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

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Chest Pain (GERD) Dimitrios Stefanidis, MD, PhD Steven B. Goldin, MD, PhD Slide 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 Slide 3 History What other points of the history do you want to know? Slide 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 Slide 5 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 Slide 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 Slide 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 Slide 8 What is your Differential Diagnosis? Slide 9 Differential Diagnosis Based on History and Presentation GERD Esophagitis Esophageal Dysmotility Gastroparesis Esophageal Cancer Achalasia PUD Esophageal Diverticulum Paraesophageal Hernia Gastric outlet obstruction Slide 10 Physical Examination What specifically would you look for? Slide 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: HEENT: eroded enamel Genital-rectal: no masses, heme positive Chest: mild bilateral wheezing Neuromuscular: non-focal exam CV: CV: RRR, no murmurs, rubs or gallops Skin/Soft Tissue: Skin/Soft Tissue: no rashes, no jaundice Abd: Abd: soft, no masses, no tenderness Remaining Examination findings non-contributory Slide 12 Studies (Labs, X-rays, Diagnostics) What would you obtain? Slide 13 Studies ordered Mr. Burns CBC Electrolytes LFTs PT/APTT Chest X-ray EKG EGD/Colonoscopy Slide 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 Slide 15 Follow-up visit Heartburn improved, regurgitation continues CBC, Electrolytes, LFTs, PT/PTT normal EKG, CXR normal Colonoscopy normal EGD Erosive esophagitis, H.pylori negative, no Barretts, moderate size Hiatal hernia, patulous hiatus Slide 16 EGD images Normal GE junction with regular Z-line (arrows) Mr. Burns EGD showing erosive esophagitis (erosions indicated by arrows) Slide 17 Given this patients heartburn improvement, how would you like to proceed with his treatment? Are there any further studies indicated and why? Slide 18 Studies ordered UGI Esophageal manometry Bravo probe The above tests were ordered due to continuation of regurgitation and atypical reflux symptoms (asthma) Slide 19 UGI Slide 20 Mr. Burns pH study note multiple episodes of pH


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