Chest Pain _GERD_.ppt by handongqp


									 Chest Pain

Dimitrios Stefanidis, MD, PhD
 Steven B. Goldin, MD, PhD
           Mr. Burns

 52 year-old male presents to the office
  with complaints of retrosternal pain
  that he has been experiencing for the
  past 2 years

What other points of the history do
       you want to know?
           History, Mr. Burns
                Consider the following:

• Characterization          • Associated signs/symptoms
  of Symptoms               • Pertinent PMH
• Temporal sequence         • ROS
• Alleviating /             • MEDS
  Exacerbating factors      • Relevant Family Hx
                            • Relevant Social Hx
             History Mr. Burns
 Characterization of Symptoms
  •   Pain is burning in nature, radiates to back
 Temporal sequence
  • More frequent after meals, especially spicy
 Alleviating / Exacerbating factors:
  • Gets worse when lying down, especially at night, worse
    after he drinks alcohol or smokes
  • Pain improves with antacids
               History Mr. Burns

 Associated signs/symptoms:
•    Brings up (regurgitates) partially digested food
•    Reports acid taste in mouth
•    Had a negative workup in the past for a heart attack
    when he presented to the ER with similar symptoms
•    Occasionally food is getting stuck behind sternum
•    Wakes up at night with choking sensation
           History Mr. Burns

 Pertinent PMH: hyperlipidemia, asthma, h/o two
  prior pneumonias
 PSH: laparoscopic cholecystectomy
 ROS: feels bloated frequently, no weight loss, avoids
  eating before bedtime, no vomiting, no melena
 MEDS : Lipitor, antacids
 Relevant Family Hx: noncontributory
 Relevant Social Hx: smoker, social drinker, works at
  construction site
What is your Differential
          Differential Diagnosis
         Based on History and Presentation

   GERD                        Achalasia
   Esophagitis                 PUD
   Esophageal Dysmotility      Esophageal Diverticulum
   Gastroparesis               Paraesophageal Hernia
   Esophageal Cancer           Gastric outlet obstruction
     Physical Examination

What specifically would you look for?
     Physical Examination Mr. Burns
• Vital Signs: Height: 6 foot, Weight 190 lbs, T: 98.6, HR: 84, BP: 146/82
• Appearance: well developed man in no distress
• Relevant Exam findings for a problem focused assessment

 HEENT: eroded enamel             Genital-rectal: no masses,
                                  heme positive
 Chest: mild bilateral            Neuromuscular: non-focal
 wheezing                         exam
 CV: RRR, no murmurs, rubs        Skin/Soft Tissue: no rashes,
 or gallops                       no jaundice
 Abd: soft, no masses, no         Remaining Examination
 tenderness                       findings non-contributory
Studies (Labs, X-rays, Diagnostics)

     What would you obtain?
Studies ordered Mr. Burns

      CBC
      Electrolytes
      LFT’s
      PT/APTT
      Chest X-ray
      EKG
      EGD/Colonoscopy
      Interventions at this point?
 Educate about lifestyle modifications that may
  alleviate symptoms
  •   Smoking, alcohol and caffeine cessation
  •   Avoid meals before bedtime
  •   Elevate head of bed
  •   Weight loss if patient obese
 Start treatment with Proton Pump Inhibitors
 Arrange for follow-up visit
            Follow-up visit
 Heartburn improved, regurgitation
 CBC, Electrolytes, LFT’s, PT/PTT normal
 EKG, CXR normal
 Colonoscopy normal
  • Erosive esophagitis, H.pylori negative, no
    Barrett’s, moderate size Hiatal hernia,
    patulous hiatus
                     EGD images

Normal GE junction             Mr. Burn’s EGD showing
with regular Z-line (arrows)   erosive esophagitis
                               (erosions indicated by arrows)
   Given this patient’s heartburn
 improvement, how would you like to
    proceed with his treatment?

Are there any further studies indicated
              and why?
       Studies ordered

 Esophageal manometry
 Bravo probe

 The above tests were ordered due to
 continuation of regurgitation and
 atypical reflux symptoms (asthma)
                Normal 48h pH study

Mr. Burn’s pH study note multiple episodes of pH<4
              Study Results
 UGI: moderate hiatal hernia, no gastric
  outlet obstruction with rapid filling of the
  small bowel, gross esophageal reflux
 Esophageal manometry: decreased lower
  esophageal sphincter pressure with
  normal relaxation, normal esophageal
 Bravo probe: DeMeester score = 47
           Study result discussion
• The Bravo probe proves that the esophagitis seen on
  EGD is a result of abnormal acid exposure of the
  distal esophagus
• The manometry points out the incompetent lower
  esophageal sphincter which is the underlying reason
  for the reflux and demonstrates normal motility
• The UGI documents the presence of a hiatal hernia
  and in this instance shows good gastric emptying
  which makes gastric dysmotility an unlikely reason
  for the reflux. If gastric dysmotility is suspected, a
  nuclear medicine gastric emptying study can be
         Final Diagnosis

• Gastroesophageal Reflux Disease
 with incomplete symptom control
 on PPI
What next?
 Continuation of PPI treatment
 Antireflux surgery
  • What are the indications for surgery in
    patients with GERD
  • Which procedure should be done?
         Indications for surgery
 Patients with incomplete symptom control or
  disease progression on PPI therapy
 Patients with well-controlled disease who do not
  want to be on life-long antisecretory treatment
 Patients with proven extra-esophageal
  manifestations of GERD like cough, wheezing,
  aspiration, hoarseness, sore throat, otitis media,
  or enamel erosion.
 The presence of Barrett esophagus is a
  controversial indication for surgery
    Antireflux Surgery Principles
 Closure of hiatus
 Replace the GE junction in a high pressure
  zone by
  • Reestablishment of intraabdominal esophageal
    length (2-3 cm)
  • Recreation of valve mechanism by stomach
    wrap around the esophagus
 The gold standard is laparoscopic Nissen
  Operative findings - Hiatal Hernia

On the right a small hiatal hernia is demonstrated. On
the left a moderate size paraesophageal hernia is seen.
                      Hiatal Closure


                       Left Crus
Right Crus                                     Crural Closure

On the right the crura have been dissected out and on the left
they are approximated with permanent sutures over a Bougie
  Nissen fundoplication


      Mr Burn’s Endoscopic Images

Preoperative retroflexed   Retroflexed view of GE
view of GE junction with    junction after Nissen
 patulous hiatus (arrow)       fundoplication
         Alternative Scenarios
 What would you do if Mr. Burns did not
  have regurgitation and atypical symptoms
  and his heartburn improved on PPIs?
 What would you do if Mr. Burns had
  uncomplicated disease but does not want to
  take life-long medications?
 What would you do if Mr. Burns had a BMI
  of 41?
 What procedure would you do if Mr Burn’s
  manometry had revealed impaired
  esophageal motility?
 Mr Burns is likely to benefit from surgery
  because his symptoms consist primarily of
  regurgitation and extraesophageal
  manifestations that are poorly controlled by
 In the absence of these symptoms he should be
  maintained on PPI therapy unless he chose to
  have surgery as an alternative to medical
 If he were morbidly obese, a Roux en Y gastric
  bypass would be likely a better antireflux
  procedure as it provides excellent symptom
  control and would also lead to the resolution of
  other obesity related comorbidities
 In the presence of impaired esophageal
  motility, a partial fundoplication or a “floppy”
  Nissen should be considered to minimize the
  chance of postoperative dysphagia
 GERD is a very common disease in the US and can be
  managed medically in most patients
 PPI are the gold standard and should be the initial
  treatment of choice in patients with uncomplicated
  classic symptoms
 Patients suspected to have complicated disease
  (dysphagia, anemia, weight loss, GI bleeding) or with
  atypical reflux symptoms (hoarseness, asthma,
  sinusitis, recurrent pneumonias, enamel erosions,
  severe nausea and vomiting) or do not respond to PPI
  treatment should undergo further evaluation
 Surgery is a very effective treatment of GERD
  with symptom resolution in over 90% of
  patients and excellent quality of life
 Randomized studies document superior efficacy
  of surgery compared to PPI in controlling the
  disease in the short-term but there are concerns
  that in the long-term some patients may need to
  go back on PPI therapy
 Patients should be carefully selected for surgery
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