Glycopyrolate-Induced Esophageal Dysmotility Leading to Food Impaction

Abstract

Introduction: Glycopyrrolate is a synthetic anticholinergic agent. It is used pre-operatively for reduction of secretions, intraoperatively for reversal of bradycardia/vagal reflexes, and for reversal of muscarinic effects of cholinergic agents. Glycopyrrolate is used by anesthesiologist during endoscopic procedures to combat bradycardia as an alternative medication to atropine as it is twice as potent in increasing heart rate, and has less central nervous system side effects due to poor passage through the Blood Brain Barrier. However, as with any anticholinergic medication, Glycopyrrolate also causes decrease motility of smooth muscles. Case report: 82 years old man with multiple comorbidities, underwent EGD for evaluation of melena. He was found to have gastric and duodenal ulcers. During the procedure, 0.4mg of Glycopyrrolate was administered intravenously for reversal of bradycardia. After the procedure patient went home and had dinner. The next day, he could not tolerate oral intake. He would get nauseous and vomit after eating. He also felt the food is stuck and would not go down. CT scan showed air-fluid level in the esophagus suggestive of food impaction. Urgent EGD showed extensive food impaction at 25cm from the incisors to the GE junction which was gently moved into the stomach. Esophagus was noted to be significantly distended with no contraction or peristalsis during food disimpaction. Discussion: Glycopyrrolate is an efficacious medication but it has some known side effects. The reported gastrointestinal side effects include vomiting, xerostomia, constipation, abdominal distention, pain, flatulence, retching, intestinal obstruction, loss of taste, nausea, and pseudo-obstruction. Slowing of GI muscular action is what leads to dysmotility. IV doses of 0.2 - 0.3mg significantly affect esophagus within 3 min, and this effect is similar to that seen with atropine 0.6mg IV; however, the effect seen with atropine only persists for 40 minutes. Glycopyrrolate is longer acting, and larger dose has more side effects. Based on animal studies, the side effects of glycopyrrolate are dose-dependent. In our patient the esophageal relaxation and lack of peristalsis is what led to food impaction. There have been case reports of Glycopyrrolate causing intestinal dysmotility in animals as well. Glycopyrrolate should be used cautiously in geriatric population at lower doses as the elderly are more prone to the anticholinergic side effects.1780_A Figure 1. Food impaction in the Esophagus1780_B Figure 2. Esophagus after clearing of the food impaction.