Upper Gastrointestinal Mucosal Changes in Patients with Congestive Heart Failure

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1 Med. J. Cairo Univ., Vol. 81, No. 1, December: , Upper Gastrointestinal Mucosal Changes in Patients with Congestive Heart Failure ZAIN E.A. SAYED, M.D. 1 ; MOHAMMAD ABDEL-GHANY, M.D. 2 ; LOBNA ABDEL-WAHID, M.D. 1 ELHAM A. HASSAN, M.D. 3 and KHALED M. ATTALLAH, M.D. 4 The Departments of Internal Medicine 1, Cardiology 2, Tropical Medicine 3, Assiut University and Tropical Medicine & Gastroenterology 4, National Liver Institute, Menoufia University, Egypt Abstract Introduction: Congestive heart failure increases systemic venous pressure which is transmitted to the inferior vena cava and the hepatic veins, this may induce gastro-intestinal changes. This research aimed to study gastro-intestinal tract changes in patients with congestive heart failure. Aims and Methods: 120 patients with congestive heart failure (CHF) presenting with gastro-intestinal symptoms underwent upper endoscopy. All patients underwent echocardiography to determine the ejection fraction and the degree of tricuspid regurgitation and pulmonary hypertension. Abdominal ultrasound was done to measure the diameters of the hepatic veins, the inferior vena cava, and the portal vein for which pulsatility index was assessed. Results: Gastric mucosal changes were present in 106 (88.4%), duodenal mucosal changes in 71 (59.2%), and esophageal mucosal changes in 3 (2.5%) patients. Gastric mucosal changes were the following: Mosaic-like pattern (n=92,76.7%), punctate spots (n=73,60%), thickened folds (n=20,16.7%), watermelon stomach (n=8,6.7%), and telangiectasia (n=35, 29.2%). Duodenal mucosal changes were the following: Mosaic-like pattern (n=58,48.4%), thickened folds (n=17,14.2%), and telangiectasia (n=7,5.9%). Gastrointestinal symptoms were significantly associated with gastropathy and duodenopathy (p<0.001). There was a positive correlation between the degree of gastro-intestinal symptoms and gastropathy and duodenopathy (Gamma=0.6, p=0.03 and 0.5, p=0.04 respectively). Patients with gastropathy and duodenopathy had higher mean inferior vena cava (IVC) and hepatic vein diameters than those without gastropathy and duodenopathy. Low EF was associated with increased portal vein, IVC and hepatic vein diameters, (p=0.02, 0.008, 0.002) respectively. Moreover it was associated with gastro-intestinal symptoms, gastropathy and duodenopathy (p<0.001). There was a positive correlation between the ejection fraction and severity of gastrointestinal symptoms (r=0.6, p<0.001). Tricuspid regurgitation was associated with gastro-intestinal symptoms, stomach gastropathy, diameter of hepatic vein and IVC ( p=0.007, 0.019, <0.001, <0.001). Mean pulsatility index in patients in the present study was 0.7 ±0.53 and there was positive corre- Correspondence to: Dr. Zain E.A. Sayed, The Department of Internal Medicine, Assiut University lation between pulsatility index and Pulmonary Artery Systolic Pressure (PASP) (r=0.61, p=0.02). Patients with low ejection fraction have a higher pulsatility index than patients with higher ejection fraction (0.7 ±0.67, 0.6±0.18, p=0.26). Conclusion: CHF is associated with gastro -intestinal changes which are significantly associated with the severity of congestive heart failure. Key Words: Congestive heart failure Duodenopathy Gastropathy Pulsatility index. Introduction CONGESTIVE changes in the gastric mucosa were first described by McCormack et al., in patients with portal hypertension (portal hypertensive or congestive gastropathy) [1]. Similar congestive mucosal changes also have been described in the duodenum, jejunum and colon [2]. Chronic heart failure (CHF) is a multi-organ disease with increasing evidence for the involvement of the gastrointestinal (GI) system in this syndrome. In CHF, the increased systemic venous congestion is readily transmitted to the inferior vena cava (IVC) and the hepatic veins (HV) and hepatic sinusoids [3]. Increased sinusoidal pressure, leads to an increase in the resistance to blood flow in the portal vein (PV) and hereby to congestion in its draining territories this leads to congestion of GIT mucosa with several structural changes [4]. The aim of this study to define gastro-intestinal tract changes in patients with CHF, assessed with upper endoscopy and abdominal ultrasound. Patients and Methods This was a cross-sectional prospective study of patients with CHF that were selected from Assiut University Hospitals based Gastroenterology and Cardiology departments during a period from March 2012 to March The study was ap- 1009

2 1010 Upper Gastrointestinal Mucosal Changes in Patients proved by the regional Ethical Committee of AUH and informed consent was obtained from all the participants before enrollment. Study population: Adult 120 patients with CHF and having gastrointestinal (GI) symptoms (e.g. abdominal pain, heartburn, nausea, vomiting, severe anorexia or weight loss) assessed by the Patient Assessment of Gastrointestinal Disorders-Symptom Severity Index (PAGI-SYM) (reference) were included in the study [5]. Heart failure defined as patients with symptoms typical of heart failure: (Breathlessness at rest or on exercise, fatigue, tiredness, ankle swelling), signs typical of heart failure: (Tachycardia, tachypnoea, orthopnoea, paroxysmal nocturnal dyspnea, pulmonary rales, pleural effusion, raised jugular venous pressure, peripheral oedema, hepatomegaly) and objective evidence of a structural or functional abnormality of the heart at rest (cardiomegaly, third heart sound, cardiac murmurs, abnormality on the echocardiogram) [6]. Patients with haemodynamic instability, positive hepatitis markers (HBsAg, HCVAb), chronic liver disease of non cardiac origin, H. pylori infection and those received mediations affecting GIT mucosa e.g. NSAIDs were excluded from this study. All patients were subjected to the following: Full clinical history and examination. Transthoracic echocardiography was done to diagnose any structural heart disease, assess LV dimensions and function, assess degree of tricuspid regurgitation (TR) and PASP. Trans-abdominal ultrasonography to assess the following: - Maximum width (in mm) of the distal part of the main trunk of the left, the middle, and the right HVs, just proximal to their entry into the IVC (during shallow inspiration after at least 5 minutes of rest). - Maximum transverse diameter of the IVC just above its confluence with the HVs (with breathing held in expiration). - Maximum width of the PV at the porta-hepatis. - Assessment of liver and spleen status and the presence of vascular collaterals. - Portal vein Pulsatility index (PI) calculated as follows: (Peak maximum velocity) - (Peak minimum velocity) / (Peak maximum velocity) using ultrasonic Doppler. Upper Endoscopy: Endoscopic changes were classified by using a modification of the grading system for portal hypertensive gastropathy [7] : Grade 0, normalappearing mucosa; grade 1 (mild), mosaic like pattern and/or fine punctate speckling of the mucosa; grade 2 (moderate), blunted and thickened folds and/or telangiectasia; and grade 3 (severe), cherry red spots and/or diffusely or linearly hyperaemic mucosa. Statistical analysis: Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS-version 17). Continuous data were expressed as Means ±Standard deviation (SD) and compared using Student t-test. Categorical variables were expressed as percentage and compared using chi-square ( χ 2 ) test. Correlations were assessed by the Spearman rank correlation coefficient among continuous variables and Gamma statistics for ordinal variables. p-values of less than 0.05 were considered significant. Results Characteristics of the study population: The baseline demographic and clinical characteristics of 120 studied patients with CHF are summarized in table 1 where the mean age of the patients was 33.4±8.8 years and males constituted 61.7%. The majority of cardiac patients presented with severe GIT symptoms (41.7%). Rheumatic heart disease was the commonest cause for these cardiac patients (44.2%) and 38.3% of them had severe degree of tricuspid regurge. Table (1): Demographic and clinical characteristics of the study patients. Patients (n=120) No (%) Male 74 (61.7) Age 33.4±8.8 Git symptoms * : Mild 21 (17.5) Moderate 49 (40.8) Severe 50 (41.7) Causes of heart failure: Dilated cardiomyopathy 13 (10.9) Ischemic cardiomyopathy 49 (40.8) Peripartum cardiomyopathy 5 (4.2) Rheumatic heart disease 53 (44.2) Degree of tricuspid regurge: No regurge 6 (5) Mild 40 (33.3) Moderate 28 (23.3) Severe 46 (38.3) * Assessed by the patient assessment of gastrointestinal disorders-symptom severity index (PAGI-SYM).

3 Zain E.A. Sayed, et al Endoscopic findings: The endoscopic findings were listed in Table (2) and Fig. (1). Gastric mucosal changes (gastropathy) were present in 106 (88.4%) patients, where, mosaic like pattern lesions were the commonest endoscopic changes. In addition, duodenal mucosal changes (duodenopathy) were found in 71 (59.2%) patients, and esophageal mucosal changes in 3 (2.5%) patients that were the least endoscopic changes. Some patients had more than one endoscopic lesion. Table (2): Endoscopic findings in the study patients. Endoscopic lesions * No. (%) Esophageal changes: Linear veins in distal third 3 (2.5) Varices 0 Gastric changes: Mosaic-like pattern 92 (76.7) Thickened folds 20 (16.7) Punctuate spots 73 (60) Watermelon stomach 8 (6.7) Telangiectasia Duodenal changes: 35 (29.2) Mosaic-like pattern 58 (48.4) Thickened folds 17 (14.2) Telangiectasia 7 (5.9) * The patient may have one or more endoscopic lesion(s). Patients with moderate and severe upper-gi symptoms had significantly more gastropathy and doudenopathy than those with mild symptoms (p<0.001 for both). In addition, there was a positive correlation between the degree of severity of upper- GI symptoms and severity of gastropathy and doudenopathy (Gamma=0.6, p=0.03 and 0.5, p=0.04 respectively). Ultrasonographic (dopplar) and Echocardiographic findings: The mean PI in patients in our patients was 0.7±0.53. There was positive correlation between PI and PASP (r=0.61, p=0.02). Patients with low EF have a higher PI than patient higher EF but without statistical significance (0.7 ±0.67 vs. 0.6±0.18, p=0.26). Comparison between GIT symptoms, endoscopic lesions and ultrasonographic and echocardiographic findings: Cardiac patients with moderate and severe upper-gi symptoms had higher mean inferior vena cava and hepatic vein diameters than those with mild symptoms indicating that hepatic vein and IVC diameters were significantly associated with the severity of upper-gi symptoms (p<0.001 for both). Despite portal vein diameter was not significantly altered it showed a tendency toward increased values with severity of upper-gi symptoms in patients with CHF Table (3). Additionally, cardiac patients with gastropathy and duodenopathy had higher mean inferior vena cava and hepatic vein diameters than those without gastropathy and duodenopathy. Tables (4,5). Regarding echocardiographic changes, low EF was associated with increasing severity of upper- GI symptoms and the presence of gastropathy and duodenopathy (p<0.001 for all). Moreover, it was associated with larger portal vein, IVC and hepatic vein diameters, (p=0.02, 0.008, 0.002) respectively. On the other hand, Tricuspid regurgitation was associated with upper-gi symptoms, stomach changes, and increased hepatic vein and IVC diameters (p=0.007, 0.019, <0.001, <0.001 respectively). Table (3): Relation between GIT symptoms and ultrasonographic findings. Patients with mild symptoms (n=21) Patients with moderate and severe symptoms (n=99) IVC diameter 13.4± ±4.9 <0.001 Hepatic vein diameter 8.3± ± 1.7 <0.001 Portal vein 9.3± ± Table (4): Ultrasonographic findings in patients with and without gastropathy. Patients with Patients without gastropathy gastropathy p (n=106) (n=14) IVC diameter 19.2± ± 1.3 <0.001 Hepatic vein diameter 9.8± ± Table (5): Ultrasonographic findings in patients with and without doudenopathy. Patients with Patients without doudenopathy doudenopathy p (n=71 ) (n=49) IVC diameter 20.4± ±4.3 <0.001 Hepatic vein diameter 10.2± ± 1.5 <0.001 p

4 1012 Upper Gastrointestinal Mucosal Changes in Patients Fig. (1-A): Esophageal linear veins. Fig. (1-B): Gastric mosaic like pattern. Fig. (1-C): Thickened gastric folds. Fig. (1-D): Gastric telangiectasia. Fig. (1-E): Watermelon stomach. Fig. (1-F): Duodenal mosaic-like pattern. Fig. (1-G): Duodenal thickened folds. Fig. (1-H): Duodenal telangiectasia. Fig. (1): Endoscopic view showing different aspects of congestive mucosopathy.

5 Zain E.A. Sayed, et al Discussion The present study assessed the frequency of upper gastrointestinal mucosal changes in patients with CHF, where gastropathy were the most common finding followed by duodenopathy. With agreement with Raja et al., [8] we found no patient had esophageal varices; only 3 patients (2.5%) have dilated veins that do not meet the criteria of esophageal varices Previous studies showed that low frequency of esophageal varies in patients with CHF ranged from 1.2% to 6.7% [9-11]. The absence of cardiac cirrhosis may explain the lack of esophageal varices in the present study patients since high porto-systemic pressure gradient is required for the formation of esophageal varices that is not present in cardiac cirrhosis [8]. Gastric mucosal changes observed in the present study were a mosaic-like pattern, thickened mucosal folds, watermelon stomach, punctate spots and telangiectasia. These results were compatible with previous studies that demonstrated several abnormalities of gastric mucosa in mosaic pattern including antral vascular ectasia, mucosal thickening and areas of telangiectasias [8,12]. These changes were similar to portal hypertensive gastropathy [13,14]. In this study, the duodenal findings were mild changes (mosaic-like pattern) that were the most common findings, followed by moderate changes (thickened mucosal folds, telangiectasia) and none had severe changes. Duodenopathy was less frequent than gastropathy. This might be clarified by the compact mucosal layer of the stomach with interruption of the area gastricae appearance with congestion as mosaic like. Similar changes are infrequent in the duodenum because of the supporting tissue in the lamina propria and the absence of the area gastricae. These results were consistent with Raja et al., [8] who found the common duodenal changes were mild but less frequent than gastropathy. In our study, these changes congestive mucosopathy in patients with CHF were similar to those caused by portal hypertension. However, a portosystemic venous pressure gradient exists in CHF, is much lower than that which occurs with cirrhosis. In congestive heart failure, the increase in systemic venous pressure is transmitted to the portal circulation via the hepatic venous bed and thus mucosal congestion is to be expected [4,15]. Patients with CHF have an increased splanchnic fluid volume, an important factor in maintaining splanchnic venous hypertension [6]. In addition, the low cardiac output state and arterial hypoxemia that occur in CHF might contribute to splanchnic hypoperfusion leading to GI mucosal changes [16]. We found that patients with moderate and severe upper-gi symptoms had significantly higher frequency of gastropathy and doudenopathy. Increasing severity of upper-gi symptoms was associated with increasing gastropathy and doudenopathy severity and increasing diameter of hepatic veins and IVC. However, severity of symptoms was not associated with portal vein diameter in our study. One possible explanation for this observation is that medication received by patients to treat CHF e.g. nitrites may control portal pressure. In this study, these cardiac patients had higher portal vein pulsatility index (PI) that was positively correlated with PASP. These results agreed with Shih et al., [17] who reported that patients with high right atrial pressure representing right sided cardiac congestion had a high PI. Furthermore; the waveform changes of portal blood flow correlate well with right heart function. So, with the agreement with Hu and colleagues [18], the measurement of portal vein PI change is a simple and noninvasive method to identify right heart failure and is helpful for the diagnosis of stagnant or hepatofugal portal blood flow. Regarding cardiac changes, degree of severity of tricuspid regurgitation was associated with gastrointestinal symptoms, stomach changes, and increased diameter of hepatic vein and IVC diameters. This can be explained by that with increasing severity of tricuspid regurgitation, the right ventricular systolic pressure is more efficiently transmitted to the systemic veins and the portal circulation; possibly, this leads to more congestive changes [19]. In addition, low EF was associated with larger IVC, hepatic vein and portal vein diameters manifested as systemic and splanchnic congestion thus, a more severe effect on the mucosa and consequently increasing severity of GIT symptoms, gastropathy and duodenopathy. In Conclusion: Congestive mucosopathy gastropathy and duodenopathy is common in patients with CHF. Severity of this finding is related to severity of hepatic congestion caused by tricuspid regurgitation and or right ventricular dysfunction that is the predominant mechanism. The measurement of

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