The most common etiology is thought to be occult gas-troesophageal reflux disease that affects up to 40 percent of these patients.7'87'89 Some of these patients have clinical features consistent with the disease, but pH studies have shown normal results,87 although up to 53 percent of patients with undiagnosed noncardiac chronic chest pain have abnormal lower esophageal sphincter and up to 44 percent have abnormal pH proximal to the lower esopha-geal sphincter.89 It is possible to have a negative pH study at rest that transforms into a positive study with an exercise-induced incompetent lower esophageal sphincter.86
Table 39.4 Comparison of angina and esophageal chest pain.100
Studies have suggested that in view of the high prevalence of gastroesophageal reflux disease in patients with noncardiac chest pain, it is recommended that a trial of proton-pump inhibitors (PPI) be conducted for four to eight weeks.7,87,90 This has proven to be cost-effective beyond one year7 when compared to investigations for gastrointestinal causes. Furthermore, when compared against placebo, the arms treated with PPI consistently showed a reduction in frequency and intensity of chest pain,90 although some of the studies only included patients with known gastroesophageal reflux disease.
Very little relation has been found between chronic noncardiac chest pain and abnormal esophageal function.91, 92 Based on the lack of correlation between chest pain and positive findings in esophageal motility tests, together with the demands imposed in patients for these tests and the poor cost-benefit ratio,93 routine testing for esophageal motility in patients with undiagnosed chronic chest pain is not routinely recommended. Furthermore, although these tests can sometimes identify the esophagus as the cause of the pain, they do not direct therapy and they lack a gold standard to compare as normal reference point.94
Some studies have shown disappointing results when targeting chronic chest pain with therapies aimed at treating esophageal pain.95,96 These trials have not included PPI and the poor response rate may be related to the small proportion that has positive provocation studies in which a smooth muscle relaxant may prove beneficial. This benefit is seen in long-term follow up and the physiological benefit of a reduction in spasm of the esophageal wall does not always translate into a reduction in reported chest pain.95 Another drug that has been used as part of diagnostic esophageal tests is the spasmomimetic agent edrophonium, but this appears to produce chest pain symptoms, as well as alterations in esophageal motility.97 Other patients have other esophageal motor disorders that do not fit into any diagnostic categories. One study reported that in 72 percent of these patients, botulinum toxin injections at the gastroesophageal junction can be beneficial for up to 18 months. The mean duration of a benefit > 50 percent was just over seven months.98 Stress can induce an increase in esophageal pressures and this increase seems to be greater when the stress is related to cognitive problems.99
Table 39.4 provides a comparison of angina and eso-phageal chest pain.
Pain description Angina Esophageal pain
Time-course Short Often prolonged
Site and radiation Precordium, jaw, arm Retrosternal, precordium, jaw, arm
Character Pressure, tight, band-like, fear Burning, pressure
Provoking factors Exercise, stress, food, cold, rare at night Food, posture, rare exercise, often at night
Relieving factors Rest nitrates Nitrates, antacids
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Gastroesophageal reflux disease is the medical term for what we know as acid reflux. Acid reflux occurs when the stomach releases its liquid back into the esophagus, causing inflammation and damage to the esophageal lining. The regurgitated acid most often consists of a few compoundsbr acid, bile, and pepsin.