Transcript NCCP
Dr Charles Panackel
Consultant Gastroenterologist
Medical Trust Kochi
Introduction
25% of general population experience chest pain at
some point of life
Of these only 11 -39% have cardiac pain
Definition
Noncardiac Chest pain can be defined as recurrent
angina-like or substernal chest pain believed to be
unrelated to the heart after reasonable cardiac
evaluation.
What is reasonable ???
Unexplained Chest Pain (UCP)
Epidemiology
• The mean annual prevalence of NCCP in the general
population is approximately 23-33%
• NCCP accounts for approximately 2% to 5% of all
presentations to hospital emergency
• Both sexes equally affected
• Women seek medical attention more commonly
Epidemiology
Prevalence of NCCP decrease with increasing age.
Patients with NCCP are
Younger,
Consume greater amounts of alcohol,
Smoke more,
Suffer from anxiety than their counterparts with ischemic heart
disease.
Natural History
The long-term mortality of NCCP is low with
reported rates of 1% at 10 yr
Morbidity is high
• At one year after diagnosis, it is seen that 47% limited
their activities, 51% were unable to work and 44% still
believed they had CAD.
NCCP patients have continued high rates
healthcare use
Differential Diagnosis
NCCP
Miscellaneous
16%
Musculoskeletal
36%
Pulmonary
pericardial
Panic disorder
7.5%
5%
Esophageal
19%
Gastric/Biliary
Pancreatic
Chest pain of Esophageal origin
Osler in 1892 first suggested that esophagus may be
source for Unexplained chest pain
23–80% of Patients with Unexplained chest pain have
esophageal abnormalities
Differential Diagnosis
Psychological
comorbidity
Esophageal
Esophageal dymotility
GERD
Functional chest pain
of esophageal origin
15-18%
50-60%
32 -35%
Pathophysiology
Chest pain of esophageal origin could be caused by
• Noxious event in the esophagus,
• Acid reflux
• Nonacid reflux
• Esophageal distension
• Disturbed motility
• Abnormal mechanophysical properties of esophagus
• Sustained contractions of longitudinal muscles
• Visceral hypersensitivity
Decrease in the esophageal nociceptive sensory receptor threshold,
Disorder in the nociceptive pathway in the peripheral or central nervous system
Autonomic dysregulation
Altered central processing of pain stimuli
Somatoform disorders
GERD and NCCP
GERD and NCCP
GERD is by far the most common cause for NCCP
Esophageal Dysmotility and NCCP
28% of patients with Non
GERD related NCCP
No correlation between
symptoms and abnormality
on Manometry
Response to muscle
relaxants poor
Functional chest pain of presumed
esophageal origin
Recurrent episodes of substernal chest pain of visceral
quality with no apparent explanation.
GERD and esophageal dysmotility should be ruled out.
Up to 80% of the patients with functional chest pain
exhibit other functional disorders
Visceral and somatic hypersensitivity
Approach to Non Cardiac Chest
Pain
Cardiac source reasonably ruled out.
Other causes ruled out
Approach to Noncardiac Chest Pain
A careful, thorough history looking for cardiac risk factors,
12-lead ECG, chest radiograph,
Serial measurements of cardiac enzymes,
If the patient is stable and the etiology is still unclear,
echocardiography and TMT
Coronary angiogram
What should be done next?
Endoscopy
Ambulatory pH monitoring
Combined Impedance-pH testing
Esophageal manometry
Acid suppression therapy or PPI test.
Endoscopy
Variable diagnostic yield (10-44%) in NCCP
patients
Not likely to change management
Reserved for patients with NCCP and alarm
symptoms (Anemia, Dysphagia, GI Bleed, Persistent Vomiting, Weight loss)
Ambulatory 24 hr pH TESTING
Ambulatory 24 hr pH TESTING
Sensitivity has ranged from 79% to 96% and specificity
from 85% to 100%
Can be done on or off PPIs.
Diary allows correlation between symptoms and acid
reflux.
Ambulatory 24 hr pH TESTING
Invasive- greater pt discomfort ( occ chest pain)
Can miss up to 25% of cases of reflux-not due to “acid”
Value in patients with NCCP in whom objective evidence is
required
Patients who do not respond to PPI
Impedance-pH monitoring
Has added sensor for
impedance.
It detects any bolus that
enters the esophagusacid, bile or other.
Increases the sensitivity
of the probe
Same disadvantages as
pH probe
The gold standard for diagnosis of GERD-related NCCP.
Impedance-pH monitoring
Impedance-pH monitoring
Esophageal Manometry
A thin probe is inserted intranasally and
advanced into distal esophagus.
Measurements are recorded
as the
pt is asked to swallow sips of
water.
Goal is to rule out motility
disorders of the esophagus as
for chest pain.
cause
Esophageal Manometry
Esophageal motility disorder is seen in approximately
one third of NCCP patients.
However, the relationship between these motility
disorders and chest pain is unclear
Considered in patients with a negative work-up for
GERD-related NCCP.
Role of manometry in NCCP is limited to diagnosis of
achalasia cardia
Proton pump inhibitor test
Empiric trial of double dose PPI therapy for 4 weeks.
Readily available
Cheap
Noninvasive
Well tolerated with few if any side effects.
Both diagnostic and therapeutic advantages
Proton Pump Inhibitor test
Two meta-analyses combining 14 studies have
validated the PPI test.
Sensitivity and specificity of 75-80%.
Positive predictive value of ~90%.
One study, using a decision analysis model, found
the “treat first” approach to be better
11% more diagnostic accuracy
43% reduction in invasive procedures
$454 saving per patient as compared to proceeding with endoscopy
and pH monitoring.
NCCP Esophageal Origin
Alarm
Symptoms
Yes
Endoscopy
No
Impedence
pH
Monitoring
Normal
Esophageal
Manometry
Achalasia
No Response
PPI Test
Response
Reflux
GERD
Normal
Other spastic
disorders
Functional
esophageal pain
Psychological
evaluation
Treatment of NCCP of esophageal
origin
GERD-related NCCP
Life style modification
Elevation of the head of the bed,
Weight loss,
Smoking cessation,
Avoidance of alcohol, coffee, fresh citrus juice,
Medications that can exacerbate reflux such as
narcotics, benzodiazepines, and calcium-channel
blockers.
GERD-related NCCP
The efficacy of histamine-2 receptor antagonists (H2
RAs) in GERD related NCCP range from 42% to 52%
The efficacy of PPI in controlling symptoms in patients
with GERD related NCCP range from 57.1% to 87%
GERD-related NCCP
PPIs reduce the number of chest pain episodes,
emergency department visits, and hospitalizations
owing to chest pain
Patients with GERD-related NCCP should be treated
with at least double the standard dose of PPI until
symptoms remit
Long-term maintenance PPI treatment has been
shown to be highly effective.
GERD-related NCCP
Lap Fundoplication
In carefully selected patients lap fundoplication results
symptom improvement in 48 % to 90% of patients with
NCCP.
NON GERD related NCCP
Visceral hyperalgesia is the primary mechanism of pain in
patients with non-GERD-related NCCP
NCCP patients with spastic esophageal motor disorders
respond better to pain modulators than to muscle relaxants.
Patients with spastic esophageal disorders should receive a
trial of PPI
Patients with achalasia respond to muscle relaxants, balloon
dilatation, botox injection or heller’s myotomy
NON GERD related NCCP
Pain Modulators
Tricyclic antidepressants (TCAs)
Selective serotonin reuptake inhibitors
Theophylline
Trazodone.
NON GERD related NCCP
TCA
Central neuromodulatory effect
Peripheral visceral analgesic effects
Calcium channels blocker
TCA are started in low dose and titrated to a maximum
based on symptom improvement and development of
side effects.
Because of their anticholinergic side effects, TCAs are
commonly administered at nighttime.
NON GERD related NCCP
Benzodiazepine
Alprazolam and clonazepam ameliorate chest pain in
patients with NCCP and panic disorder
Addiction
Psychological evaluation
Between 17 and 43% of the patients with NCCP have
some type of psychological abnormality.
Psychological co-morbidity can lead to Visceral
Hypersensitivity.
Psychotherapy is useful in patients with NCCP and
hypochondriasis, anxiety, or panic disorder.
NCCP
Esophageal
Origin
Impedance
pH
Monitoring
No Response
Response
PPI for 2-4
months
PPI Test
GERD
No GERD
Response
Increase dose of
PPI
Esophageal
Manometry
Achalasia
Relaxants
Balloon dilatation
Hellers myotomy
Normal
Other spastic
disorders
Functional
esophageal pain
PPI
Pain Modulators
Psychotherapy
Maintenance
Summary
NCCP is a very common problem with high cost to the
healthcare system and significant morbidity to the
patient.
The most common cause of NCCP is GERD.
An empiric trial of high dose PPI therapy is the single
most effective approach to dealing with NCCP.
Summary
Endoscopy is reserved for patients with alarm signs
Impedence pH monitoring and Esophageal
manometry, has a limited role in NCCP
TREATMENT
Summary
GERD related NCCP is treated with double dose PPI
Non GERD related NCCP – the main stay of treatment
is Pain Modulators
Psychotherapy for patients with psychological
comorbidity.
Typical angina (80-90% likelihood of obstructive CAD),
Atypical angina (40-80% likelihood)
Noncardiac (20%-70% likelihood).
Typical angina is characterized by the following three
characteristics:
Retrosternal chest discomfort experienced as pressure or
heaviness;
Duration of 5-15 min
Induced by stress or exertion, a large meal, or exposure to
cold and relieved by rest or nitroglycerin.
Mechanical distention, acid exposure, temperature,
and osmolality-related stimuli can all induce
esophageal pain.
Esophageal dysmotility may also induce symptoms of
heartburn and chest pain.
Visceral hypersensitivity has been implicated in the
pathogenesis of esophageal pain.
Psychiatric disease plays a role in heartburn and chest
pain.
The entity of noncardiac chest pain (NCCP) was first
described during the American Civil War when a
Philadelphia physician, Jacob Mendez Da Costa,
NCCP
Esophageal
Origin
Alarm
symptoms
No
Yes
PPI Test
Endoscopy
Response
present
No response
Impedence
pH
Measurement
GERD
No GERD
Esophageal
Manometry
Motility
disorder
Normal
Psychological
Evaluation