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Chest pain of unknown origin (CPUO): role of the esophagus

Chest pain of unknown origin (CPUO): role of the esophagus. Richard I. Rothstein, MD Chief, Section of Gastroenterology and Hepatology Dartmouth Hitchcock Medical Center Professor of Medicine Dartmouth Medical School. Chest Pain of Unknown Origin.

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Chest pain of unknown origin (CPUO): role of the esophagus

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  1. Chest pain of unknown origin (CPUO): role of the esophagus Richard I. Rothstein, MD Chief, Section of Gastroenterology and Hepatology Dartmouth Hitchcock Medical Center Professor of Medicine Dartmouth Medical School

  2. Chest Pain of Unknown Origin

  3. Prognosis for angina-like pain with normal coronary anatomy Chambers, Prog Cardiovasc Dis 1990 Kemp, Am J Med 1973

  4. Functional Status – normal coronary anatomy Ockene N Engl J Med 1980

  5. Reflux common in pts with coronary disease n = 30, 164 chest pain episodes Singh, Ann Intern Med,1992; 117:824-30

  6. Abnormal esophageal motility (n = 910) (n = 255) Katz, Ann Intern Med, 1987; 106:593-7

  7. Edrophonium Testing 80 mcg/Kg IV

  8. Diagnostic Yield of Esophageal Testing Katz, Ann Intern Med, 1987; 106:593-7

  9. Intraesophageal Balloon Inflation:Esophageal Hypersensitivity n = 30 NCCP, 30 controls Richter, Gastroenterol, 1986; 91:845-52

  10. Provocative Testing Barrish, Dig Dis Sci, 1986; 31:1292-8

  11. Anxiety/Somatization Neurosis Subgroups of Patients With Chest Pain With Esophageal Symptoms Isolated Chest Pain

  12. Subgroups of Patients With Chest Pain Isolated Chest Pain • Rare for esophageal pathology • Question the “non-cardiac” • Reassurance, tincture of time

  13. Subgroups of Patients With Chest Pain • Heartburn • Regurgitation • Dysphagia • Water brash • Nausea • Vomiting With Esophageal Symptoms Evaluate or treat for recognized esophageal disorders

  14. Esophageal stricture/web • Achalasia • Esophageal spasm Barium swallow ± manometry pH • EGD-negative GERD Detection of Esophageal Disorders Potentially Responsible for Symptoms • Reflux esophagitis • Infectious esophagitis • Pill esophagitis • Esophageal cancer • Esophageal stricture/web Endoscopy

  15. pH testing - Conventional Catheter Based: • Patient Intolerance • Uncomfortable • Pharyngeal and Throat Discomfort • Runny Nose • Artifact Prone • Alters Regular Diet and Activity

  16. Bravo pH System™ • Catheter-Free pH Monitoring System • pH Capsule attached to the esophageal wall transmits data to pager-sized Receiver • Eliminates uncomfortable 24-hr trans-nasal catheter • Allows normal activities, showering and does not interfere with sleeping

  17. Bravo pH Capsule with Delivery System Handle Catheter pH Capsule

  18. Capsule Attachment Step 1 Position Bravo Capsule Step 2 Apply Suction Step 3 Advance Pin Step 4 Release Capsule Step 5 Begin pH Recording

  19. Bravo pH Receiver • pH Capsule transmits data to pager-sized Receiver Receiver pH Capsule

  20. Digital Radio-Telemetry • Use Digital Radio-Telemetry • Capsule measures pH every 6 sec and transmits data to receiver every 12 sec • Keep the receiver within 1m to prevent data loss (range up to 3m)

  21. Esophageal Testing in 123 Patients with Chest Pain and Normal Coronary Arteriograms Test % Abnormal Ambulatory pH monitoring 82 Esophageal motility 29 Bernstein Test 10 Edrophonium 6 Endoscopy 5 Balloon distention 4 Treadmill with pH monitor 4 Chenan P, et al Dis Esophagus 1995; 8:129

  22. Pulmonary Asthma Bronchitis Aspiration pneumonia Apnea Atelectasis Pulmonary fibrosis ENT Hoarseness Cough Globus Halitosis Vocal cord granuloma Laryngeal stenosis Laryngeal cancer Loss of dental enamel Sinusitis, otitis Atypical presentations of GERD Chest Pain

  23. Esophageal Chest Pain Work-Up • Traditionally • Endoscopy • pH probe • Manometry • Provocative testing • Emerging role for up-front empiricism

  24. PPI Trial in GERD Patients With Non-Cardiac Chest Pain • 37 patients with daily chest pain and negative cardiologic evaluation • Categorized as GERD+ or GERD- by EGD and pH study • Randomized to omeprazole (40 mg q AM and 20 mg q PM for 7 days) or placebo then crossed over after washout • 50% reduction in symptoms constituted positive response • GERD-Positive • n=23 • 78% response • GERD-Negative • n=14 • 14% response Fass et al. Gastroenterology. 1998;115:42-49.

  25. Characteristics of the Patients Patients with NCCP GERD-positive GERD-negative Subjects 23 14 Age (yr) 58.2± 2.3 61.6± 2.8 Range (yr) 35-76 47-83 Sex (M / F) 22 / 1 14 / 0 Upper endoscopy results Normal (grade 0-1) 7 14 Erosive esophagitis (grade 2-5) 16 Ambulatory 24-h esophageal pH monitoring (%)* Mean 9.6± 1.8 1.2± 0.3 Range 0.5-29.1 0.0-2.9 *% total time pH<4 Fass R, et al Gastroenterol 1998; 115:42-9

  26. Enrollment Upper endoscopy & Ambulatory 24-hour esophageal pH monitoring GERD + GERD - Week 1 Baseline symptom assessment Randomization Week 2 Placebo Omeprazole (40 mg AM + 20 mg PM) Washout period Week 3 Baseline symptom assessment Week 4 Fass R, et al Gastroenterol 1998; 115:42-9 Week 5 Omeprazole Placebo (40 mg AM + 20 mg PM)

  27. Omeprazole Test in NCCP Positive OT • 18/23 GERD-positive (78%) • 2/14 GERD-negative (14%) • Sensitivity 78.3% • Sensitivity 85.7% • 59% reduction in number of diagnostic procedures ($573 savings per patient evaluation) Fass R, et al Gastroenterol 1998; 115:42-9

  28. Results of Economic Analysis Conventional work-up OT Difference % Change Cost ($) 2025 1452 573 28 Reduction No. of endoscopies/ 1000 patients 1000 190 810 81 Reduction No. of ambulatory 24-hr pH tests/ 1000 patients 650 140 510 79 Reduction No. of esophageal motility tests / 1000 patients 310 470 -160 52 Increase Total no. of diagnostic procedures / 1000 patients 1960 800 1160 59 Reduction Fass R, et al Gastroenterol 1998; 115:42-9

  29. Omeprazole Test in NCCP Issues • Generalizability? • Male, veteran population • High % esophagitis, GERD symptoms • Pain pattern of frequent chest pain (≥ 3x/wk) • Small numbers, short course treatment • Medication dosing, strength • Role of endoscopy • Reassurance factor • Once-in-a-lifetime Barrett’s check

  30. Los Angeles (LA) Grade Classification of Erosive Esophagitis LA Grade A LA Grade B One or more mucosal breaks no longer than 5mm, not bridging the tops of mucosal folds One or more mucosal breaks longer than 5mm, not bridging the tops of mucosal folds LA Grade C LA Grade D One or more mucosal breaks bridging the tops of mucosal folds involving <75% of the circumference One or more mucosal breaks bridging the tops of mucosal folds involving >75% of the circumference Lundell et al. Gut. 1999;45:172-180.

  31. Patients with esophagitis Patients without esophagitis The spectrum of heartburn frequency and severity is similar in GERD patients with and without esophagitis Severity ofheartburn Severe Moderate Mild Smout 1997

  32. GERD Therapeutic Options Prokinetics “First - aid” : Life-style modifications and antacids OTC or prescription H2RAs Treatments OTC or prescription PPIs Surgery (Lap Nissen fundoplication) Endoscopic techniques (plication, RF, implant)

  33. Life-style Modifications Reduce weight Stop smoking Elevate head of bed Modifications Avoid reflux-promoting agents e.g, alcohol, coffee; some foods • Not evidence-based Consider alternatives to reflux-promoting drugs e.g., theophilline, anticholinergics Eat small meals, no late meals, reduce fat

  34. POSITION AND REFLUX 8 Right side down pH 4 0 8 Left side down pH 4 0 (Katz,LC. Et al, J Clin Gastro 1994;18(4):280-3

  35. GERD HEALING AND ACID CONTROL 100 80 60 Patients Healed (%) 40 20 0 2 4 6 8 10 12 14 16 18 20 22 Duration Intragastric pH >4.0 (Hours) (Bell et al. Digestion. 1992;51(suppl 1):59-67.)

  36. Medical Rx Outcomes(with H2RAs) • Relief of symptoms 50% • Healing esophagitis <50% • Prevent complications --- • Remission 25%

  37. Medical Rx Outcomes (PPIs) • Relief of symptoms 85-95% • Healing esophagitis 85-95% • Prevent complications 80% • Remission 90%

  38. GERD: Endoscopic Therapies • Endoscopic suturing – i.e., Endocinch (this leads to partial thickness plication) • Full thickness plication – i.e., NDO • Radiofrequency ablation – i.e., Stretta • Injection therapy with augmentation of LES – i.e., Enteryx • Bulking procedures with augmentation of LES – i.e., Gatekeeper

  39. BARD EndoCinch Suction of tissue just beneath z-line Needle with pre-loaded suture advanced Cinching/cutting catheter advanced to tissue Final appearance of plication in cardia

  40. NDO Plicator™ 1 2 3 Plicator and gastroscope retroflexed Arms opened, tissue retractor advanced Gastric wall retracted, arms closed. 4 5 Single, pre-tied implant deployed. Full-thickness plication completed

  41. Antegrade techniqueBalloon inflationNeedle deployment1 cm above z-line

  42. Injection at the Z-Line

  43. Gatekeeper™ System Create pocket Stabilize site Access pocket Expansion Deliver prosthesis

  44. MAINTENANCE THERAPY OF GERDOmeprazole vs surgery (Lundel et al: J Am Col Surg, 192:172, 2001)

  45. Outcomes of Atypical GERD Symptoms Treated by LNF Preoperative Postoperative • Atypical Sx Improvement • Overall 58% of patients • Pulmonary 48% • Atypical chest pain 58% • Pharyngo/laryngeal 76% Symptom Score Typical Symptoms (n=115)Improvement 6.2 points Atypical Symptoms (n=35) Improvement 4.4 points So et al. Surgery. 1998;124:28-32.

  46. Esophageal Chest Pain • GERD related • Motility related • Esophageal hyperalgesia

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