Dr Charles PanackelConsultant Gastroenterologist

Medical Trust Kochi

Introduction

25% of general population experience chest pain at some point of life

Of these only 11 -39% have cardiac pain

DefinitionNoncardiac Chest pain can be defined as

recurrent angina-like or substernal chest pain believed to be unrelated to the heart after reasonable cardiac evaluation.

What is reasonable ???Unexplained Chest Pain (UCP)

Epidemiology• The mean annual prevalence of NCCP in the

general population is approximately 23-33%

• NCCP accounts for approximately 2% to 5% of all presentations to hospital emergency

• Both sexes equally affected

• Women seek medical attention more commonly

Epidemiology Prevalence of NCCP decrease with increasing

age.

Patients with NCCP are Younger, Consume greater amounts of alcohol, Smoke more, Suffer from anxiety than their counterparts with

ischemic heart disease.

Natural HistoryThe long-term mortality of NCCP is low

with reported rates of 1% at 10 yr

Morbidity is high• At one year after diagnosis, it is seen that 47%

limited their activities, 51% were unable to work and 44% still believed they had CAD.

NCCP patients have continued high rates healthcare use

Differential Diagnosis

Chest pain of Esophageal origin

Osler in 1892 first suggested that esophagus may be source for Unexplained chest pain

23–80% of Patients with Unexplained chest pain have esophageal abnormalities

Differential Diagnosis

PathophysiologyChest pain of esophageal origin could be caused by

• Noxious event in the esophagus, • Acid reflux• Nonacid reflux• Esophageal distension• Disturbed motility

• Abnormal mechanophysical properties of esophagus

• Sustained contractions of longitudinal muscles

• Visceral hypersensitivity

Decrease in the esophageal nociceptive sensory receptor threshold, Disorder in the nociceptive pathway in the peripheral or central

nervous system Autonomic dysregulation Altered central processing of pain stimuli

Somatoform disorders

GERD and NCCP

GERD and NCCPGERD is by far the most common cause for

NCCP

Esophageal Dysmotility and NCCP

28% of patients with Non GERD related NCCP

No correlation between symptoms and abnormality on Manometry

Response to muscle relaxants poor

Functional chest pain of presumed esophageal origin

Recurrent episodes of substernal chest pain of visceral quality with no apparent explanation.

GERD and esophageal dysmotility should be ruled out.

Up to 80% of the patients with functional chest pain exhibit other functional disorders

Visceral and somatic hypersensitivity

Approach to Non Cardiac Chest PainCardiac source reasonably ruled out.

Other causes ruled out

Approach to Noncardiac Chest PainA careful, thorough history looking for cardiac risk

factors,

12-lead ECG, chest radiograph,

Serial measurements of cardiac enzymes,

If the patient is stable and the etiology is still unclear, echocardiography and TMT

Coronary angiogram

What should be done next?

Endoscopy

Ambulatory pH monitoring

Combined Impedance-pH testing

Esophageal manometry

Acid suppression therapy or PPI test.

EndoscopyVariable diagnostic yield (10-44%) in

NCCP patients

Not likely to change management

Reserved for patients with NCCP and alarm symptoms (Anemia, Dysphagia, GI Bleed, Persistent Vomiting, Weight loss)

Ambulatory 24 hr pH TESTING

Ambulatory 24 hr pH TESTING

Sensitivity has ranged from 79% to 96% and specificity from 85% to 100%

Can be done on or off PPIs.

Diary allows correlation between symptoms and acid reflux.

Ambulatory 24 hr pH TESTING

Invasive- greater pt discomfort ( occ chest pain)

Can miss up to 25% of cases of reflux-not due to “acid”

Value in patients with NCCP in whom objective evidence is required

Patients who do not respond to PPI

Impedance-pH monitoring

Has added sensor for impedance.

It detects any bolus that enters the esophagus- acid, bile or other.

Increases the sensitivity of the probe

Same disadvantages as pH probe

The gold standard for diagnosis of GERD-related NCCP.

Impedance-pH monitoring

Impedance-pH monitoring

Esophageal ManometryA thin probe is inserted intranasally

and advanced into distal esophagus.

Measurements are recorded as the pt is asked to swallow sips of water.

Goal is to rule out motility disorders of the esophagus as cause for chest pain.

Esophageal ManometryEsophageal motility disorder is seen in

approximately one third of NCCP patients.

However, the relationship between these motility disorders and chest pain is unclear

Considered in patients with a negative work-up for GERD-related NCCP.

Role of manometry in NCCP is limited to diagnosis of achalasia cardia

Proton pump inhibitor testEmpiric trial of double dose PPI therapy for 4

weeks.Readily available CheapNoninvasive

Well tolerated with few if any side effects.Both diagnostic and therapeutic advantages

Proton Pump Inhibitor testTwo meta-analyses combining 14 studies

have validated the PPI test.Sensitivity and specificity of 75-80%.Positive predictive value of ~90%.

One study, using a decision analysis model, found the “treat first” approach to be better11% more diagnostic accuracy43% reduction in invasive procedures$454 saving per patient as compared to proceeding with

endoscopy and pH monitoring.

NCCP Esophageal Origin

Alarm Symptoms

PPI Test

Endoscopy

Impedence pH

Monitoring

Esophageal Manometry

GERD

Other spastic disorders

Functional esophageal

pain

Achalasia

Yes

No

Response

No Response

Normal

Normal

Reflux

Psychological evaluation

GERD-related NCCPLife style modification

Elevation of the head of the bed, Weight loss, Smoking cessation, Avoidance of alcohol, coffee, fresh citrus juice, Medications that can exacerbate reflux such as

narcotics, benzodiazepines, and calcium-channel blockers.

GERD-related NCCPThe efficacy of histamine-2 receptor

antagonists (H2 RAs) in GERD related NCCP range from 42% to 52%

The efficacy of PPI in controlling symptoms in patients with GERD related NCCP range from 57.1% to 87%

GERD-related NCCPPPIs reduce the number of chest pain

episodes, emergency department visits, and hospitalizations owing to chest pain

Patients with GERD-related NCCP should be treated with at least double the standard dose of PPI until symptoms remit

Long-term maintenance PPI treatment has been shown to be highly effective.

GERD-related NCCP

Lap Fundoplication

In carefully selected patients lap fundoplication results symptom improvement in 48 % to 90% of patients with NCCP.

NON GERD related NCCPVisceral hyperalgesia is the primary mechanism of pain in

patients with non-GERD-related NCCP

NCCP patients with spastic esophageal motor disorders respond better to pain modulators than to muscle relaxants.

Patients with spastic esophageal disorders should receive a trial of PPI

Patients with achalasia respond to muscle relaxants, balloon dilatation, botox injection or heller’s myotomy

NON GERD related NCCPPain Modulators

Tricyclic antidepressants (TCAs)

Selective serotonin reuptake inhibitors

Theophylline

Trazodone.

NON GERD related NCCPTCA

Central neuromodulatory effect Peripheral visceral analgesic effects Calcium channels blocker

TCA are started in low dose and titrated to a maximum based on symptom improvement and development of side effects.

Because of their anticholinergic side effects, TCAs are commonly administered at nighttime.

NON GERD related NCCP

Benzodiazepine

Alprazolam and clonazepam ameliorate chest pain in patients with NCCP and panic disorder

Addiction

Psychological evaluationBetween 17 and 43% of the patients with

NCCP have some type of psychological abnormality.

Psychological co-morbidity can lead to Visceral Hypersensitivity.

Psychotherapy is useful in patients with NCCP and hypochondriasis, anxiety, or panic disorder.

NCCP Esophageal

Origin

PPI Test

Impedance pH

Monitoring

PPI for 2-4 months

Esophageal

Manometry

Achalasia

Increase dose of PPI

Other spastic disorders

Functional esophageal

pain

Maintenance

PPIPain ModulatorsPsychotherapy

RelaxantsBalloon dilatationHellers myotomy

Response

Response

No Response

GERD

No GERD

Normal

SummaryNCCP is a very common problem with high

cost to the healthcare system and significant morbidity to the patient.

The most common cause of NCCP is GERD.

An empiric trial of high dose PPI therapy is the single most effective approach to dealing with NCCP.

Summary

Endoscopy is reserved for patients with alarm signs

Impedence pH monitoring and Esophageal manometry, has a limited role in NCCP

TREATMENT

Summary

GERD related NCCP is treated with double dose PPI

Non GERD related NCCP – the main stay of treatment is Pain Modulators

Psychotherapy for patients with psychological comorbidity.

Typical angina (80-90% likelihood of obstructive CAD),

Atypical angina (40-80% likelihood)Noncardiac (20%-70% likelihood). Typical angina is characterized by the following

three characteristics:Retrosternal chest discomfort experienced as

pressure or heaviness;Duration of 5-15 minInduced by stress or exertion, a large meal, or

exposure to cold and relieved by rest or nitroglycerin.

Mechanical distention, acid exposure, temperature, and osmolality-related stimuli can all induce esophageal pain.

Esophageal dysmotility may also induce symptoms of heartburn and chest pain.

Visceral hypersensitivity has been implicated in the pathogenesis of esophageal pain.

Psychiatric disease plays a role in heartburn and chest pain.

The entity of noncardiac chest pain (NCCP) was first described during the American Civil War when a Philadelphia physician, Jacob Mendez Da Costa, 

Psychological

Evaluation