Endoscopic Retrograde Cholangiopancreatography after Recent Myocardial Infarction

Abstract

Purpose: There is little data on the safety and outcome of endoscopic retrograde cholangiopancreatography (ERCP) in patients with recent myocardial infarction (MI). Methods: Review of all 4,200 cases undergoing ERCP at the 3 William Beaumont Hospitals during the past 10 years revealed 2 cases of ERCP performed within 7 days after MI. Results: Case 1: An 87-year-old female status post cholecystectomy and recurrent choledocholithiasis presented with angina and dyspnea. The patient had peak CK of 394 ng/ml and MB fraction of 13.7 ng/ml. The EKG showed new lateral Twave inversions. The patient was treated with nitrates, heparin, metoprolol, and aspirin with resolution of symptoms. Two days later she developed severe epigastric pain, like the pain she had previously experienced from choledocholithiasis. The patient had elevated alkaline phosphatase (AP) of 144 u/1, with normal AST, ALT, bilirubin, and lipase. ERCP with balloon pull-through, performed 3 days after MI, revealed a patent prior sphincterotomy, dilated (2 cm wide) distal common bile duct, no stones, and no other abnormalities. Midazolam and morphine were used for sedation. Vital signs remained stable during the ERCP and arterial oxygen saturation was above 95%. Continuous electrocardiography revealed no new cardiac ischemia, arrhythmias or other abnormalities. After ERCP the abdominal pain resolved and the AP level normalized. She was discharged 1 day later and remained asymptomatic during the following month. Case 2: A 75-year-old female was evaluated for angina occurring during elective coronary angioplasty complicated by dissection of the proximal LAD artery. The patient developed elevated cardiac enzymes (maximal CK-MB 17.7 ng/ml, CK index 13.5%, troponin 0.38 ng/ml). EKG showed flattened T waves in anterior and lateral leads, with subsequent Q-wave development in lateral leads. She was treated with a beta-blocker, nitrate, and heparin for non-ST segment elevation MI with clinical improvement. Two days after the MI she developed right upper quadrant abdominal pain and nausea, associated with elevated liver enzymes (peak AP 514 u/l, AST 572 u/l, ALT 350 u/l, and total bilirubin 2.2 mg/dl). Serologic tests revealed no acute viral hepatitis. ERCP performed with conscious sedation on day 4 post MI revealed a normal biliary tract with no filling defects. No sphincterotomy was performed. Vital signs and arterial oxygen saturation remained normal. It was thought that biliary microlithiasis had caused the biliary symptoms. The patient improved clinically and the liver function tests nearly normalized, allowing for discharge 2 days later. Conclusion: These 2 cases illustrate that ERCP can be performed very soon after MI when strongly indicated.