulsatile, expansile abdominal mass.

- With rupture, the pain is frequently associated with
hypotension, tachycardia, profound anaemia and sudden
death.
- An enlarging aneurysm may produce local mass effects as a
result of compression of adjacent mediastinal structures, with
symptoms including coughing, wheezing, dyspnea, dysphagia,
hoarseness or recurrent pneumonia.
- Rarely, aortic aneurysm leads to aorto-oesophageal or aorto-
duodenal fistula which may cause haematemesis.

4) Aortic dissection
- Aortic dissection occurs when the media of the blood vessel is
cleaved longitudinally to form a false lumen that communicates
with the true lumen.
- Severe central chest pain radiating to the back, abdomen or
lower extremities mimicking myocardial infarction is the most
common initial symptom.
- Aortic dissection may result in vascular complications
including mesenteric ischaemia or frank intestinal infarction.

5) Cardiovascular drugs
- Optimal treatment of patients with cardiovascular disease
often requires the use of multiple medications, which have
several GIT side effects.
A) Drugs producing upper GIT adverse effects; mechanisms:
• Direct mucosal irritation or injury: aspirin and other NSAIDs,
potassium supplementation.
• Relaxation of the cardiac sphincter: Ca+2 channel blockers, nitrates.
• Alteration of gastric motility (bradykinin-mediated dysmotility): ACEIs,
ARBs.

5) Cardiovascular drugs
B) Antiplatelets (aspirin, clopidogrel) and anticoagulants
(warfarin, heparin) may produce GIT ulceration and bleeding.
C) Digoxin toxicity: nausea, vomiting, diarrhea, abdominal pain.

Effect of GIT on the Heart
1) Rhythm disturbance and syncope related to esophageal
disease
- Disturbances in cardiac rhythm accompanying swallowing are
well documented.
- Bradyarrhythmias including (AV block, sinus bradycardia and
ventricular asystole) are more common. However, swallowing
induced tachyarrhythmias have also been described such as
AF.

- Evaluation of these patients has revealed that many of them
suffer from an underlying gastrointestinal disorders including
GERD, hiatus hernia, achalasia and gastric diverticulae.

2) Linked angina
- This term is used to describe a condition in which
gastrointestinal factors can induce angina like chest pain and
ECG changes in patients with proven coronary artery disease.
- It had previously been shown that raising the pressure in the
bile ducts of patients with angina could provoke typical angina
pain, and that hiatus hernia correction could lead to
symptomatic relief of co-existent symptoms of IHD.

- More recently, it has been demonstrated that administering
acid into the esophagus of patients with coronary artery
stenosis will reduce their exercise tolerance levels.
- Therefore, it has been postulated that there is a neural reflex
capable of altering cardiac blood flow or cardiac pain
perception on stimulation of the esophageal mucosa.
- Ischaemic ECG changes had been described at times of
esophageal spasm in variant angina patients, this postulates
that esophageal spasm and coronary spasm are mutual and
reciprocal.

3) Noncardiac chest pain (NCCP)
- The term noncardiac chest pain generally means pain in the
chest that mimics or may be confused with cardiac chest pain.
- Many patients who present to a physician with acute chest
pain have a noncardiac cause.
- Diagnosis is particularly confusing in patients who have both
cardiac and noncardiac chest pain.

- GIT causes of NCCP:
A) Esophageal disease.
a. Motility disorders.
1) Achalasia.
2) Diffuse esophageal spasm.
3) Nutcracker esophagus.
4) Nonspecific motor disorder.
b. Mucosal disorders.
1) GERD, NERD.
2) Viral and fungal infections.
3) Acid or alkali ingestion.
4) Cancer.
B) Gall bladder disease.
C) Pancreatitis.
D) Peptic ulcer.

4) Malabsorption
a) Beriberi
- Refers to a cluster of symptoms caused primarily by a
nutritional deficit in vitamin B1 (thiamine).
- Beriberi has conventionally been divided into three separate
entities, dry, wet and infantile.
- Wet beriberi is the type that affect the heart.

4) Malabsorption
Wet Beriberi
- Wet beriberi affects the heart and circulatory system. It is
sometimes fatal, as it causes a combination of heart failure and
weakening of the capillary walls, which causes the peripheral
tissues to become edematous.
- Wet beriberi is characterized by:
• Increased heart rate.
• Vasodilation leading to decreased systemic vascular resistance, and
high output heart failure.

4) Malabsorption
Wet Beriberi
• Elevated jugular venous pressure.
• Dyspnea on exertion.
• Paroxysmal nocturnal dyspnea.
• Peripheral oedema.

4) Malabsorption
b) Pellagra
- Pellagra is a vitamin deficiency disease most frequently
caused by a chronic lack of niacin (vitamin B3).
- Pellagra is classically described by "the three Ds": diarrhea,
dermatitis, dementia. Symptoms includes:
• Photosensitivity, aggression, dermatitis, alopecia, oedema, glossitis,
red skin lesions, insomnia, weakness, mental confusion, ataxia,
paralysis of extremities, peripheral neuritis, diarrhea, dilated
cardiomyopathy, dementia.

4) Malabsorption
c) Anaemic heart failure.
d) Hypokalemia, leads to prominent U wave, bradycardia,
cardiac arrest.

5) Carcinoid syndrome
- Occurs in approximately 5% of carcinoid tumors.
- It is caused by endogenous secretion of mainly serotonin and
kallikrein.
- Carcinoid syndrome generally does not occur until the
disease is so advanced that it overwhelms the liver's ability to
metabolize the released serotonin.

- It is characterized by:
• Flushing.
• Diarrhea, nausea, and vomiting.
• Bronchoconstriction.
• Secondary restrictive cardiomyopathy. Occurs in about 50%
of patients, caused by serotonin induced fibrosis of the
valvular endocardium, notably the tricuspid and pulmonary
valves. It ends with heart failure.

6) Inflammatory bowel disease (IBD)
- Pericarditis with or without an effusion have been described in
patients with active IBD.
- Cardiac arrhythmias are observed in patients with IBD more
commonly ulcerative colitis than chron’s disease. There are
several case reports of patients presented by collapse due to
arrhythmias or complete heart block.

7) GIT drugs
1) Proton pump inhibitors competitively inhibit the cytochrome
P450 2C19 isoenzyme (CYP2C19). Omeprazole and
esomeprazole are the most potent CYP2C19 inhibitors.
Clopidogrel is a CYP2C19 substrate and needs to be activated
by this isoenzyme. When given concurrently with proton pump
inhibitors, there is a reduction in the produced active form of
clopidogrel and greater platelet reactivity.

7) GIT drugs
2) Cisapride is a prokinetic drug that cause QT prolongation,
resulting in fatal cardiac arrhythmia.
3) IV erythromycin stimulates motilin receptors and can be
used as a prokinetic agent. It cause QT prolongation and
arrhythmogenic risk as well.
4) The 5HT3 antagonists (dolasetron, granisetron,
ondansetron, etc) and the histamine 2 receptor antagonists
(cimetidine, ranitidine) can cause bradycardia or heart block
when used in excessive doses or in intravenous forms.

7) GIT drugs
5) Metoclopramide can profoundly elevate blood pressure in
patients with pheochromocytoma. In addition, it has been
shown to modestly attenuate the antihypertensive effects of
bromocriptine and labetolol.

Diseases that affect
both heart and GIT

Diseases that affect both heart and GIT
A) Atherosclerosis, systemic vasculitis, hypercoagulable states,
thromboembolism
- Effect on GIT:
- They are risk factors for mesenteric and colonic ischaemia.
- Effect on heart:
- They are risk factors for IHD and ACS.

B) Parasitic diseases
1) Trichinella spiralis
- Effect on GIT:
- This occurs during the initial intestinal phase, that occurs
within days after infection. There is mild symptoms in the form
of diarrhoea, abdominal pain and vomiting.
- Effect on heart:
- T. spiralis can lead to myocarditis that may result in
myocardial damage, heart failure, or arrhythmias.

2) Heterophys heterophys
- Effect on GIT:
- Presence of the worm in the intestine can lead to abdominal
colic, diarrhoea, bloody stool.
- Effect on heart:
- Egg emboli can lead to myocarditis, cardiomyopathy and
heart failure.

3) Schistosomiasis
- Effect on GIT:
- Abdominal pain, bilharzial dysentery, prolapse of anal mucosa
due to tenesmus, anal fistula and fissure.
- Effect on heart:
- Bilharzial pulmonary hypertension, cor pulmonale, pulmonary
aneurysm. Bilharzial ova can cause military foci of fibrosis in
the myocardium.

4) Taenia solium
- Effect on GIT:
- Presence of the worm in the intestine can lead to abdominal
discomfort, nausea, anorexia.
- Effect on heart:
- Cardiac cysticercosis is a rare and typically asymptomatic
infection. However, there is a few case reports about
conduction defects and arrhythmias.

5) Trypanosoma cruzi (Chagas’ disease)
- Effect on GIT:
- Affection of the esophagus leads to megaesophagus with
symptoms similar to those of achalasia.
- Affection of the colon leads to megacolon intermittent
abdominal pain and chronic constipation.

5) Trypanosoma cruzi (Chagas’ disease)
- Effect on heart:
- During acute stage of the disease severe myocarditis may
occur leading to congestive heart failure.
- During chronic stage there is arrhythmias, cardiomyopathy,
heart failure.

6) Entamoeba histolytica
- Effect on GIT:
- Acute amoebic dysentery.
- Chronic amoebiasis with dyspepsia, abdominal distention,
bulky offensive stool.

6) Entamoeba histolytica
- Effect on heart:
- Amoebic pericarditis.
- Emetine side effects in the form of myocarditis, pericardial
pain and ECG changes.

7) Sarcocystis spp.
- Effect on GIT:
- Often asymptomatic; nausea, vomiting, abdominal pain, and
diarrhea may occur, eosinophilic necrotizing enteritis has been
reported.
- Effect on heart:
- Cardiac involvement is very rare, usually asymptomatic.
However, conduction abnormalities have been reported.

8) Malaria
- Effect on GIT:
- Persistent vomiting, epigastric pain, diarrhoea may develop
early.
- Algid malaria, characterized by watery diarrhoea (cholera like)
or dysentery symptoms.

8) Malaria
- Effect on heart:
- Early in the disease, chest pain, palpitation, rarely heart
failure.
- Microthrombosis of coronaries and occlusion by the parasite.
- Myocardial lesions may occur due to interstitial infiltrates and
haemorrhages.

9) Visceral leishmaniasis (Kala azar)
- Effect on GIT:
- Diarrhoea or dysentery due to intestinal ulcers.
- Effect on heart:
- Myocarditis and suppurative pericarditis.

10) Balantidium coli
- Effect on GIT:
- Chronic dysentery.
- Effect on heart:
- Myocarditis, cardiac dilatation and pericardial effusion.

C) Bacterial diseases
1) Brucellosis
- Effect on GIT:
- During acute disease, there is may be abdominal pain,
diarrhoea, constipation, vomiting.
- Effect on heart:
- Bacterial endocarditis affecting mainly aortic valve.

2) Abdominal TB
- Effect on GIT:
- Abdominal pain, episodes of diarrhoea and constipation,
malabsorption, intestinal obstruction.
- Effect on heart:
- TB pericarditis.

3) Typhoid fever
- Effect on GIT:
- Abdominal pain, distension, diarrhoea, constipation, anorexia,
nausea, vomiting, GIT bleeding, perforation.
- Effect on heart:
- Toxic myocarditis.

4) Q fever
- Effect on GIT:
- Non specific symptoms; Abdominal pain, anorexia, nausea,
vomiting.
- Effect on heart:
- During acute disease, there is may be myocarditis and
pericarditis.

4) Q fever
- In chronic disease, there is may be:
• Q fever endocarditis with progressive degradation of valve function
and progressive heart failure.
• Vascular aneurysms.
• Chronic pericarditis

5) Whipple Disease
- The disease is caused by actinobacter Tropheryma whipplei.
- Effect on GIT:
- Intestinal malabsorption.
- Effect on heart:
- Endocarditis, pericarditis.

6) Listeriosis
- Effect on GIT:
- Self limited febrile gastroenteritis in healthy persons.
- Effect on heart:
- Endocarditis in immunosuppressed.

7) Helicobacter pylori
- Effect on GIT:
- Peptic ulcer disease.
- Adenocarcinoma and MALT lymphoma.
- Effect on heart:
- There is an association between H. pylori infection and
coronary artery disease.

7) Helicobacter pylori
- The possible mechanisms include persistent local or systemic
inflammation and initiating autoimmune responses (vasculitis).

8) Campylobacter jejuni
- Effect on GIT:
- Abdominal pain, watery or bloody diarrhoea, vomiting.
- Effect on heart:
- Rarely endocarditis.

D) Fungal diseases
1) Candidiasis
- Effect on GIT:
- Oropharyngeal Candidiasis, esophagitis.
- Effect on heart:
- Endocarditis, usually fatal complication of candidemia.

D) Fungal diseases
2) Aspergillosis
- Effect on GIT:
- Esophageal and intestinal ulcers, mesenteric thrombosis with
GIT bleeding.
- Effect on heart:
- Endocarditis.

E) Hyperesinophilic syndrome
- Characterized by sustained eosinophilia for at least 6 months,
organ dysfunction and exclusion of other aetiologies.
- Effect on GIT:
- Dysphagia, nausea, vomiting, abdominal pain, diarrhoea,
malabsorption.
- Effect on heart:
- Thromboembolism, tricuspid regurge, mitral regurge, heart
failure.

F) Non-Hodgkin’s lymphoma (NHL)
- NHL can involve any organ in the body.
- Effect on GIT:
- Depends on its location:
• Esophageal lymphoma: dysphagia, odynophagia.
• Gastric lymphoma: dyspepsia, nausea, vomiting, rarely mass.
• Small intestinal lymphoma: malabsorption, diarrhoea.
• Colorectal lymphoma: abdominal pain, bleeding per rectum, mass.

F) Non-Hodgkin’s lymphoma (NHL)
- Effect on heart:
- Cardiac lymphoma is very rare.
- May be presented by; arrhythmias, valve incompetence, heart
failure, pericardial effusion.

G) Leukaemia
- Leukaemia can infiltrate any organ.
- Effect on GIT:
- Depends on its location.
- Effect on heart:
- Arrhythmia, cardiomyopathy, heart failure, pericarditis.

H) Inherited syndromes
1) Down’s syndrome (Triosomy 21)
- It is a genetic disorder caused by the presence of all or part of
a third copy of chromosome 21.
- Effect on GIT:
- Constipation occurs in nearly 50% (2-15% due to
Hirschsprung's disease).
- Other frequent congenital problems include duodenal atresia,
pyloric stenosis, Meckel diverticulum, and imperforate anus.

1) Down syndrome (Triosomy 21)
- Celiac disease affects about 7–20% and GERD is also more
common.
- Effect on heart:
- The rate of congenital heart disease is around 40%.
- ASD, VSD, mitral valve problems, tetralogy of Fallot and PDA.

2) Edward’s syndrome (Triosomy 18)
- It is a chromosomal abnormality caused by the presence of
all, or part of, an extra 18th chromosome.
- Effect on GIT:
- Omphalocele, esophageal atresia.
- Effect on heart:
- ASD, VSD, PDA.

3) Heyde's syndrome
- It is a syndrome of aortic valve stenosis associated with
gastrointestinal bleeding from colonic angiodysplasia.

4) Noonan syndrome
- It is a relatively common autosomal dominant congenital
disorder that affects both males and females. It is referred to as
the male version of Turner's syndrome.
- Effect on GIT:
- Dysphagia, anorexia, vomiting, intestinal malrotation,
gastroparesis.

4) Noonan syndrome
- Effect on heart:
- ASD, VSD, pulmonary stenosis, hypertrophic cardiomyopathy.

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