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

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 Temporal sequence 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 Diagnosis Based on History and Presentation GERD Esophagitis Esophageal Dysmotility Gastroparesis Esophageal Cancer Achalasia PUD Esophageal Diverticulum Paraesophageal Hernia Gastric outlet obstruction

What specifically would you look for? 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 wheezing Neuromuscular: non-focal exam CV: RRR, no murmurs, rubs or gallops Skin/Soft Tissue: no rashes, no jaundice Abd: soft, no masses, no tenderness Remaining Examination 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 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 junction with regular Z-line (arrows) Mr. Burn’s EGD showing erosive esophagitis (erosions indicated by arrows)

Are there any further studies indicated and why? 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 Mr. Burn’s pH study note multiple episodes of pH<4 (arrows)

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 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

Nissen fundoplication Esophagus Fundoplication

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 34

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 37

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