Non Cardiac Chest Pain (NCCP) Related to GERD

Dadang Makmun Division of Gastroenterology Department of Internal Medicine Medical Faculty University of Indonesia, Jakarta
(Jakarta March 12, 2011 - KPPIK FKUI )

INTRODUCTION
GERD is the pathologic condition caused by effortless movement of gastric contents to the esophagus, including symptoms or signs referable to the esophagus, pharynx, larynx and respiratory tract esophagus as well as extra esophagus manifestation severe complication: Stricture Barretts esophagus Adenocarcinoma

The Montral definition of GERD

GERD is a condition which develops when the reflux of stomach content causes troublesome symptoms and / or complications Esophageal Syndromes
Extra-esophageal Syndromes

Symptomatic Syndromes
Typical Reflux Syndrome Reflux Chest Pain Syndrome

Syndromes with Esophageal Injury

Reflux Esophagitis Reflux Stricture Barretts Esophagus Adenocarcinoma

Established Associations
Reflux Cough Reflux Laryngitis Reflux Asthma Reflux Dental Eros.

Proposed Associations
Pharyngitis Sinusitis Idiopathic Pulmonary Fibrosis Recurrent Otitis Media

Vakil N et al. Am J Gastroenterol 2006; in press

CLINICAL MANIFESTATION Spectrum of Gastroesophageal Reflux Disease

Organ General Symptoms Esophagus Throat Mouth Lung Types of Disease Manifestation Belching, heartburn, regurgitation, chest pain, dysphagia, pharyngeal soreness, hoarseness, coughing Erosion, ulcer, stricture, Barretts metaplasia, adenocarcinoma Pharyngitis, laryngitis, sinusitis, aphonia, laryngeal stenosis, cancer Tooth decay, gingivitis Asthma, chronic obstructive pulmonary disease, pneumonia

Fass, 2004

Kasus :
Ny. X 38 thn, karyawati sebuah bank nasional (supervisor) sejak satu bulan yang lalu sering mengeluh sakit dada bagian tengah, seperti ditusuk-tusuk, kadang2 rasa sakit tembus sampai ke punggung. Pasien sering mengeluh rasa kembung, kadang2 jika sedang menelan makanan seperti tertahan di dada bagian tengah. Pasien sesekali mencoba minum obat penghilang rasa sakit (pain killer) dari toko obat namun tidak menolong, keluhan tetap ada bahkan makin sering terasa

Kasus : (lanjutan)
Karena kadang2 terasa kembung, pasien sering mencoba obat maag yang dijual bebas namun keluhan tidak banyak berkurang. Pada pemeriksaan fisik: TD 120/80, nadi:72x/menit, pernafasan normal. Conjunctiva tidak anemis, sclera tidak ikterik. Pemeriksaan jantung, paru, abdomen dan ekstremitas tidak ditemukan kelainan yang nyata

Kasus : (lanjutan)
Pertanyaan:
Apa diagnosis kerja pada pasien ini ? Apa rencana penatalaksanaan selanjutnya ?

Kasus : (lanjutan)
Hasil pemeriksaan penunjang yang dilakukan:
Lab: darah tepi, fungsi hati, fungsi ginjal serta gula darah dalam batas-batas normal. Foto thoraks: cor dan pulmo tak tampak kelainan EKG: dalam batas-batas normal

Pertanyaan:
Apa diagnosis kerja pada pasien ini ? Pemeriksaan dan penatalaksanaan apa yang harus dilakukan ?

Kasus : (lanjutan)
Pasien dikonsulkan ke ahli penyakit jantung. Setelah dilakukan pemeriksaan yang memadai disimpulkan bahwa tidak ada kelainan jantung. Ultrasonografi menunjukkan bahwa organ2 intraabdomen (hepar, lien, kandung empedu, ginjal dan pankreas) dalam batas normal Pemeriksaan endoskopi saluran cerna bagian atas (esofagogastroduodenoskopi) menunjukkan adanya erosi/ulkus superficial multipel yang memanjang didekat LES

Kasus : (lanjutan)
Pertanyaan:
Apa diagnosis pada pasien ini ? Apa rencana pengobatan selanjutnya ?

Pathophysiology of GERD
salivary HCO3

Impaired mucosal defence

esophageal clearance of acid (lying flat, alcohol, coffee) Hiatus hernia acid output (smoking, coffee) intragastric pressure (obesity, lying flat)

Impaired LES (smoking, fat, alcohol) transient LES relaxations basal tone
Bile and pancreatic enzymes

Pepsin

H+

bile reflux

gastric emptying (fat)

de Caestecker, BMJ 2001; 323:7369. Johanson, Am J Med 2000; 108(Suppl 4A): S99103.

Refluxed acid and pepsin causes pain and cell damage

Penetration of acid and pepsin allows contact of acid with nerve endings Entry of acid into cells via the basolateral membrane, leading to cell edema and necrosis

acid pepsin bicarbonate Nerve ending

Orlando RC. Am J Gastroenterol 1996;91: 16926

Heartburn affects many aspects of everyday life in adults with GERD

Individuals affected (%)
100% 80% 60% 40% 20% 0%

n >130,000

Intimacy/sex

Playing with kids

Enjoying food

Travel for pleasure

Socializing

Eating out

Time with spouse

Gardening

Business travel

Sleep

Family activities

Exercise

Hobbies

Activity affected

Liker H et al. J Am Board Fam Pract 2005;18:393400

Team sports

Work

Grade A esophagitis

Grade B esophagitis

Grade C esophagitis

Grade D esophagitis

Barretts esophagus

 NCCP chest pain of esophageal origin Defined as recurring angina-like substernal chest pain of non cardiac origin Overall prevalence of NCCP 23,1% in one population base (Fass, 2004) inversely associated with increasing age. Squeezing or burning substernal chest pain, which may radiate to the back, neck, arms and jaws most of these patients are evaluated initially by a cardiologist

Different underlying mechanisms for noncardiac chest pain

 The mechanism by which acid reflux causes heartburn in some patients and chest pain in others remainds poorly understood The prevalence of erosive esophagitis in patients with GERD-related NCCP has been reported to be varied from 10-70% is likely to be related to the different population

The proton pump inhibitor (PPI) test why? Readily available and at the disposal of primary care physicians Increases the role of primary care physicians in evaluating and treating patients with spectrum of GERD Decreases patients discomfort-less invasive tests Offres significant cost saving

The proton pump inhibitor test in patients with NCCP

Group (first author) Young Squillace Fass Patients, n Proton pump inhibitor Omeprazol Omeprazol Omeprazol Dose Cutoff symptom improvement, % 75 50 50 Duration, days Sensitivity, %

30 17 37

80 mg/day 80 mg/day 40 mg AM/ 20 md PM 20 mg AM/ 20 mg PM 60 mg AM/ 30 mg PM

1 1 7

80 69 78

Fass

36

Rabeprazole

50

78

Fass

40

lansoprazole

50

78

Fass, Dig Dis 18(1):20-26. 2000

MANAGEMENT
Even though this condition is rarely fatal because of long-term complication (ulceration, esophageal stricture, Barretts esophagus) GERD requires adequate management Management of GERD:
Lifestyle modification Drugs Surgical therapy Endoscopic therapy

Goals in the management of GERD

Provide complete (sufficient) relief from heartburn and other symptoms Heal underlying esophagitis Maintain symptomatic and endoscopic remission

Treat or, ideally, prevent complications

Dent et al 1999

Lifestyle modifications for the management of GERD

Reduce weight Stop smoking Elevate head of bed

Modifications Avoid reflux-promoting agents (e.g. alcohol, coffee, some foods) (not evidence based) Eat small meals, no late meals, reduce fat Consider alternatives to reflux-promoting drugs (e.g. theophylline, anticholinergics)

Mainstream options for therapy of GERD

Highest efficacy
? x2 daily PPI + H2RA x2 daily PPI

Recommended
x1 daily PPI x1 daily PPI Prokinetic + H2RA Prokinetic*

Current guidelines

OR

H2RA*

Should be abandoned

Antacids + lifestyle Antacids

Lowest efficacy
*no clear dose-response established

Lifestyle after Dent et al 2002

Diagnosis and treatment flow chart for NCCP.

NCCP Alarm Symptoms

PPI test (for 7 days) Treat as GERD (at least double-dose PPI)

24-hour esophageal pH monitoring (off therapy)

Upper endoscopy

Treat mucosal findings Treat as GERD

Taper down to lower PPI dose that controls symptoms

Esophageal manometry

Alarm symptoms: dysphagia, odynophagia, Weight loss, anorexia, anemia

Spastic motility disorders: calcium channel blockers, nitrates, pain modulators Achalasia: calcium channel blockers, nitrates, botulinum toxin, pnuematic dilation, sugery

Pain modulators

(PPI=proton pump inhibitor; GERD = gastroesophageal reflux disease, NCCP = noncardiac chest pain)

Thank You