Gastrointestinal bleeding, particularly when severe, is frequently associated with myocardial infarction (MI) but the MI is frequently undiagnosed because of failure to test for MI in the patient with severe gastrointestinal bleeding. Simultaneous disease often presents as a distinct syndrome that differs from either disease alone and often raises unique questions about the safety of the usual evaluation and therapy. First, the clinical presentation differs from that of either disease alone. For example, the symptoms and signs of MI may be overshadowed by severe gastrointestinal bleeding, and MI may not be appreciated unless specifically tested for. Second, the pathophysiology of MI associated with gastrointestinal bleeding differs from that of either disease alone. For example, gastrointestinal bleeding, particularly when massive, may precipitate MI from hypovolemia, hemodynamic compromise, and myocardial hypoperfusion. Third, the diagnostic evaluation raises unique questions. Although gastrointestinal endoscopy is safe and nearly universally applied to evaluate gastrointestinal bleeding, the safety of endoscopy after MI must be carefully considered separately because of potential cardiopulmonary endoscopic complications. Likewise, cardiac catheterization after acute MI raises concern in the gastrointestinal bleeder about potential bleeding exacerbation during intraprocedure anticoagulation. Fourth, many therapies for each individual disease become problematic when the other disease occurs simultaneously. For example, anticoagulation, antithrombolytic, or antiplatelet therapy for MI raises issues of safety from potential exacerbation of gastrointestinal bleeding. Likewise, intravenous vasopressin therapy for bleeding esophageal varices or endoscopic epinephrine injection for bleeding ulcers raises issues of safety from potential exacerbation of myocardial ischemia. Fifth, the prognosis of gastrointestinal bleeding associated with MI markedly differs from that of either disease alone.

This article focuses on these unique characteristics and potential concerns in the clinical presentation, pathophysiology, treatment, and prognosis of gastrointestinal bleeding associated with MI to familiarize the physician with the diagnosis and management of this common but frequently overlooked clinical syndrome. This article concentrates on upper gastrointestinal bleeding because this is commoner and better studied than lower gastrointestinal bleeding associated with MI. The literature on simultaneous gastrointestinal bleeding and MI consists of a few studies involving only a moderate number of patients, but the safety of esophagogastroduodenoscopy (EGD) after MI has been examined by several studies, including one large study.