Esophageal chest pain

Anisa Shaker, C. Prakash Gyawali

Research output: Chapter in Book/Report/Conference proceedingChapterpeer-review

Abstract

Non-cardiac chest pain (NCCP) consists of recurrent angina-type pain unrelated to ischemic heart disease or other cardiac source after a reasonable workup. The most common esophageal cause of NCCP is gastro-esophageal reflux disease (GERD), followed by esophageal motor disorders and esophageal visceral hypersensitivity. Noxious triggers for NCCP include acidic and non-acidic reflux events, mechanical distension and muscle spasm, particularly longitudinal smooth muscle contraction. Functional chest pain of esopha-geal origin is diagnosed when endoscopy and esophageal physiologic studies (manometry, ambulatory pH/pH-impedance monitoring) do not reveal a source for NCCP. Once a cardiac etiology has been reliably excluded, an empiric proton pump inhibitor (PPI) trial provides a clinically useful and cost effective mechanism for diagnosis of GERD related NCCP. While endoscopy has a limited diagnostic yield because of the high prevalence of nonerosive disease, histopathology may help evaluate for microscopic evidence of reflux and eosinophilic esophagitis. Ambulatory pH or pH/impedance monitoring off PPI therapy assesses for abnormal esophageal acid exposure and reflux association with NCCP events using simple and statistical symptom association probability tests. Esophageal manometry is typically performed concurrent with ambulatory pH monitoring and can identify esophageal dysmotility, some patterns of which may be associated with esophageal hypersensitivity. Acid suppression with a PPI is the first therapeutic measure initiated even prior to investigation in NCCP. Pain modulators (e.g. low dose tricyclic antidepressants) are often the mainstay of therapy in refractory situations. Smooth muscle relaxants (sublingual nitroglycerine, phosphodiesterase-5 inhibitors, and calcium channel blockers) can be used in hypermotility states, although their efficacy has not been conclusively demonstrated in controlled trials. Hypnotherapy, biofeedback, transcutaneous nerve stimulation, and cognitive and behavioral therapy complement pharmacologic therapy, although additional -studies are needed; acupuncture may also be of benefit.

Original languageEnglish
Title of host publicationChest Pain with Normal Coronary Arteries
Subtitle of host publicationA Multidisciplinary Approach
PublisherSpringer-Verlag London Ltd
Pages23-34
Number of pages12
Volume9781447148388
ISBN (Electronic)9781447148388
ISBN (Print)1447148371, 9781447148371
DOIs
StatePublished - Sep 1 2013

Keywords

  • Ambulatory pH monitoring
  • Esophageal manometry
  • Esophageal motor disorder
  • Esophageal visceral hypersensitivity
  • Gastroesophageal reflux disease
  • Neuromodulator
  • Non-cardiac chest pain
  • Proton pump inhibitor

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