Presentation on theme: "Dimitrios Stefanidis, MD, PhD Steven B. Goldin, MD, PhD"— Presentation transcript:
1 Dimitrios Stefanidis, MD, PhD Steven B. Goldin, MD, PhD Chest Pain (GERD)Dimitrios Stefanidis, MD, PhDSteven B. Goldin, MD, PhD
2 Mr. Burns52 year-old male presents to the office with complaints of retrosternal pain that he has been experiencing for the past 2 years
3 What other points of the history do you want to know?
4 History, Mr. Burns Consider the following: Characterizationof SymptomsTemporal sequenceAlleviating / Exacerbating factorsAssociated signs/symptomsPertinent PMHROSMEDSRelevant Family HxRelevant Social Hx
5 History Mr. Burns Characterization of Symptoms Temporal sequence Pain is burning in nature, radiates to backTemporal sequenceMore frequent after meals, especially spicyAlleviating / Exacerbating factors:Gets worse when lying down, especially at night, worse after he drinks alcohol or smokesPain improves with antacids
6 History Mr. Burns Associated signs/symptoms: Brings up (regurgitates) partially digested foodReports acid taste in mouthHad a negative workup in the past for a heart attack when he presented to the ER with similar symptomsOccasionally food is getting stuck behind sternumWakes up at night with choking sensation
7 History Mr. BurnsPertinent PMH: hyperlipidemia, asthma, h/o two prior pneumoniasPSH: laparoscopic cholecystectomyROS: feels bloated frequently, no weight loss, avoids eating before bedtime, no vomiting, no melenaMEDS : Lipitor, antacidsRelevant Family Hx: noncontributoryRelevant Social Hx: smoker, social drinker, works at construction site
9 Differential Diagnosis Based on History and Presentation GERDEsophagitisEsophageal DysmotilityGastroparesisEsophageal CancerAchalasiaPUDEsophageal DiverticulumParaesophageal HerniaGastric outlet obstruction
10 What specifically would you look for? Physical ExaminationWhat specifically would you look for?
11 Physical Examination Mr. Burns Vital Signs: Height: 6 foot, Weight 190 lbs, T: 98.6, HR: 84, BP: 146/82Appearance: well developed man in no distressRelevant Exam findings for a problem focused assessmentHEENT: eroded enamelGenital-rectal: no masses, heme positiveChest: mild bilateral wheezingNeuromuscular: non-focal examCV: RRR, no murmurs, rubs or gallopsSkin/Soft Tissue: no rashes, no jaundiceAbd: soft, no masses, no tendernessRemaining Examination findings non-contributory
12 Studies (Labs, X-rays, Diagnostics) What would you obtain?
13 Studies ordered Mr. Burns CBCElectrolytesLFT’sPT/APTTChest X-rayEKGEGD/Colonoscopy
14 Interventions at this point? Educate about lifestyle modifications that may alleviate symptomsSmoking, alcohol and caffeine cessationAvoid meals before bedtimeElevate head of bedWeight loss if patient obeseStart treatment with Proton Pump InhibitorsArrange for follow-up visit
20 Mr. Burn’s pH study note multiple episodes of pH<4 (arrows) Normal 48h pH studyMr. Burn’s pH study note multiple episodes of pH< (arrows)
21 Study ResultsUGI: moderate hiatal hernia, no gastric outlet obstruction with rapid filling of the small bowel, gross esophageal refluxEsophageal manometry: decreased lower esophageal sphincter pressure with normal relaxation, normal esophageal motilityBravo probe: DeMeester score = 47
22 Study result discussion The Bravo probe proves that the esophagitis seen on EGD is a result of abnormal acid exposure of the distal esophagusThe manometry points out the incompetent lower esophageal sphincter which is the underlying reason for the reflux and demonstrates normal motilityThe 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
23 Final DiagnosisGastroesophageal Reflux Disease with incomplete symptom control on PPI
25 Management Continuation of PPI treatment or Antireflux surgery What are the indications for surgery in patients with GERDWhich procedure should be done?
26 Indications for surgery Patients with incomplete symptom control or disease progression on PPI therapyPatients with well-controlled disease who do not want to be on life-long antisecretory treatmentPatients 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
27 Antireflux Surgery Principles Closure of hiatusReplace the GE junction in a high pressure zone byReestablishment of intraabdominal esophageal length (2-3 cm)Recreation of valve mechanism by stomach wrap around the esophagusThe gold standard is laparoscopic Nissen fundoplication
28 Operative findings - Hiatal Hernia On the right a small hiatal hernia is demonstrated. On the left a moderate size paraesophageal hernia is seen.
29 Hiatal Closure Esophagus Esophagus Left Crus Crural Closure Right Crus On the right the crura have been dissected out and on the left they are approximated with permanent sutures over a Bougie
31 Mr Burn’s Endoscopic Images Preoperative retroflexed view of GE junction with patulous hiatus (arrow)Retroflexed view of GE junction after Nissen fundoplication
32 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?
33 DiscussionMr Burns is likely to benefit from surgery because his symptoms consist primarily of regurgitation and extraesophageal manifestations that are poorly controlled by PPIsIn the absence of these symptoms he should be maintained on PPI therapy unless he chose to have surgery as an alternative to medical treatment
34 DiscussionIf 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 comorbiditiesIn the presence of impaired esophageal motility, a partial fundoplication or a “floppy” Nissen should be considered to minimize the chance of postoperative dysphagia34
36 SummaryGERD is a very common disease in the US and can be managed medically in most patientsPPI are the gold standard and should be the initial treatment of choice in patients with uncomplicated classic symptomsPatients 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
37 SummarySurgery is a very effective treatment of GERD with symptom resolution in over 90% of patients and excellent quality of lifeRandomized 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 therapyPatients should be carefully selected for surgery37
38 AcknowledgmentThe preceding educational materials were made available through the ASSOCIATION FOR SURGICAL EDUCATIONIn order to improve our educational materials we welcome your comments/ suggestions at: