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Non-cardiac Chest Pain

Non-cardiac Chest Pain. Vladimir Ferrer , DO MetroHealth Gastroenterology 1.26.14. Differential Diagnosis. Cardiovascular CP related to Hyperadrenergic states Chest wall Pulmonary Mediastinal Psychiatric. GI Esophageal Reflux Rupture Spasm Esophagitis Pancreatobiliary

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Non-cardiac Chest Pain

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  1. Non-cardiac Chest Pain Vladimir Ferrer, DO MetroHealth Gastroenterology 1.26.14

  2. Differential Diagnosis • Cardiovascular • CP related to Hyperadrenergic states • Chest wall • Pulmonary • Mediastinal • Psychiatric • GI • Esophageal • Reflux • Rupture • Spasm • Esophagitis • Pancreatobiliary • Pancreatitis • Cholecystitis • Cholangitis • Biliary Colic • PUD

  3. Non-Cardiac Chest Pain • More than 50% of patients presenting to ED • Sustained concern 1yr after negative LHC • 51% unable to work, 47% limited activity, 44% still with perceived CAD • Esophageal spasms? • 910 patients with negative LHC • 28% with abnormal motility (10% due to spasms) • GERD most common cause • Abnormal acid exposure in 50% in recurrent noncardiac chest pain

  4. Non-Cardiac Chest Pain • Esophageal Hypersensitivity • Lower threshold for non-cardiac chest pain with intraesophageal balloon distension • 24 patients with CP and negative cardiac workup, EGD, Motility studies, 24h pH probe • Typical CP reproduced in 83% compared to none in controls • Related to altered cerebral processing rather than abnormal receptors

  5. Approach to patient • Exclude CAD • Angiography eliminates life-threatening disease as cause of CP • Clues for esophageal etiology • Pain persistent for > 1 hr • Postprandial pain • Lack of pain radiation • Associated esophageal symptoms (heartburn, regurgitation, dysphagia) • Pain relieved by antacid ingestion • Relief with NTG does not indicate cardiac origin • Out of 459 patients, 39% relieved (35% with, 41% w/o)

  6. GERD • Definition: Symptoms or complications resulting from the reflux of gastric contents into the esophagus or beyond, into the oral cavity (including larynx) or lung. • Further classified as the presence of symptoms without erosions on endoscopic examination (non-erosive disease or NERD) or GERD symptoms with erosions present (ERD) Guidelines for the Diagnosis and Management of GERD, Katz, et al; Am J Gastroenterol 2013;108:308-328

  7. Symptoms and Epidemiology • Prevalence of 10-20% of Western world • Clinically troublesome heartburn is seen in about 6% of the population • Regurgitation was reported in 16% • Distinguishing cardiac from non-cardiac chest pain is required before considering GERD as a cause of chest pain. • Although the symptom of dysphagia can be associated with uncomplicated GERD, its presence warrants investigation for a potential complication including an underlying motility disorder, stricture, ring, or malignancy

  8. Symptoms and Epidemiology • Extraesophageal symptoms: chronic cough, asthma, chronic laryngitis, other airway symptoms • Atypical symptoms including dyspepsia (38%), epigastric pain, nausea, bloating, and belching may be indicative of GERD but overlap with other conditions. • QOL: increase time off work, decrease physical functioning, nocturnal > daytime symptoms, sleep disturbances

  9. Symptoms and Epidemiology • Symptom frequency does not change with age • Symptom intensity decreases after age 50 • Aging increases prevalence of erosive esophagitis (LA Grades C and D) • Barrett’s Esophagus increases in prevalence after age 50 (Caucasian males); M > F • Men: more Erosive Esophagitis; Women: more NERD • Esophageal Adenocarcinoma 8:1 male to female • GERD associated with increased BMI, waist circumference, wt gain, ERD, and Barrett’s Esophagus

  10. Diagnosis • Made by combination of: • Symptom presentation • Objective testing with endoscopy • Ambulatory reflux monitoring • Heartburn and regurgitation correlates poorly with presence of Erosive Esophagitis • Sensitivity 30-76% ; Specificity 62-96% • Empiric PPI trial • Sensitivity 78%; Specificity 54%

  11. Diagnosis • Non-cardiac chest pain • Generally associated with GERD • Generally responds to aggressive acid suppression • Cost-effective (when cardiac cause excluded) • Response greater than placebo in patients with objective evidence of GERD (ERD on EGD and/or abnormal pH monitoring) • Dysphagia • Alarming symptom requiring endoscopy

  12. Diagnosis • Unreliable signs and symptoms • Dental erosions, sinusitis, chronic laryngitis, voice disturbance (not reliable) • Reliable symptoms • Heartburn, regurgitation, non-cardiac chest pain • Causal relationship between GERD and extraesophageal symptoms remains difficult with only history

  13. Diagnostic testing for GERD and utility

  14. Diagnostic testing for GERD and utility

  15. Efficacy of Lifestyle Interventions for GERD

  16. Efficacy of Lifestyle Interventions for GERD

  17. Medical Therapy • Antacids, H2RAs, PPIs • PPI vs. H2RAs • Superior healing, decreased relapse rates, greater symptom relief (including NERD) • PPI vs PPI • 7 available, 3 OTC • No significant difference in symptom relief • Administered 30-60 min before meals • Dexlansoprazole (dual-delayed release) • Omeprazole-bicarbonate (control of nighttime pH)

  18. Medical Therapy • PPI • Limited data for switching • BID Lansoprazole as effective as QD Esomeprazole • No data to support switching more than once • Maintenance • Continued in ERD and Barrett’s Esophagus (decrease risk of dysplasia) • 2/3 relapse in NERD • 100% relapse in 6 months for LA Grade B-C • On-demand treatment • Equivalent symptom-free days compared to continuous PPI

  19. Medical Therapy • Incomplete response • Options limited • Tachyphylaxis of H2RA • Prokinetics • No clear role of Reglan in absence of GP • Baclofen • Rescue for refractory GERD • Reduces transient LES relaxations, reflux episodes, nocturnal reflux activity, belching episodes • No long-term data, limited by side effects

  20. Surgical Therapy • Treatment option for long-term therapy • Not recommended if no response to PPIs • pH monitoring mandatory in absence of ERD • As effective as medical therapy in carefully selected patients • Obese patients should be considered for bariatric surgery • Endoscopic or transoralincisionless fundoplication cannot be recommended as alternative to medical or traditional surgical therapy

  21. PPI Potential Risk • PPI switch in the setting of side effects • Patients with know osteoporosis can remain on PPI therapy • Concern for hip fractures and osteoporosis should not affect decision of long-term PPI use except in patients with other risk factors • PPI use a risk factor for C.diff infection • Short-term PPI use associated with CAP • No apparent risk in long-term users • PPI therapy does not need to be altered with use of Clopidogrel • Data does not support increased risk of CV events

  22. Extraesophageal Manifestations • GERD considered as co-factor in asthma, chronic cough, laryngitis, atypical chest pain • Evaluate for non-GERD etiologies • EGD or Laryngoscopy unreliable alone • PPI trial adequate with typical GERD symptoms • BID for up to 2-3 months • Reflux Monitoring before PPI trial with atypical GERD symptoms • Bravo Capsule Study

  23. Bravo Capsule Study

  24. High Resolution Manometry

  25. HRM: Achalasia

  26. HRM: Nutcracker & DES

  27. Approach to the Patient

  28. The end

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