Upload
ryley-faires
View
225
Download
3
Tags:
Embed Size (px)
Citation preview
Chest Pain (GERD)
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
History
What other points of the history do you want to know?
History, Mr. Burns Consider the following:
• Characterization
of Symptoms• Temporal sequence• Alleviating /
Exacerbating factors
• Associated signs/symptoms• Pertinent PMH• ROS• MEDS• 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 Diagnosis?
Differential DiagnosisBased on History and Presentation
GERD Esophagitis Esophageal Dysmotility Gastroparesis Esophageal Cancer
Achalasia PUD Esophageal Diverticulum Paraesophageal Hernia 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: HEENT: eroded enamel Genital-rectal: Genital-rectal: no masses, no masses, heme positiveheme positive
Chest: Chest: mild bilateral mild bilateral wheezingwheezing
Neuromuscular: Neuromuscular: non-focal non-focal examexam
CV: CV: RRR, no murmurs, rubs or gallops
Skin/Soft Tissue: Skin/Soft Tissue: no rashes, no jaundice
Abd: Abd: soft, no masses, no tenderness
Remaining Examination Remaining Examination findings non-contributoryfindings 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 continues
CBC, Electrolytes, LFT’s, PT/PTT normal
EKG, CXR normal Colonoscopy normal EGD
• Erosive esophagitis, H.pylori negative, no Barrett’s, moderate size Hiatal hernia, patulous hiatus
EGD images
Normal GE junctionwith regular Z-line (arrows)
Mr. Burn’s EGD showing 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
UGI Esophageal manometry Bravo probe
The above tests were ordered due to continuation of regurgitation and atypical reflux symptoms (asthma)
UGI
Mr. Burn’s pH study note multiple episodes of pH<4 (arrows)
Normal 48h pH study
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 motility
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 obtained
Final Diagnosis
• Gastroesophageal Reflux Disease with incomplete symptom control on PPI
What next?
Management
Continuation of PPI treatment
or 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
fundoplication
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
Right CrusRight CrusLeft CrusLeft Crus
EsophagusEsophagus
Crural ClosureCrural Closure
EsophagusEsophagus
On the right the crura have been dissected out and on the left they are approximated with permanent sutures over a Bougie
Nissen fundoplication
EsophagusEsophagus
FundoplicationFundoplication
Mr Burn’s Endoscopic Images
Preoperative retroflexed view of GE junction with patulous hiatus (arrow)
Retroflexed view of GE junction after Nissen
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?
Discussion Mr Burns is likely to benefit from surgery
because his symptoms consist primarily of regurgitation and extraesophageal manifestations that are poorly controlled by PPIs
In the absence of these symptoms he should be maintained on PPI therapy unless he chose to have surgery as an alternative to medical treatment
Discussion 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
QUESTIONS ??????
Summary 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
Summary 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
Acknowledgment The preceding educational materials were made available through the
ASSOCIATION FOR SURGICAL EDUCATIONASSOCIATION FOR SURGICAL EDUCATION
In order to improve our educational materials wewelcome your comments/ suggestions at: