Time for another quick clinical case
Your next patient is Joan – a semi-regular attender to your family practice.
Joan is a 67 yo woman who is usually reasonably well. She works as a book keeper in a small business.
She has been troubled by some gastro-oesophaeal reflux symptoms over the last few years and has been taking some omeprazole “most days” for symptom relief.
Today she presents with a sheaf of discharge letters from the local ED. 7 in total! She has been seen in the ED 7 times in the last 6 weeks with “chest pain – non-specific”.
She tells you that she has been experiencing dull, spasms of pain in her substernal area that sometimes radiate to her back. They are not really like her usual ‘heartburn’ symptoms. She doesn’t feel sick or sweaty. Just worried.
These are quite unpleasant and stop her from working at her computer. The last couple of episodes have occurred at night and woken her from sleep – her husband has called the ambulance service twice in the last fortnight! On each attendance to the ED she has been “fast tracked” into the chest pain protocolised management. And spent a few uncomfortable nights on a stretcher in the corridor of the ED….. awaiting a second troponin.
Amidst the paperwork there are formatted letters from ED interns, Registrars and even one from a consultant ED Physician.
There are a batch of plumb normal ECGs and photocopies of many negative troponin results. She even stayed in for an exercise stress test one day – which was non-suggestive of ischemia.
She has been diagnosed consistently with: “Chest pain – non-specific.” or “Chest pain, not cardiac.” on each occasion. On the latest visit the senior Doc has ventured a positive diagnosis – “Probable Oesophageal spasm.”
Interestingly there have been a number of therapeutic trials of “Pink Lady” i.e.. the Mylanta & Xylocain viscous cocktail so loved by triage nurses the world over! Joan says that the pain is usually short-lived – coming in spasms. It seems to go away after a few minutes then return. She says a lot of the doctors ordered the Pink stuff and when her pain got better… told her it was from her oesophagus. [ see this post from Dr Seth Trueger on this topic. ] Maybe best left until after the troponin has settled the question!!
She has received advice to take her omeprazole twice a day and to follow up with her GP. OK, here she is….
So, it seems clear that she is in the low-risk group for cardiac disease as a cause of her chest pain. Let us assume that the ED Docs have excluded ACS as a cause.
SO, if you are the GP how do you go about making an actual diagnosis in this scenario?
Is a therapeutic trial of PPIs a reasonable strategy?
Depends…. are you trying to give relief to the patient or make a diagnosis? After searching through the databases I found this decent sized trial from Flook et al, in Amer Journal of Gastroenterology (January 2013)
It looked at 600 patients with reflux symptoms giving chest pain. A placebo, RCT (esomeprazole 40 mg BD for 4 weeks) They found a significant improvement in symptoms at the end – but this was really only for patients with less frequent reflux sx at the outset. Not so effective for the pts with more than 2 days a week of symptoms.
There is also a meta-analysis [Wang et al, JAMA, June 2005 ] looking at 6 papers ( only 220 pt in total) which tried to answer the question about the diagnostic characteristics of a “trial of PPI” for reflux-related chest pain in patients with “non-cardiac chest pain” . The conclusion of the authors was that is was an acceptable “test” with a sensitivity of 80% and specificity of 74% roughly. So – it might help – but to my mind those are not stellar numbers. I would want a reasonable high or low pretest probability of “GORD” before hanging my patient’s hat upon those figures.
Should she have endoscopy to look for serious upper GI problems?
Well that is a tricky one. Not a lot of data. Just opinion. The surgeons that I work with would suggest everyone with severe enough , persistent symptoms should probably have a scope to exclude malignancy or other correctable lesions in the oesophagus. In the good old days we would send them for a Barium swallow. But nowadays it seems easy to get a scope, and then you have the option of a CLO, biopsy or whatever else they need on the day.
So I think it is reasonable to get a scope if you have persisting symptoms or severe symptoms so that you know what you are dealing with. It would be disastrous and unfortunate to treat a malignant process for months and months with symptomatic care.
What is the role of manometry or pH monitoring to try and correlate her symptoms with events in her oesophagus?
This is not something that I really see much of – but I work a long way from any Gastroenterolgists! Certainly I have seen this done in patients with bad GORD – i.e.. those whom are contemplating a fundoplication procedure.
Found this paper in the BMJ – Barham et al from Gut, 1997. [Diffuse oesophageal spasm: diagnosis ] It is old – but suggests that for intermittent symptoms like our patient is suffering – you really need to get continuous outpatient / 24 hour ambulatory monitoring of pH and pressure in order to make this diagnosis. Diffuse oesophageal spasm is also known as “nutcracker oesophagus” or “corkscrew oesophagus” as it has characteristic appearances on imaging. However – you would be lucky to see this phenomenon as it is fleeting! IN order to correlate symptoms with measured anomalous peristalsis or pH spikes – you would need ambulatory monitoring. I guess it is like the Holter of the gut?
The task of the ED team is to exclude life threatening diseases and give relief from symptoms.
When it comes to chest pain – once the serious diagnoses have been “excluded” to a reasonable degree of certainty [aortic dissection, ACS, pneumothorax, large PE….] then we are left with a cluster of other possibilities.
These are rarely “diagnosed” in the ED. The evidence would suggest that the oesophagus is a major source of chest pain in this group – with GORD and motility disorders being the most likely disease processes.
So – if you want to have a go at symptom relief after excluding the bad diagnoses then it seems reasonable to tackle the oesophagus as your first step.
Given to complex and costly nature of the investigations involved – this is not really within the scope of the ED provider to actually ‘make’ these diagnoses. They can wait until review by the primary care doc or Gastro team if warranted.
But… it would seem that a trial of a decent dose of PPI is not a bad option. There seems to be little on the downside and a good number of patients will get symptomatic relief. In my opinion – if you are going to do this then give a good dose for a reasonable period [as in above study] e.g.. a month of b.i.d. PPI-de jour seems like a good start. ** This is my opinion – not evidence*
This may even prevent them needing to come back to the ED with subsequent chest pain and go through the whole rigmorole again! Not that this should be a primary objective of therapy – but it does seem to be a win-win for patient and the ED.