1. Dimitrios Stefanidis, MD, PhD Steven B. Goldin, MD, PhD
Chest Pain (GERD)
Dimitrios Stefanidis, MD, PhD
Steven B. Goldin, MD, PhD

2. 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

3. What other points of the history do you want to know?

4. 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

5. 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

6. 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

7. 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

8. What is your Differential Diagnosis?

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

10. What specifically would you look for?
Physical Examination
What specifically would you look for?

11. 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

12. Studies (Labs, X-rays, Diagnostics)
What would you obtain?

13. Studies ordered Mr. Burns
CBC
Electrolytes
LFT’s
PT/APTT
Chest X-ray
EKG
EGD/Colonoscopy

14. 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

15. 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

16. EGD images Normal GE junction
with regular Z-line (arrows)
Mr. Burn’s EGD showing erosive esophagitis
(erosions indicated by arrows)

17. 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?

18. Studies ordered UGI Esophageal manometry Bravo probe
The above tests were ordered due to continuation of regurgitation and atypical reflux symptoms (asthma)

19. UGI

20. 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< (arrows)

21. 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

22. 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

23. Final Diagnosis
Gastroesophageal Reflux Disease with incomplete symptom control on PPI

24. What next?

25. Management Continuation of PPI treatment or Antireflux surgery
What are the indications for surgery in patients with GERD
Which procedure should be done?

26. 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

27. 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

28. Operative findings - Hiatal Hernia
On the right a small hiatal hernia is demonstrated. On the left a moderate size paraesophageal hernia is seen.

29. 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

30. Nissen fundoplication
Esophagus
Fundoplication

31. Mr Burn’s Endoscopic Images
Preoperative retroflexed view of GE junction with patulous hiatus (arrow)
Retroflexed view of GE junction after Nissen fundoplication

32. 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?

33. 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

34. 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

35. QUESTIONS ??????

36. 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

37. 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

38. Acknowledgment
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