Gut 1992; 33: 1427-1429 1427 Ulcerative colitis complicated by Wenckebach

atrioventricular block Gut: first published as 10.1136/gut.33.10.1427 on 1 October 1992. Downloaded from

A Ballinger, M J G Farthing

Abstract normal limits. Serum aspartate transaminase Extracolonic manifestations of inflammatory 32 IU/1 (normal range 10-40 IU/1) and hydroxy- bowel disease are common and diverse. butyrate dehydrogenase 72 IU/1 (normal range Cardiac complications, however, are rare and 40-140 IU/1) were normal and remained within of these pericarditis is the most frequently the normal range over the next three days. Blood described association. A 57 year old man with cultures taken on three occasions were all a 20 year history ofulcerative colitis presented negative. The admission electrocardiogram with a four day history of retrosternal chest showed Wenckebach atrioventricular block (Fig pain and exertional dyspnoea. Electrocardio- 1) whereas a previous examination in 1982 had gram showed Wenckebach atrioventricular been normal. Chest radiograph and echocardio- block. Three days later he developed bloody gram were both normal. diarrhoea and sigmoidoscopy showed active The chest pain was thought to be caused by proctocolitis. He was treated with oral pericarditis and indomethacin was started. Two prednisolone after which the chest pain and days after admission he developed bloody diarrhoea settled within 48 hours. At outpatient diarrhoea and abdominal pain; rigid sigmoido- review two weeks later he was completely well scopy showed active proctocolitis whichextended and the electrocardiogram had returned to beyond the reach of the sigmoidscope. Treat- normal. ment was started with 40 mg prednisolone orally (Gut 1992; 33: 1427-1429) each day and within 48 hours the chest pain and bloody diarrhoea were substantially improved. Two weeks later at outpatient review bowel habit Case report was normal and the chest pain had resolved A 57 year old man with a past history of completely. Review of viral serology showed no ulcerative colitis presented to the Accident and evidence of a recent viral infection. The Emergency Department with a four day history erthrocyte sedimentation rate had decreased to

of retrosternal chest pain which was worse on 30 mm/hour and a repeat electrocardiogram was http://gut.bmj.com/ inspiration and lying down. He also complained entirely normal (Fig 2). An exercise electro- ofshortness ofbreath on exertion. The ulcerative cardiograph was entirely normal (Fig 2). An colitis had been in remission for four months. exercise electrocardiograph after full recovery He first presented in 1961 with bloody showed no evidence of myocardial ischaemia. diarrhoea and a diagnosis of ulcerative colitis The patient remains well six months later. affecting the distal colon was made on the basis of

barium enema, sigmoidoscopic appearances, on October 1, 2021 by guest. Protected copyright. and confirmed by typical histological features of Discussion ulcerative colitis in a rectal biopsy. In 1982 he Extragastrointestinal features of inflammatory presented with fever, arthritis of the wrist and bowel disease are well recognised and affect ankle joints and a macular rash on the legs. many systems.' Cardiac involvement has been Biopsy of one of the skin lesions showed described only rarely. The character of the chest appearances of an allergic vasculitis. Autoanti- pain in this patient was very suggestive of bodies were negative and a rectal biopsy specimen pericarditis. A pericardial rub, ST changes on showed active ulcerative colitis. His symptoms electrocardigraph or the demonstration of a settled with the introduction of prednisolone. pericardial effusion on the echocardiogram Since that time he has required intermittent would have supported the diagnosis but acute courses of oral prednisolone for relapse of inflammation may occur in the absence of these symptoms; typically arthritis has been more findings with only a fever or typical chest pain to troublesome than diarrhoea. There is no other suggest the diagnosis.2 Several cases of peri- past medical history and at the time of admission carditis in patients with ulcerative colitis and he was taking 150 mg azathioprine and 4 g Crohn's disease have been reported, usually in sulphasalazine daily. association with relapse of bowel symptoms. Department of On examination the temperature was 38°C, Pericarditis and bowel symptoms have res- Gastroenterology, St pulse 60 beats per minute and blood pressure ponded rapidly to corticosteroid therapy. Bartholomew's Hospital, London 120/70 mm Hg. The jugular venous pressure was Reports of heart block are uncommon and all A Ballinger not raised, the heart sounds were normal with no have occurred in patients with ulcerative M J G Farthing added sounds and examination of the chest and colitis.7-9 Of the three patients with complete Correspondence to: abdomen was normal. Rectal examination and heart block, one has required a permanent Professor M J G Farthing, Department of sigmoidoscopy were not done. Haemoglobin on pacemaker,7 another improved but continued Gastroenterology, St admission was 12-4 g/dl, white cell count 9 8x with first degree heart block8 and a third Bartholomew's Hospital, London ECIA 7BE. 109/litre (neutrophils 8.4 x 109/litre), platelets recovered completely after treatment with pred- Accepted for publication 199 x 109/litre, erythrocyte sedimentation rate nisolone.9 An association between heart block 9 March 1992 70 mm/hour. Urea and electrolytes were within with ulcerative colitis was suggested in these 1428 Ballinger, Farthing Gut: first published as 10.1136/gut.33.10.1427 on 1 October 1992. Downloaded from

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Figure 2: Electrocardiogram at atientohreview tw w k after admissionshowingW n sign atriovInt Iar and c pleT

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reco_eiya_rioenticuarofthe block observed two weeks pre sT I y

II I !I L B J 7 I# http://gut.bmj.com/ on October 1, 2021 by guest. Protected copyright.

Ld_ t, TEHltEHM 01 936 S"419 DS Figure 2: Electrocardiogram at outpatient review two weeks after admission showing no significant abnormality and complete recovery ofthe atrioventricular block observed tWO weeks previously.

cases because ofa temporal relationship between viral myocarditis or ischaemic heart disease. development of heart block and a relapse of the Cutaneous vasculitis may complicate ulcera- colitis. Other causes ofheart block, in particular tive colitis and indeed had occurred previously in ischaemic heart disease, however, were not our patient. Systemic vasculitis is very excluded and the two conditions may have been uncommon; arteritis of large vessels and pul- coincidental. monary vasculitis has been reported in patients There are several features ofour patient which with ulcerative colitis and has improved with suggest that heart block was a complication of steroids.'°"I This is the first reported case of ulcerative colitis and not a coincidental Wenckebach atrioventricular block complicating association. The cardiac abnormalities were ulcerative colitis and we suggest that it was closely associated with a relapse of bowel probably caused by an arteritis of nodal vessels. symptoms and both improved in parallel after the introduction of prednisolone. Echocardio- gram and an exercise test were both normal. We 1 Edwards FC, Truelove SC. Course and prognosis of ulcerative colitis. III Complications. Gut 1964; 5: 1-22. therefore considered it unlikely that heart block 2 O'Connell JB, Robinson JA, Henkin RE, Gunnar RM. in this case was secondary to other causes such as Gallium-67 citrate scanning for non invasive detection of Ulcerative colitis complicated by Wenckebach atrioventricular block 1429

inflammation in pericardial diseases. AmJ Cardiol 1980; 46: 7 Jowett NI, Burden AZ. Ulcerative colitis complicated by 879-84. chronic complete heart block. BMJ7 1985; 290: 1788. 3 Goodman MJ, Moir DJ, Holt JM, Truelove SC. Pericarditis 8 Fear JD, Hutton WN. Ulcerative colitis complicated by associated with ulcerative colitis and Crohn's disease. Dig complete heart block. BMJ 1985; 291: 143.

Dis 1976; 21: 98-102. 9 Thuesen L, Sorensen J. Ulcerative colitis complicated by Gut: first published as 10.1136/gut.33.10.1427 on 1 October 1992. Downloaded from 4 Thompson JE, Lennard-Jones JE, Swarbrick ET, Bown R. myopericarditis and complete heart block. Ugeskr Laeger Pericarditis and inflammatory bowel disease. Q J Med 1979; 1979; 141:2760. 48:93-7. 10 Yassinger S, Adelman R, Cantor D, Halsted CH, Bolt RJ. 5 Manomohan V, Subbuswamy SG, Willoughby CP. Crohn's Association ofinflammatory bowel disease and large vascular disease and pericarditis. Postgrad MedJ 1984; 60: 682-4. lesions. Gastroenterology 1976; 71: 844-6. 6 Breitenstein RA, Salel AF, Watson DW. Chronic inflammatory 11 Isenberg JJ, Goldstein H, Korn AR, Ozeran RS, Rosen V. bowel disease; acute pericarditis and pericardial tamponade. Pulmonary vasculitis-an uncommon complication of ulcera- Ann Intern Med 1974; 81: 406. tive colitis. N Englj Med 1968; 279: 1376-7. http://gut.bmj.com/ on October 1, 2021 by guest. Protected copyright.