The role of the modified barium swallow study & esophagram in patients with GERD/Globus sensation

Transcription

1 The role of the modified barium swallow study & esophagram in patients with GERD/Globus sensation James P. Dworkin, Ph.D. Jayme Dowdall, M.D. Adam Folbe, M.D. Tom Willis, M.S. Richard Culatta, Ph.D. Wayne State University & Detroit Medical Center Depts. of Otolaryngology

2 Globus: Overview Globus sensation: Feeling of a lump in the throat Globus: Frequent throat clearing & commonly ascribed to laryngopharyngeal reflux Anti-reflux diet & nocturnal reflux precautions result in symptomatic improvement in 50% of patients Batch AJ.. J Laryngol Otol.1988; Alaani A,. Eur Arch Otorhinolaryngol. 2007;.Harar RP,. J Laryngol Otol. 2004; Caylakli F, Laryngoscope. 2006

3 Globus Tx: Overview Twice-daily dosing of PPI therapy, along with behavioral modifications Patients are reevaluated at twomonth intervals H 2 -blockers may be added to limit nighttime acid breakthrough Postma G.N., Johnson L.F., Koufman J.A.: Treatment of laryngopharyngeal reflux. ENT 2002; 81(S2):24.

4 Globus Tx (Cont.) Treatment of globus with reflux meds has been reported to improve symptoms in as many as 70% of patients Tsikoudas A, Clin Otolaryngol. 2007; Batch AJ. J Laryngol Otol. 1988

5 Globus: UK Practice Trends 10% of practitioners provide reassurance alone 4% of practitioners provide reflux medication alone 86% of practitioners order an investigation 61% performed rigid endoscopy 56% ordered modified barium swallow study 17.5% of practitioners do both Harar RP. J Laryngol Otol. 2004; Webb CJ, Clin Otolaryn Allied Sci. 2000; Tsikoudas A, Clin Otolaryngol. Dec 2007

6 Globus Evaluation: Overview MBSS + esophagram show to have 90% accuracy in identifying esophageal and upper aerodigestive tract pathology MBSS for globus shown to be normal 36%-88% of time Patients with abn. findings on MBSS: 64% are considered benign Richter JE. Am J Gastroenterol. 2000; Agrawal A, Arch Otolaryngol Head Neck Surg. Aug 1998; Hajioff D Int J Clin Pract. 2004; Fenton JE, BMJ.1995.

7 Approximate Costs of Diagnostic Exams MBSS + Esophagram: $1,000-$1,500 EGD: $2,000 CT Neck: $2,000

8 Cost of Medical Therapy Zantac 150mg $ month supply Omeprazole 40mg BID $37 1 month supply

9 Study Design Retrospective chart review Patients presenting with globus & GERD between 2006 and 2009 who underwent MBSS + esophagram Demographics: presenting symptoms, medicines, social history, swallow test results --plus additional test results (ie., EGD, CT) Wayne State University: IRB Approval

10 Current Hypothesis: Radiographic swallow studies do not add diagnostically significant information in the investigation or in the treatment of GERD/Globus symptoms

11 Subjects: Demographics Of the 380 patients who underwent MBSS/esophagram examinations, only 68 patients were eligible for inclusion AGES 20s M F older younger 30s 40s 50s 60s 70s 80s 90s

12 Results: Meds/Social hx (N=68) N=48 N=20 N=47 N=21 N=2 N=6 N=29

13 Primary Initial Symptoms (N=68) 40% dysphagia/solids (N=27) 37% hoarseness (N=25) 20% odynophagia (N=14) 17% dysphagia/liquids (N=12) 15% throat clearing (N=10) 10% choking/aspiration (N=7) 10% throat pain, cough, heartburn (N=7) 8% allergic rhinitis, asthma (N=5) 4% regurgitation, weight loss (N=3)

14 MBSS Results (N=68) Piriform retention ,5 N=2 Vallec. Spillage/retent. N=9 NORMAL N=55 1. bar noted from cervical fusion, 2. slow oral phase, 3. penetration with thin liquids, 4. pharyngeal dysmotility, 5. reflux at level of UES Note: some patients had more than one finding

15 Esophagram Results other Normal 62% reflux 10% (n=7/68) Ter. Contraction 7% (N=5/68) hernia 18% (n=12/68) normal 62% (n=42/68) Hiatal hernia 18% Mild reflux 10% Tertiary contractions in lower third of esophagus 7% Other: marked reflux, non-pulsatile contractions, partial esophageal web, compression of posterior esophagus by cervical osteophytes, diverticulum Note: some patients had more than one finding

16 Results: Esophagoscopy 55% of patients did not undergo esophagoscopy Of the 45% (n=31) of patients who did undergo EGD: polyps Esophagitis or gastritis N=15 N=3 other normal hiatal hernia N=14 N=11 normal 35% hiatal hernia 45% gastritis 23% esophagitis 23% gastric polyps 10% other 3% Other: Initially EGD normal then subsequent adenocarcinoma of stomach, gastric ulcer, esophageal ulcer, duodenal ulcer, esophageal stricture, ringlike exudate, AV malformations, esophageal web Note: some patients had more than one finding

17 Results: 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Average cost of diagnostic workup: $3560

18 Conclusions MBSS was normal 81% of time *ALL abn.findings: clinically insignificant Esophagram was normal 62% of time *Hernia most common finding: None of patients elected surgical management Esophagoscopy did not demonstrate significant pathologies CT findings were generally benign & serendipitous More aggressive medical management & Pt counseling would have sufficed in lieu of laboratory examinations in the vast majority of study population