Chest pain of unknown Chest pain of unknown origin (CPUO): role of origin (CPUO): role of the esophagus the esophagus Richard I. Rothstein, MD Richard I. Rothstein, MD Chief, Section of Gastroenterology and Chief, Section of Gastroenterology and Hepatology Hepatology Dartmouth Hitchcock Medical Center Dartmouth Hitchcock Medical Center Professor of Medicine Professor of Medicine Dartmouth Medical School Dartmouth Medical School
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Chest pain of unknown Chest pain of unknown origin (CPUO): role of the origin (CPUO): role of the
esophagusesophagus
Richard I. Rothstein, MDRichard I. Rothstein, MDChief, Section of Gastroenterology and HepatologyChief, Section of Gastroenterology and Hepatology
Dartmouth Hitchcock Medical CenterDartmouth Hitchcock Medical CenterProfessor of MedicineProfessor of Medicine
Dartmouth Medical SchoolDartmouth Medical School
Chest Pain of Unknown OriginChest Pain of Unknown Origin
Prognosis for angina-like pain with Prognosis for angina-like pain with normal coronary anatomynormal coronary anatomy
Chambers, Prog Cardiovasc Dis 1990
Kemp, Am J Med 1973
Functional Status – normal Functional Status – normal coronary anatomycoronary anatomy
Ockene N Engl J Med 1980
Reflux common in pts Reflux common in pts withwith coronary diseasecoronary disease
• Rare for esophageal pathologyRare for esophageal pathology• Question the “non-cardiac”Question the “non-cardiac”• Reassurance, tincture of timeReassurance, tincture of time
Subgroups of Patients With Chest Subgroups of Patients With Chest PainPain
IsolatedIsolatedChestChestPainPain
• HeartburnHeartburn
• RegurgitationRegurgitation
• DysphagiaDysphagia
• Water brashWater brash
• NauseaNausea
• VomitingVomiting
Evaluate or treat for recognized esophageal disordersEvaluate or treat for recognized esophageal disorders
WithWithEsophagealEsophagealSymptomsSymptoms
Subgroups of Patients With Chest Subgroups of Patients With Chest PainPain
EndoscopyEndoscopy
Detection of Esophageal Disorders Detection of Esophageal Disorders Potentially Responsible for Potentially Responsible for
Allows normal activities, showering and does not interfere with sleeping
Bravo pH System™Bravo pH System™
pH Capsule
Catheter
Handle
Bravo pH Capsule with Bravo pH Capsule with Delivery SystemDelivery System
Step 1
Position Bravo Capsule
Step 2
Apply Suction
Step 3
Advance Pin
Step 5
Begin pH Recording
Step 4
Release Capsule
Capsule Attachment
pH Capsule transmits data to pager-sized Receiver
pH Capsule
Receiver
Bravo pH ReceiverBravo pH Receiver
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)
Digital Radio-TelemetryDigital Radio-Telemetry
Esophageal Testing in 123 Patients with Chest Pain Esophageal Testing in 123 Patients with Chest Pain and Normal Coronary Arteriogramsand Normal Coronary Arteriograms
PPI Trial in GERD Patients With PPI Trial in GERD Patients With Non-Cardiac Chest PainNon-Cardiac Chest Pain
37 patients with daily chest pain and negative cardiologic 37 patients with daily chest pain and negative cardiologic evaluationevaluation
Categorized as GERD+ or GERD- by EGD and pH studyCategorized as GERD+ or GERD- by EGD and pH study Randomized to omeprazole (40 mg q AM and 20 mg q PM for 7 Randomized to omeprazole (40 mg q AM and 20 mg q PM for 7
days) or placebo then crossed over after washoutdays) or placebo then crossed over after washout 50% reduction in symptoms constituted positive response50% reduction in symptoms constituted positive response
Characteristics of the PatientsCharacteristics of the Patients
59% reduction in number of diagnostic 59% reduction in number of diagnostic procedures procedures ($573 savings per patient evaluation)($573 savings per patient evaluation)
Fass R, et al Gastroenterol 1998; 115:42-9Fass R, et al Gastroenterol 1998; 115:42-9
Positive Positive OTOT
Results of Economic AnalysisResults of Economic Analysis
Role of endoscopyRole of endoscopy Reassurance factorReassurance factor Once-in-a-lifetime Barrett’s checkOnce-in-a-lifetime Barrett’s check
IssuesIssues
LA Grade CLA Grade C LA Grade DLA Grade D
One or more mucosal breaks no longer than 5mm, not bridging the tops of mucosal folds
One or more mucosal breaks no longer than 5mm, not bridging the tops of mucosal folds
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
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
One or more mucosal breaks 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 BLA Grade BLA Grade ALA Grade A
Los Angeles (LA) Grade Los Angeles (LA) Grade Classification of Erosive EsophagitisClassification of Erosive Esophagitis
Lundell et al. Gut. 1999;45:172-180.Lundell et al. Gut. 1999;45:172-180.
The spectrum of heartburn frequency The spectrum of heartburn frequency and severity is similar in GERD patients and severity is similar in GERD patients
with and without esophagitiswith and without esophagitis
Severe
Moderate
Mild
Patients without esophagitisSeverity ofheartburn
Smout 1997
Patients with esophagitis
GERD Therapeutic OptionsGERD Therapeutic Options
ProkineticsProkinetics
OTC or prescription OTC or prescription H2RAsH2RAs
Full thickness plication – i.e., NDOFull thickness plication – i.e., NDO Radiofrequency ablation – i.e., StrettaRadiofrequency ablation – i.e., Stretta Injection therapy with augmentation of LES Injection therapy with augmentation of LES
– i.e., Enteryx– i.e., Enteryx Bulking procedures with augmentation of Bulking procedures with augmentation of
LES – i.e., GatekeeperLES – i.e., Gatekeeper
BARD EndoCinchBARD EndoCinch
Suction of tissue Suction of tissue just beneath z-linejust beneath z-line
Needle with Needle with pre-loaded pre-loaded suture advancedsuture advanced
Cinching/cutting Cinching/cutting catheter catheter advanced to advanced to tissuetissue
Final appearance Final appearance of plication in of plication in cardiacardia
NDO Plicator™NDO Plicator™
Plicator and gastroscope Plicator and gastroscope retroflexed retroflexed
Initial Perception Threshold (S1) Before and 40 Initial Perception Threshold (S1) Before and 40 Minutes after Octreotide InjectionMinutes after Octreotide Injection
BaseBase 40 min40 min00
1010
2020
3030
>30>30
CC
CC
pp < 0.02 < 0.02
Johnson BT, et al Am J Gastroenterol 1999; 94:65-70Johnson BT, et al Am J Gastroenterol 1999; 94:65-70
Maximally Tolerated Pain Threshold (S2) Before and 40 Maximally Tolerated Pain Threshold (S2) Before and 40 Minutes after Octreotide InjectionMinutes after Octreotide Injection
BaseBase 40 min40 min00
1010
2020
3030
>30>30
CC
CC
Johnson BT, et al Am J Gastroenterol 1999; 94:65-70Johnson BT, et al Am J Gastroenterol 1999; 94:65-70
Overlap Syndrome of Altered Pain Overlap Syndrome of Altered Pain SensitivitySensitivity
Approach to the NCCP PatientApproach to the NCCP Patient
Take a historyTake a history Exclude coronary / cardiac diseaseExclude coronary / cardiac disease Check for musculoskeletal diseaseCheck for musculoskeletal disease Look for GERDLook for GERD Check for dysmotilityCheck for dysmotility Consider esophageal hyperalgesiaConsider esophageal hyperalgesia Collaborative managementCollaborative management