ATLANTOAXIAL INSTABILITY (AAI) IN RHEUMATOID ARTHRITIS: IS THE PATIENT AT RISK DURING ENDOSCOPY OF THE UPPER GI TRACT?

Background: Rheumatoid arthritis (RA) of the cervical spine joints affects up to 40% of patients with long-standing disease. The use of non-steroidal antirheumatic drugs is associated with increased rates of upper gastrointestinal disease, which require endoscopic evaluation. Arthritis/Deformation of the cervical spine has been described as a particular hazard for endoscopists. However, data regarding the specific risks of esophago-gastroduodenoscopy (EGD) in patients with AAI are lacking.Objectives: The history of patients with RA/AAI was analyzed retrospectively to evaluate specific risks of EGD.Methods: Data were collected retrospectively by review of examination reports. All radiographs (projections of the cervical spine in full extension and flexion), were examined by two radiologists. AAI was diagnosed as follows: Anterior atlantoaxial subluxation was defined i) as an atlantodental interval of ≥4 mm in neutral position or if a normal atlantodental interval increased to ≥ 4 mm during flexion, or ii) posterior dental interval <14 mm. iii)A perpendicular distance <13 mm was defined as vertical subluxation. Endoscopy and histopathological reports were reviewed.Results: We found nine patients with RA/AAI, who underwent twelve EGD examinations in our institution (7/12), or in office endoscopy setting (5/12), between June 2002 and March 2004. There was no morbidity or mortality related to the performance of EGD. Indications for EGD were dyspepsia (3/9), epigastric pain (2/9), evaluation of anemia/weight loss (2/9), and heartburn (2/9). One peptic ulcer of the pyloric antrum was diagnosed. Short Barrett''s esophagus could be detected in two patients. Helicobacter pylori infection was diagnosed by pathohistological examination of biopsies in three patients. Esophageal varices were found in one patient. Complications. 65 y.o. male patient was referred to EGD to rule out malignancy. Compression of the Nervus occipitalis major was diagnosed as a complication of cervical spine arthritis. The first EGD (without sedation) was stopped because intubation of the upper esophagus (endoscope: GIF 130, Olympus, outer diameter 9.8 mm) failed. One week later, second EGD (endoscope: GIF-Q 145, Olympus; outer diameter 9.8 mm; conscious sedation: 4 mg midazolam and 40 mg propofol) could rule out gastric malignancy but demonstrated deformation of the pyloric antrum.Conclusion: Our retrospective evaluation indicates that performance of EGD with or without conscious sedation is not associated with a particular risk in patients with RA/AAI. We did not note significant morbidity, with the exception of difficult intubation in 1/12 EGDs.References: [1] Neva MH, et al. Early and Extensive Erosiveness in Peripheral Joints predicts Atlantoaxial Subluxations in Patients With Rheumatoid Arthritis. Arthritis Rheum 2003 Jul; 48(7): 1808-13[2] Norton ML, et al. Atlantoaxial instability revisited. An alert for endoscopists. Ann Otol Rhinol Laryngol. 1982 Nov-Dec;91(6 Pt 1):567-70[3] Barnsley L, Denham JM, Duggan JM. Is the patient with an arthritic neck at risk during endoscopy? J Gastroenterol Hepatol. 1992 Jan-Feb;7(1):107-8.[4] Helmreich-Becker I, Lohse AW. Grundlagen und Übersicht. In: Gastroskopie. Stuttgart, New York. Thieme 1999: p 1[5] Escourrou J, Salcédo J, Buscail L. Obere gastrointestinale Endoskopie. In: Gastroenterologische Endoskopie. Classen M, Tytgat GNJ, Lightdale C (edts); Stuttgart, New York. Thieme 2004Citation: Ann Rheum Dis, volume 64, supplement III, year 2005, page 209Session: Rheumatoid arthritis – Clinical aspects