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
History
What other points of the history do
you want to know?
History, Mr. Burns
Consider the following:
• Characterization
• Associated signs/symptoms
of Symptoms
• Temporal sequence
• Alleviating /
Exacerbating factors
• Pertinent PMH
• ROS
• MEDS
• Relevant Family Hx
• Relevant Social Hx
History Mr. Burns
 Characterization of Symptoms
•
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
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 Skin/Soft Tissue: no rashes,
or gallops
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)
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
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
Right Crus
Left Crus
Esophagus
Crural Closure
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
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
Acknowledgment
The preceding educational materials were made available through the
ASSOCIATION FOR SURGICAL EDUCATION
In order to improve our educational materials we
welcome your comments/ suggestions at:
feedbackPPTM@surgicaleducation.com