Speaker : Dr Shim Hang Hock gutCARE GI MODULE 2020

1. Non GI presentation of GI
disorders
How to avoid pitfalls
Speaker: Dr Shim Hang Hock
Gastroenterologist

2. Aim
• Some GI diseases commonly have non-GI
presentations
• to provide overview and approach in avoiding pitfalls
2

3. GERD
3
• Common
• US population study
• 44% monthly
• 7% daily
• Diagnosis made based on:
• Typical symptoms
• Endoscopy findings
• Ambulatory reflux monitoring
• Response to anti secretory medications
Locke et al. Gastroenterology. 1997;112(5):1448-1456.

4. GERD
4
Typical
Heartburn
Regurgitation

5. Atypical manifestation
5

6. 6

7. Asthma and GERD
• Postulated pathogenic mechanism:
• GERD
• Microaspirate  bronchospasm
• Esophagus and bronchial tree shares the same neural innervation via
vagus nerve
• Low pH / distension of oesophagus vagal stimulation
bronchospasm
• Asthma
• Increased pressure gradient across diaphragm
• Effect of asthma medications (bronchodilators) on LES pressure/
gastric secretion
7

8. GERD related asthma
• Symptoms of regurgitation/heartburn before onset
of asthma
• Symptoms made worse
• after large meal
• Lying in supine position
• Nocturnal cough
8

9. Asthma
• 28 studies
• Prevalence of GERD:
• asthma 59.2% vs control 38.1%
• Prevalence of asthma:
• GERD 4.6% vs. control 3.9%
• Inconsistent findings on response-relationship
• Significant association but paucity of data on direction of causation

10. 10
OR 2.3 (95% CI 1.8-2.8)

11. • Fewer patients had at least one asthma exacerbation
when treated with lansoprazole than when given
placebo (8 versus 22 patients, respectively; P<0.05)
11
RDB = randomized double-blind; RSB = randomized single-blind; PC = placebo controlled trial; CO = crossover trial; PG =
parallel-group trial.

12. 12

13. Small improvement and unlikely of
clinical significance
13

14. Chronic cough
• Chronic cough
• 94% related to
• asthma,
• postnasal drip, or
• GERD alone or in combination
14 Irwin RS. Chest. 2006;129(1 suppl):80S-94S

15. 15

16. 16
Chang AB , Lasserson TJ , Gaffney J et al. Gastro-oesophageal reflux treatment for
prolonged non-specifi c cough in children and adults. Cochrane Database Syst Rev 2011

17. • Underlying IHD should always be excluded first for all
patients, especially those with risk factors
• Mechanism connecting GERD and chest pain poorly
understood
• Esophageal factors for non cardiac chest pain
• GERD
• Dysmotility
• Visceral hypersensitivity
• Eosinophilic esophagitis
17
Non cardiac chest pain
Fass R et al. Gastroenterology. 1998;115(6):1363-1373

18. Non cardiac chest pain
18
• May sometime be the only presenting complaint for GERD
• 8 RCT
• Pooled risk ratio of continued chest pain post PPI 0.54 (95% CI 0.41-0.71)
• PPI vs 24hr pH monitoring/endoscopy
• Pooled sensitivity 80%
• Specificity 74%
• Odds ratio 13.83 ((95% CI 5.48-34.91)

19. GERD related ENT symptoms
• 10% Hoarseness
• Up to 60% of refractory sorethroat / reflux laryngitis
• 25-50% of globus sensation
• Symptoms in isolation not specific
19
Vaezi MF. J Clin Gastroenterol. 2003;36(3):198-203.
Hicks DM et al. J Voice. 2002;16(4):564-579

20. “Reflux” laryngitis
• Diagnosis should not be made based on
laryngoscopy alone
• May be present in up to 80% of normal population
20 Vaezi MF. Nat Clin Pract Gastroenterol Hepatol. 2005;2(12):595-603.
• Response to irritants:
• alcohol, smoking, postnasal
drip,
• viral illness, voice overuse,
• environmental allergens

21. • Poor concordance with extreme intrarater variability
• 40-50% “reflux laryngitis” do not respond to
antisecretary treatment
21
Branski RC , Bhattacharyya N , Shapiro J . Th e reliability of the assessment of endoscopic laryngeal
findings associated with laryngopharyngeal reflux disease . Laryngoscope 2002 ; 112 : 1019 – 24 .

22. 22
• 8 RCT (n =344, study duration 8-16 weeks)
• PPI therapy resulted in a nonsignificant symptom
reduction compared to placebo (relative risk 1.28,
95% CI 0.94-1.74)

23. 23 Katz et al. Am J Gastroenterol 2013; 108:308 – 328

24. 24

25. Catheter-based pH monitoring

26. Catheter-based pH monitoring

27. 27
Symptom Indices
• The three main symptom indices include
1. Symptom index (SI)
• % of symptom episodes that are related to reflux.
• (Number of symptom episodes related to pH < 4)/(Total number
of symptom episodes) × 100.
• considered positive when ≥ 50%.
2. Symptom sensitivity index (SSI)
• (Number of symptom episodes related to pH < 4)/(Total number
of reflux episodes) × 100.
• considered positive when ≥ 10%.
3. Symptom association probability (SAP).

28. 28
Symptom Indices
• Symptom association probability (SAP)
– Divide total 24-hour pH recording data into 2-minute
segments.
– In each 2-minute segment, it is determined if there are
reflux events and if there are reported symptoms.
– The data are then summarized into a 2 × 2 table.

29. 29
Symptom Indices
• Symptom association probability (SAP)
• The association between reflux and symptoms is then
calculated using Fisher’s exact test.
• An SAP > 95% is considered positive and indicates that the
probability of the association of reflux and symptoms
occurring by chance is < 5%.
• A high SAP suggests that a patient’s symptoms are likely
secondary to reflux.

30. 30
Combined impedance-pH
monitoring

31. 31
Multichannel
intraluminal impedance (MII)

32. Multichannel
Intraluminal impedance (MII)
• Impedance
• a measure of total resistance to the alternating current
flow
• inversely proportional to
• Electrical conductivity of the luminal contents
• Cross-sectional area between the two electrodes.
• Air has a low conductivity  impedance increase
• Swallowed or refluxed material has a high conductivity  impedance
drop

33. 33

34. 34

35. 35

36. 36
Heidelbaugh et al. Am Fam Physician. 2008 Aug 15;78(4):483-488

37. What to do if GERD symptoms
refractory to PPI?
37

38. John E. Pandolfino, et al.Gastrointestinal Endoscopy, Volume 69, Issue 4, April 2009, Pages 917-930

39. Role of surgery for atypical
symptoms
• Less encouraging
39
• N=243. PPI vs. surgery
• No significant improvement in PFT

40. 40
N=72
47 (65%)
Responsive
25(35%)
Non-Responsive
10(40%)
Surgery
10(60%)
medical
4/12 HD PPI
1 (10%)
1 (6.7%)
P=1.0
Improvement in
laryngeal reflux

41. American College of Gastroenterology
2013
41

42. 42

43. Chest pain
• Common
• Etiology:
• Muscular skeletal 30-50%
• GI 10-20%
• Stable angina 10%
• Respiratory 5%
• Acute coronary syndrome 2-4%
43 Ebell MH. Am Fam Physician 2011; 83:603.

44. Esophageal causes of chest pain:
• GERD (Majority~ 50%)
• Others:
• Non reflux esophagitis
• Eosinophilic esophagitis
• Esophageal motility disorder
• Functional chest pain
44

45. Esophageal causes of chest pain:
• GERD (Majority~ 50%)
• Others:
• Non reflux esophagitis
• Eosinophilic esophagitis
• Esophageal motility disorder
• Functional chest pain
45

46. Non reflux esophagitis
• Medications
• Infection
• Candidiasis, CMV etc
• Radiation injury
46
Antibiotics Tetracycline
Doxycycline
Clindamycin
Anti-inflammatory Aspirin, NSAIDS
Bisphosphonates Riseronate < alendronate
Others KCl,
Quinidine
Iron compounds

47. Esophageal causes of chest pain:
• GERD (Majority~ 50%)
• Others:
• Non reflux esophagitis
• Eosinophilic esophagitis
• Esophageal motility disorder
• Functional chest pain
47

48. Eosinophilic esophagitis
• 50 : 100,000
• Immune/antigen mediated esophageal disease
characterized histologically by eosinophils
predominant inflammation
48

49. • Symptoms:
• Dysphagia (predominant)
• History of food impaction (up to 50%)
• Heartburn
• Chest pain
• Spontaneous esophageal perforation
49
Noel RJ et al. N Engl J Med 2004; 351:940.

50. • Strong association with allergic conditions (90%)
• Food allergy
• Environment allergy
• Asthma
• Atopic dermatitis
50
Noel RJ et al. N Engl J Med 2004; 351:940.

51. 51
Dietary Pharmacologic Endoscopic

52. 52
Dietary Pharmacologic Endoscopic
• Delayed, cell mediated hypersensitivity driven by
food allergen
• Clinical response on elimination diet
• as early as 7-14 days
• 4 Food Elimination Diet
• milk, egg, soy/legumes, wheat
• Efficacy 50-70%
Rank MA et al. Gastroenterology 2020; 158:1789.

53. 53
Dietary Pharmacologic Endoscopic
• Acid suppression (PPI)
• Topical glucocorticoid
• Fluticasone propionate
• Systemic glucocorticoid
• Little additional benefit due to high relapse rate and adverse events
• Experimental
• Azathioprine, biologics (anti IL13, IL 4 and IL 5)

54. 54
Dietary Pharmacologic Endoscopic
• Endoscopic dilation for esophageal stricture failing
medical treatment
• Risk of perforation 5-7%
Hirano I. Gastrointest Endosc 2010; 71:713.

55. Esophageal causes of chest pain:
• GERD (Majority~ 50%)
• Others:
• Non reflux esophagitis
• Eosinophilic esophagitis
• Esophageal motility disorder
• Functional chest pain
55

56. Esophageal motility disorder
• Achalasia
• esophageal spasm
• nutcracker esophagus
56

57. 57

58. 58

59. 59

60. Achalasia
• High resolution manometry (HRM) has allowed
subtyping of achalasia
• Type I (classic achalasia)
• minimal oesophageal pressurization
• Type II
• absent peristalsis with oesophageal pressurization
• Type III
• lumen obliterating spasm

61. Type I achalasia

62. Type II achalasia

63. Type III achalasia

64. Treatment
• Pneumatic dilatation
• Surgical myotomy
• Botox injection
• Treatment response
• Type II > I > III
64

65. Hypercontractile/Nutcracker
esophagus
• First described in 1977
• Increased distal esophageal amplitude (>180 mmHg)
• Peristalsis is present throughout

66. Hypercontractile esophagus
66

67. Case 1
• 63 years old woman with
a 10-year history of
intermittent chest
discomfort with
occasional dysphagia to
solids and liquids.
• Physical exam of the
hands
• OGD and esophageal
biopsy normal

68. High Resolution Manometry
68

69. What is the diagnosis?

70. Systemic sclerosis
• Dysphagia is multifactorial:
• Esophageal dysmotility
• Esophagitis/ peptic stricture
• Candida

71. Systemic sclerosis
• Most patients. will have abnormal esophageal
manometry:
• Striated esophagus is normal
• Decreased amplitude in the
smooth muscle esophagus
• Aperistalsis may occur
• LES hypotonic

72. Esophageal causes of chest pain:
• GERD (Majority~ 50%)
• Others:
• Non reflux esophagitis
• Eosinophilic esophagitis
• Esophageal motility disorder
• Functional chest pain
72

73. Functional chest pain
• Rome IV criteria
• Retrosternal chest pain
• Absence of esophageal symptoms
• Heartburn, dysphagia
• Exclusion of other etiologies
• Symptoms for last 3 months with symptoms onset at
least 6 months before diagnosis
73

74. Potential mechanism
• esophageal hypersensitivity
• altered cerebral processing of esophageal pain,
• autonomic dysregulation, or
• abnormal mechanophysical properties of the
esophagus
74 Maradey-Romero C et al. Curr Gastroenterol Rep 2014; 16:390.

75. Approach to noncardiac chest pain
• History
• Exclusion of ACS and other life threatening conditions
• PE, aortic dissection, esophageal rupture, tension
pneumothorax
• Associated esophageal symptoms
• Heartburn, regurgitation, dysphagia
• Relieve with PPI
• Alarm symptoms
• Dysphagia, odynophagia, bleeding, LOW, recurrent
vomiting
75

76. • Drug history
• PMHx: asthma, allergies
• Social history: smoking
76

77. Cutaneous signs of GI disease
• Advanced
cirrhosis
77

78. Eruptive xanthoma
• Associated with
high TG
• Risk of
pancreatitis
78

79. Dermatitis herpetiformis
• Symmetrical
• Extensor surface
• Celiac disease
79

80. • Inflammatory
bowel disease
• May parallel GI
disease activity
80
Erythema nodosum
Pyoderma gangrenosum

81. • Predominantly face
and mouth
• 50% of patient <30
years old
• Hereditary
haemorrhagic
telangiectasia
81

82. Blue rubber bleb naevus syndrome
• Rare
• Venous
malformation
• GI tract, skin
• Liver, bladder,
kidney, lung, brain
• Risk of GI bleeding
82

83. • Iron deficiency
anaemia
83

84. Cutaneous signs a/w GI malignancy
(Paraneoplastic effects)
Acanthosis nigricans Tripe palms
Seborrheic keratosis (Leser-Trelat sign) Tylosis

85. Sister Mary Joseph nodule
• Firm, nontender
nodule of
red/purple hue
• Lymphatic mets
• Gastric/ovarian
adenocarcinoma
85

86. Thank you