Treatment of Esophageal (Noncardiac) Chest Pain: An Expert Review

Abstract

Objectives Chest pain is a common and frightening symptom. Once cardiac disease has been excluded, an esophageal source is most likely. Pathophysiologically, gastroesophageal reflux disease (GERD), esophageal dysmotility, esophageal hypersensitivity and anxiety disorders have been implicated. Treatment however remains a challenge. Here, we examined the efficacy and safety of various commonly used modalities for treatment of esophageal (non-cardiac) chest pain (ECP) and provided evidence-based recommendations. Methods We reviewed the English literature for drug trials evaluating treatment of ECP in PUBMED, COCHRANE and MEDLINE databases from 1968 to 2012. Standard forms were used to abstract data regarding study design, duration, outcome measures and adverse events and study quality. Results Thirty five studies comprising of various treatments were included and grouped under five broad catagories. Patient inclusion criteria were extremely variable and studies were generally small with methodological concerns. There was good evidence to support the use of omeprazole, and fair evidence for lansoprazole, rabeprazole, theophylline, sertraline, trazodone, venlafaxine, imipramine and cognitive behavioral therapy (CBT). There was poor evidence for nifedipine, diltiazem, paroxetine, biofeedback therapy, ranitidine, nitrates, botulinum toxin, esophageal myotomy and hypnotherapy. Conclusions Ideally, treatment of ECP should be aimed at correcting the underlying mechanism(s) and relieving symptoms. PPIs, antidepressants, theophylline and CBT appear to be useful for the treatment of ECP. However, there is urgent and unmet need for effective treatments and for rigorous, randomized controlled trials.

Diagnostic yield of 24‐hour esophageal manometry in non‐cardiac chest pain

“…In a recent literature review, Coss‐Adame et al . showed that in patients with NCCP, PPIs, theophylline, antidepressants, and cognitive behavioral therapy were more effective than calcium blockers and nitrates, or even botulinum toxin and esophageal myotomy . Clearly, this finding reflects the fact that the spectrum of NCCP mainly comprises patients with functional chest pain and GERD.…”

“…However, functional esophageal testing, including esophageal stationary manometry and pH‐impedance monitoring, is usually required in the patient workup. It can identify esophageal motility disorders, non‐erosive GERD, or functional chest pain and provide guidance in the choice of the appropriate treatment . Since esophageal spasm may occur randomly during the day, and can therefore be missed during the stationary manometry recording, it is not surprising that ambulatory 24‐h manometry has proved to be more sensitive than conventional stationary manometry .…”

“…It can identify esophageal motility disorders, nonerosive GERD, or functional chest pain and provide guidance in the choice of the appropriate treatment. 8 Since esophageal spasm may occur randomly during the day, and can therefore be missed during the stationary manometry recording, it is not surprising that ambulatory 24-h manometry has proved to be more sensitive than conventional stationary manometry. 9 Ambulatory manometry has not become widespread, however, mainly due to a poor diagnostic yield for motor abnormalities and the difficult interpretation of the findings in terms of clinical relevance.…”

Mellkasi panasz ritka oka

“…Amennyiben a beteg kórelőzményében szerepel hiatushernia, úgy felmerül a sürgős hasi és mellkasi kontrasztos CT-vizsgálat elvégzése elsődleges diagnosztikus képalkotó vizsgálat-ként. A sürgősségi osztályokon dolgozó orvosok mindennapjait nehezíti, hogy a mellkasi fájdalmat okozó kórképek "ezer arca" tárul eléjük, így fontos a multidiszciplináris szemlélet, a társszakmákkal való szoros együtt-működés [7].…”

Noncardiac Chest Pain: Update on the Diagnosis and Management

“…Several studies have demonstrated good efficacy of CBT in patients with chest pain. 2,4,84,85 In an RCT, patients who received CBT for 4-12 weeks had significantly better chest pain control (48%) than those in the control group (12%) at a 12-month follow-up. 86 In another study involving patients with persisting NCCP after negative cardiac evaluation, 12 sessions of CBT significantly decreased the pain severity and the number of pain-free days as compared to control, at 3 and 6 months.…”