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The Significance of Gastro-Intestinal Tract Abnormalities as Related to the Management of Cardiac Disorders *
THE SIGNIFICANCE OF GASTRO-INTESTINAL TRACT ABNORMALITIES AS RELATED TO THE MANAGEMENT OF CARDIAC DISORDERS" CLARENCE F. G. BROWN. M.D •• t and RALPH E. DOLKART. M.D.:\: PRIOR to Herrick's recognition of coronary occlusion as a disease entity, and prior to the availability of the electrocardiogram as an adjunct in diagnosis, "acute indigestion" was an acceptable cause of death. Although we now use the term coronary occlusion, the tendency for occurrence following overeating is still an accepted phenomenon. In recent years an everincreasing emphasis is being placed upon the interrelationship between reflex phenomena involving the cardiovascular and gastro-intestinal systems.
CHRONIC GALLBLADDER DISEASE
Willius and Fitzpatrick1 almost twenty years ago reported that 39 per cent of patients with chronic gallbladder disease had associated changes of the cardiovascular system, coronary artery sclerosis being the most common in occurrence. More recently Ravdin and his co-workers have attached considerable importance to these concomitantly occurring disease entities and recommend cholecystectomy in patients who have symptoms of angina and in whom pathologic gallbladders can be demonstrated. Although Maisel and Alvarez2 report that there is no proof that biliary tract disease has any direct influence in the production of heart disease, in our opinion the clinical problem does not revolve around the presence or absence of such a relationship. Rather, if the presence of gallbladder disease acts as a reflex trigger mechanism through which the frequency of anginal attacks is increased, then removal of· the associated ab~ From the Medical Departments of Northwestern University Medical School and St. Luke's Hospital. t Assistant Professor of Medicine, Northwestern University Medical School; Senior Attending Physician, St. Luke's Hospital. :\: Instructor in Medicine, Northwestern University Medical School; Assistant Attending Physician, St. Luke's Hospital. 107
108
CLARENCE F. G. BROWN, RALPH E. DOLKART
nonnality, the gallbladder, is a constructive step in therapy. Studies by W oollard, Ankep and Stacey, M ann, Wiggers, and others would seem to indicate that the coronary arteries are dilated by sympathetic impulses of adrenalin, and constricted by the vagus. 3 It is probably through mediation with such reflex connections that gallbladder abnormalities alter the course of individuals with coronary artery disease. From a clinical point of view, careful study and search for gallbladder disease should be made in the case of individuals who manifest food intolerances, have associated stomach or bowel distress as indicated by gaseous distention after meals, or upper right quadrant distress, together with evidence of coronary artery disease. Not uncommonly, there may be variations from the usual sites of pain radiation or pain reference of both cardiac and gallbladder origin. Surgical removal of the gallbladder in properly selected risks is definitely indicated not only in our own experience but in the cumulative case reports in the literature. Individuals who are not proper surgical risks should be managed with care and caution with a view toward minimizing the reflex stimuli arising from the gallbladder. These principles we have previously discussed. 4 • 5 Briefly they entail consistent use of antispasmodic drugs, preferably tincture of belladonna or atropine up to the point of atropinization consistent with the patient's welfare and comfort; dietary control, use of a frequentfeeding bland diet, of low-caloric content with an obese patient. avoidance of cooked fats but use of uncooked fats within limits of fat tolerance as discussed by Ivy; use of oxidized bile salts, again dependent upon the patient's tolerance. Frequent feedings may still be achieved in obese patients through the use of gelatin feedings between meals instead of foods with higher caloric content. HIATUS HERNIA
Hiatus hernia is a second category in which there is considerable interrelationship between the cardiac and gastro-intestinal systems. Not infrequently substernal pain radiating to the shoulder may be a presenting symptom of hiatus hernia which is commonly misinterpreted as of coronary artery origin. Exertional dyspnea may be present but may result from reduction of vital . capacity due to the presence of a large amount of the stomach in the chest. Other cardiac symptoms may be the result of rota-
GASTRO-INTESTINAL ABNORMALITIES AND THE HEART
109
tion or displacement of the heart or from increased intra-abdominal pressure from below. The foregoing indicate the mechanical aspects of hiatus hernia which may mimic heart disease. Both conditions may occur together and in such instances there is no doubt a reflex trigger mechanism as in gallbladder disease which accentuates the frequency or degree of coronary artery spasm. Treatment of hiatus hernia is largely in either of two categories-surgical repair or palliative. Small frequent feedings, careful observance of an upright posture during and considerably after the ingestion of food, and use of antispasmodics. It is interesting to note that more frequently symptoms from a hiatus hernia develop in later life. The age incidence of the group reported by Murphy and Hoy6 was in the third decade of life or beyond. It is our impression that the occurrence of symptoms in later years even though the abnormality probably existed for a considerable period of years, if not at birth, may be explained by reduction in threshold levels for visceral stimuli or because of increased changes in the blood vessels themselves. I
IRRITABLE BOWEL SYNDROME.
Irritable bowel syndrome or nervous indigestion is by far one of the commonest gastro-intestinal tract abnormalities. It is our opinion that almost any intra-abdominal viscus may initiate reflexes which may affect the coronary circulation, heart rate or rhythm. It is well established that actual torsion or simple tension from any cause which twists or pulls a viscus sets up visceral reflexes which affect the entire circulatory system. In searching for causes of coronary embarrassment, the abdominal organs classed as the hollow visci are the more frequent offenders. Emptying an over-full urinary bladder many times relieves a dull precordial di~omfort. In a spastic bowel, relief of chest pain is often achieved by a redistribution of the gases or by a bowel movement with free expulsion of gas and resultant lowering of the intraluminal pressure thresholds. All of these phenomena are increased by the presence of organic changes in the wall of the intestine. In diverticulosis increased production of reflex stimulation may result when there is mechanical embarrassment in one or more of the diverticula which is further increased when an actual diverticulitis is present with actual inflammation and concomitant colon spasm wherever it occurs.
110
CLARENCE F. G. BROWN, RALPH E. DOLKART
Gilbert, Fenn, and LeRoy7 as well as others have demonstrated definite vasoconstriction of the coronary arteries upon distention of an inflated balloon in the stomach. Distention of the free abdominal cavity with air also caused constriction of the coronary arteries, which did not occur if the vagi had been cut or if atropine had been administered. They believe the latter phenomenon is an explanation of the relief of an anginal attack occurring in a patient whose abdomen is distended with gas, by the passage of flatus or belching. It is equally interesting to correlate the high incidence of all types of sudden vascular accidents with either the desire to defecate or during or immediately after the bowel movement. This formerly was considered to be "straining at stool," but as many occur with just the urge to defecate and happen while the patient is on his way to the toilet. In this connection one of us has recently seen a patient hospitalized for a cataract extraction who had a coronary occlusion on his tenth postoperative day following the administration of a large saline purgative. Pos"" sibly with any radical change of intraluminal pressure thresholds of the hollow visci there is a general vascular repercussion and readjustment which brings out defects in the coronary arteries or any portion of the cardiovascular system. Careful observance of physiologic principles of bowel management obviously is indicated. It cannot be stressed too strongly that functional disorders should be evaluated and treated inasmuch as they predominate in bringing out the early pathologic manifestations via the route of visceral reflexes. RAPID
ENLARG~MENT
OF LIVER WITH RIGHT HEART FAILURE
The last entity we should like to consider is one we have previously mentioned8 and which Boyer and White 9 have recently discussed, namely rapid enlargement of the liver ass(}ciated with right heart failure. This is well borne out in individuals with a marked kyphoscoliosis with heart failure due to chest deformity and reduction in vital capacity. Right heart failure occurs in the great majority of these individuals, and right upper quadrant pain is one of the earliest symptoms. Apparently enlargement of the liver with distention of Glisson's capsule produces a sensation of fullness and pressure in the abdomen and frequently with severe and intense right upper quad-
GASTRO-INTESTINAL ABNORMALITIES AND THE HEART
111
rant pain. Kuntz believes that pulling down on the attachment to the diaphragm is also an important mechanism. SUMMARY
The interrelationship of reflex phenomena between the abdominal viscera and the cardiovascular system have been indicated. Therapeutic efforts must be directed toward physiologic control of the gastro-intestinal as well as the cardiovascular systems. BIBLIOGRAPHY
1. Willius, F., A. and Fitzpatrick, J.: 2. Maisel, J. J. and Alvarez, \V. 23:12, 1933.
J.
c.:
Iowa M. Soc., 15:589 (Nov.) 1925. Proc. Med. Sec. Am. Life Convention,
3. Best, C. H. and Taylor, N. B.: Physiological Basis of Medical Practice, Baltimore, \Villiams & Wilkins, 1939, p. 456. 4. Brown, C. F. G. and Dolkart, R. E.: Treatment of Biliary Dyskinesia. MED. CLIN. N. AM., 23:63-74, 1939. 5. Brown, C. F. G., Dolkart, R. E. and Mock, H. E.: The Conservative Treatment of Gallbladder Disease. Stirg., Gynec. & Obst., 66:79-87, 1933. 6. Murphy, W. P. and Hoy, W. c.: Symptoms and Incidence of Anemia in Hernia at the Esophageal Hiatus. Arch. Int. Med., 72:58, 1943. 7. Gilbert, N. c.: Factors Influencing Coronary Flow. Quart. Bull. Northwestern Univ. Med. School, 16:179-190, 1942. 8. Brown, C. F. G. and Dolkart, R. E.: Abdominal Pain: Its Significance to the Clinician. MED. CLIN. N. AM., 25.:15-33 (Jan.) 1941. 9. Boyer, N. H. and White, P. D.: Right Upper Quadrant Pain on Effort: An Early Symptom of Failure of the Right Ventricle. New England J. Med., 226:217, 1942.
CHRONIC GALLBLADDER DISEASE
Willius and Fitzpatrick1 almost twenty years ago reported that 39 per cent of patients with chronic gallbladder disease had associated changes of the cardiovascular system, coronary artery sclerosis being the most common in occurrence. More recently Ravdin and his co-workers have attached considerable importance to these concomitantly occurring disease entities and recommend cholecystectomy in patients who have symptoms of angina and in whom pathologic gallbladders can be demonstrated. Although Maisel and Alvarez2 report that there is no proof that biliary tract disease has any direct influence in the production of heart disease, in our opinion the clinical problem does not revolve around the presence or absence of such a relationship. Rather, if the presence of gallbladder disease acts as a reflex trigger mechanism through which the frequency of anginal attacks is increased, then removal of· the associated ab~ From the Medical Departments of Northwestern University Medical School and St. Luke's Hospital. t Assistant Professor of Medicine, Northwestern University Medical School; Senior Attending Physician, St. Luke's Hospital. :\: Instructor in Medicine, Northwestern University Medical School; Assistant Attending Physician, St. Luke's Hospital. 107
108
CLARENCE F. G. BROWN, RALPH E. DOLKART
nonnality, the gallbladder, is a constructive step in therapy. Studies by W oollard, Ankep and Stacey, M ann, Wiggers, and others would seem to indicate that the coronary arteries are dilated by sympathetic impulses of adrenalin, and constricted by the vagus. 3 It is probably through mediation with such reflex connections that gallbladder abnormalities alter the course of individuals with coronary artery disease. From a clinical point of view, careful study and search for gallbladder disease should be made in the case of individuals who manifest food intolerances, have associated stomach or bowel distress as indicated by gaseous distention after meals, or upper right quadrant distress, together with evidence of coronary artery disease. Not uncommonly, there may be variations from the usual sites of pain radiation or pain reference of both cardiac and gallbladder origin. Surgical removal of the gallbladder in properly selected risks is definitely indicated not only in our own experience but in the cumulative case reports in the literature. Individuals who are not proper surgical risks should be managed with care and caution with a view toward minimizing the reflex stimuli arising from the gallbladder. These principles we have previously discussed. 4 • 5 Briefly they entail consistent use of antispasmodic drugs, preferably tincture of belladonna or atropine up to the point of atropinization consistent with the patient's welfare and comfort; dietary control, use of a frequentfeeding bland diet, of low-caloric content with an obese patient. avoidance of cooked fats but use of uncooked fats within limits of fat tolerance as discussed by Ivy; use of oxidized bile salts, again dependent upon the patient's tolerance. Frequent feedings may still be achieved in obese patients through the use of gelatin feedings between meals instead of foods with higher caloric content. HIATUS HERNIA
Hiatus hernia is a second category in which there is considerable interrelationship between the cardiac and gastro-intestinal systems. Not infrequently substernal pain radiating to the shoulder may be a presenting symptom of hiatus hernia which is commonly misinterpreted as of coronary artery origin. Exertional dyspnea may be present but may result from reduction of vital . capacity due to the presence of a large amount of the stomach in the chest. Other cardiac symptoms may be the result of rota-
GASTRO-INTESTINAL ABNORMALITIES AND THE HEART
109
tion or displacement of the heart or from increased intra-abdominal pressure from below. The foregoing indicate the mechanical aspects of hiatus hernia which may mimic heart disease. Both conditions may occur together and in such instances there is no doubt a reflex trigger mechanism as in gallbladder disease which accentuates the frequency or degree of coronary artery spasm. Treatment of hiatus hernia is largely in either of two categories-surgical repair or palliative. Small frequent feedings, careful observance of an upright posture during and considerably after the ingestion of food, and use of antispasmodics. It is interesting to note that more frequently symptoms from a hiatus hernia develop in later life. The age incidence of the group reported by Murphy and Hoy6 was in the third decade of life or beyond. It is our impression that the occurrence of symptoms in later years even though the abnormality probably existed for a considerable period of years, if not at birth, may be explained by reduction in threshold levels for visceral stimuli or because of increased changes in the blood vessels themselves. I
IRRITABLE BOWEL SYNDROME.
Irritable bowel syndrome or nervous indigestion is by far one of the commonest gastro-intestinal tract abnormalities. It is our opinion that almost any intra-abdominal viscus may initiate reflexes which may affect the coronary circulation, heart rate or rhythm. It is well established that actual torsion or simple tension from any cause which twists or pulls a viscus sets up visceral reflexes which affect the entire circulatory system. In searching for causes of coronary embarrassment, the abdominal organs classed as the hollow visci are the more frequent offenders. Emptying an over-full urinary bladder many times relieves a dull precordial di~omfort. In a spastic bowel, relief of chest pain is often achieved by a redistribution of the gases or by a bowel movement with free expulsion of gas and resultant lowering of the intraluminal pressure thresholds. All of these phenomena are increased by the presence of organic changes in the wall of the intestine. In diverticulosis increased production of reflex stimulation may result when there is mechanical embarrassment in one or more of the diverticula which is further increased when an actual diverticulitis is present with actual inflammation and concomitant colon spasm wherever it occurs.
110
CLARENCE F. G. BROWN, RALPH E. DOLKART
Gilbert, Fenn, and LeRoy7 as well as others have demonstrated definite vasoconstriction of the coronary arteries upon distention of an inflated balloon in the stomach. Distention of the free abdominal cavity with air also caused constriction of the coronary arteries, which did not occur if the vagi had been cut or if atropine had been administered. They believe the latter phenomenon is an explanation of the relief of an anginal attack occurring in a patient whose abdomen is distended with gas, by the passage of flatus or belching. It is equally interesting to correlate the high incidence of all types of sudden vascular accidents with either the desire to defecate or during or immediately after the bowel movement. This formerly was considered to be "straining at stool," but as many occur with just the urge to defecate and happen while the patient is on his way to the toilet. In this connection one of us has recently seen a patient hospitalized for a cataract extraction who had a coronary occlusion on his tenth postoperative day following the administration of a large saline purgative. Pos"" sibly with any radical change of intraluminal pressure thresholds of the hollow visci there is a general vascular repercussion and readjustment which brings out defects in the coronary arteries or any portion of the cardiovascular system. Careful observance of physiologic principles of bowel management obviously is indicated. It cannot be stressed too strongly that functional disorders should be evaluated and treated inasmuch as they predominate in bringing out the early pathologic manifestations via the route of visceral reflexes. RAPID
ENLARG~MENT
OF LIVER WITH RIGHT HEART FAILURE
The last entity we should like to consider is one we have previously mentioned8 and which Boyer and White 9 have recently discussed, namely rapid enlargement of the liver ass(}ciated with right heart failure. This is well borne out in individuals with a marked kyphoscoliosis with heart failure due to chest deformity and reduction in vital capacity. Right heart failure occurs in the great majority of these individuals, and right upper quadrant pain is one of the earliest symptoms. Apparently enlargement of the liver with distention of Glisson's capsule produces a sensation of fullness and pressure in the abdomen and frequently with severe and intense right upper quad-
GASTRO-INTESTINAL ABNORMALITIES AND THE HEART
111
rant pain. Kuntz believes that pulling down on the attachment to the diaphragm is also an important mechanism. SUMMARY
The interrelationship of reflex phenomena between the abdominal viscera and the cardiovascular system have been indicated. Therapeutic efforts must be directed toward physiologic control of the gastro-intestinal as well as the cardiovascular systems. BIBLIOGRAPHY
1. Willius, F., A. and Fitzpatrick, J.: 2. Maisel, J. J. and Alvarez, \V. 23:12, 1933.
J.
c.:
Iowa M. Soc., 15:589 (Nov.) 1925. Proc. Med. Sec. Am. Life Convention,
3. Best, C. H. and Taylor, N. B.: Physiological Basis of Medical Practice, Baltimore, \Villiams & Wilkins, 1939, p. 456. 4. Brown, C. F. G. and Dolkart, R. E.: Treatment of Biliary Dyskinesia. MED. CLIN. N. AM., 23:63-74, 1939. 5. Brown, C. F. G., Dolkart, R. E. and Mock, H. E.: The Conservative Treatment of Gallbladder Disease. Stirg., Gynec. & Obst., 66:79-87, 1933. 6. Murphy, W. P. and Hoy, W. c.: Symptoms and Incidence of Anemia in Hernia at the Esophageal Hiatus. Arch. Int. Med., 72:58, 1943. 7. Gilbert, N. c.: Factors Influencing Coronary Flow. Quart. Bull. Northwestern Univ. Med. School, 16:179-190, 1942. 8. Brown, C. F. G. and Dolkart, R. E.: Abdominal Pain: Its Significance to the Clinician. MED. CLIN. N. AM., 25.:15-33 (Jan.) 1941. 9. Boyer, N. H. and White, P. D.: Right Upper Quadrant Pain on Effort: An Early Symptom of Failure of the Right Ventricle. New England J. Med., 226:217, 1942.