Effects of omeprazole versus placebo in treatment of noncardiac chest pain and gastroesophageal reflux

Thailand guideline 2020 for medical management of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is one of the most prevalent and bothersome functional gastrointestinal disorders worldwide, including in Thailand. After a decade of the first Thailand GERD guideline, physician and gastroenterologist encountered substantially increase of patients with GERD. Many of them are complicated case and refractory to standard treatment. Concurrently, the evolution of clinical characteristics as well as the progression of investigations and treatment have developed and changed tremendously. As a member of Association of Southeast Asian Nations, which are developing countries, we considered that the counterbalance between advancement and sufficient economy is essential in taking care of patients with GERD. We gather physicians from university hospitals, as well as internist and general practitioners who served in rural area, to make a consensus in this updated version of GERD guideline focusing in medical management of GERD. This clinical practice guideline was constructed adhering with standard procedure. We categorized the guideline in to four parts including definition, investigation, treatment, and long-term follow up. We anticipate that this guideline would improve physicians' proficiency and help direct readers to choose investigations and treatments in patients with GERD wisely. Moreover, we wish that this guideline would be applicable in countries with limited resources as well.

The views of African and Middle Eastern Gastroenterologists on the management of mild-to-moderate, non-erosive gastro-esophageal reflux disease (GERD)

INTRODUCTION

Gastro-esophageal reflux disease (GERD) is a common gastrointestinal disorder that occurs when backflow of the gastric contents into the esophagus results in troublesome symptoms. Though GERD has been extensively studied in Western populations, literature on the management of GERD in patients in Africa and Middle East (AME) is scarce.

AREAS COVERED

In this review, we provide an overview of the management of mild-to-moderate GERD in AME. Here we focus on the efficacy and safety of currently available treatments for GERD to help physicians and community pharmacists appropriately manage patients with mild-to-moderate GERD in the primary healthcare setting, detailing specific situations and patient scenarios that are relevant to the region, including management of GERD during Ramadan and post-bariatric surgery.

EXPERT OPINION

Under-appreciation of the burden of GERD in the region has resulted in a lack of consensus on management. Barriers that currently prevent the adoption of treatment guidelines in the primary healthcare setting may include lack of availability of local guidelines and referral systems, a paucity of region-specific research, and dogmatic adherence to traditional practice. By increasing awareness, strengthening knowledge, and by more effective utilization of resources, physicians and pharmacists could optimize GERD management strategies to better support patients.

2020 Seoul Consensus on the Diagnosis and Management of Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is a condition in which gastric contents regurgitate into the esophagus or beyond, resulting in either troublesome symptoms or complications. GERD is heterogeneous in terms of varied manifestations, test findings, and treatment responsiveness. GERD diagnosis can be established with symptomatology, pathology, or physiology. Recently the Lyon consensus defined the "proven GERD" with concrete evidence for reflux, including advanced grade erosive esophagitis (Los Angeles classification grades C and or D esophagitis), long-segment Barrett's mucosa or peptic strictures on endoscopy or distal esophageal acid exposure time > 6% on 24-hour ambulatory pH-impedance monitoring. However, some Asian researchers have different opinions on whether the same standards should be applied to the Asian population. The prevalence of GERD is increasing in Asia. The present evidence-based guidelines were developed using a systematic review and meta-analysis approach. In GERD with typical symptoms, a proton pump inhibitor test can be recommended as a sensitive, cost-effective, and practical test for GERD diagnosis. Based on a meta-analysis of 19 estimated acid-exposure time values in Asians, the reference range upper limit for esophageal acid exposure time was 3.2% (95% confidence interval, 2.7-3.9%) in the Asian countries. Esophageal manometry and novel impedance measurements, including mucosal impedance and a post-reflux swallow-induced peristaltic wave, are promising in discrimination of GERD among different reflux phenotypes, thus increasing its diagnostic yield. We also propose a long-term strategy of evidence-based GERD treatment with proton pump inhibitors and other drugs.

Use of Bioelectronics in the Gastrointestinal Tract

Gastrointestinal (GI) motility disorders are major contributing factors to functional GI diseases that account for >40% of patients seen in gastroenterology clinics and affect >20% of the general population. The autonomic and enteric nervous systems and the muscles within the luminal GI tract have key roles in motility. In health, this complex integrated system works seamlessly to transport liquid, solid, and gas through the GI tract. However, major and minor motility disorders occur when these systems fail. Common functional GI motility disorders include dysphagia, gastroesophageal reflux disease, functional dyspepsia, gastroparesis, chronic intestinal pseudo-obstruction, postoperative ileus, irritable bowel syndrome, functional diarrhea, functional constipation, and fecal incontinence. Although still in its infancy, bioelectronic therapy in the GI tract holds great promise through the targeted stimulation of nerves and muscles.

The Mexican consensus on non-cardiac chest pain

INTRODUCTION

Non-cardiac chest pain is defined as a clinical syndrome characterized by retrosternal pain similar to that of angina pectoris, but of non-cardiac origin and produced by esophageal, musculoskeletal, pulmonary, or psychiatric diseases.

AIM

To present a consensus review based on evidence regarding the definition, epidemiology, pathophysiology, and diagnosis of non-cardiac chest pain, as well as the therapeutic options for those patients.

METHODS

Three general coordinators carried out a literature review of all articles published in English and Spanish on the theme and formulated 38 initial statements, dividing them into 3 main categories: (i)definitions, epidemiology, and pathophysiology; (ii)diagnosis, and (iii)treatment. The statements underwent 3rounds of voting, utilizing the Delphi system. The final statements were those that reached >75% agreement, and they were rated utilizing the GRADE system.

RESULTS AND CONCLUSIONS

The final consensus included 29 statements. All patients presenting with chest pain should initially be evaluated by a cardiologist. The most common cause of non-cardiac chest pain is gastroesophageal reflux disease. If there are no alarm symptoms, the initial approach should be a therapeutic trial with a proton pump inhibitor for 2-4weeks. If dysphagia or alarm symptoms are present, endoscopy is recommended. High-resolution manometry is the best method for ruling out spastic motor disorders and achalasia and pH monitoring aids in demonstrating abnormal esophageal acid exposure. Treatment should be directed at the pathophysiologic mechanism. It can include proton pump inhibitors, neuromodulators and/or smooth muscle relaxants, psychologic intervention and/or cognitive therapy, and occasionally surgery or endoscopic therapy.

Proton pump inhibitor and selective serotonin reuptake inhibitor therapy for the management of noncardiac chest pain

INTRODUCTION

Although gastroesophageal reflux disease is the main cause of noncardiac chest pain (NCCP), proton pump inhibitors (PPIs) benefit a minority of patients. Our prospective study evaluated the effect of PPI and selective serotonin reuptake inhibitors on the different subtypes of NCCP characterized by impedance-pH monitoring.

METHODS

All NCCP patients underwent impedance-pH monitoring and on the basis of the results, those with abnormal distal esophageal acid exposure received PPIs twice daily (group A), those with a positive symptom index for chest pain received citalopram 20 mg and PPI once daily (group B), and those with a negative symptom index for chest pain received citalopram 20 mg once daily (group C). Therapy was administered for 12 weeks and treatment success was defined as complete disappearance of chest pain.

RESULTS

From March 2015 to March 2016, 63 patients were included (group A=9, group B=18, group C=36). After 12 weeks of therapy, complete resolution of chest pain was noted in 8/9 (88.9%) group A, 13/18 (72.2%) group B, and 24/36 (66.7%) group C patients.

CONCLUSION

Combined impedance-pH monitoring identifies different subtypes of NCCP patients who can receive tailored management. Targeted therapy with PPIs and/or citalopram offers complete symptom relief in the great majority of them.

Review article: the current treatment of non-cardiac chest pain

BACKGROUND

Non-cardiac chest pain is one of the most common functional gastrointestinal disorders. By recognising that gastro-oesophageal reflux disease (GERD), oesophageal dysmotility and oesophageal hypersensitivity are the main underlying mechanisms of NCCP, a more directed therapeutic approach has been developed.

AIM

To determine the value of the current therapeutic modalities for NCCP.

METHODS

Electronic (Pubmed/Medline/Cochrane central) and manual search.

RESULTS

Double-dose PPI treatment for two months is a reasonable first choice approach in patients with NCCP because GERD is the most common aetiology. Studies evaluating the role of medical therapy in NCCP patients with hypercontractile oesophageal motility suggest a limited value to muscle relaxants like calcium channel blockers (nifedipine, diltiazem), nitrates and sildenafil. While most trials evaluating pain modulators are small and many are not placebo-controlled, these type of medications appear efficacious in both patients with NCCP due to oesophageal dysmotility and those with functional chest pain. Cognitive behavioural therapy has been extensively studied in patients with functional chest pain with good results. Other psychological techniques such as hypnotherapy, group therapy or coping skills have been scarcely studied but appear to be effective in NCCP patients.

CONCLUSION

Medical, endoscopic and surgical therapeutic options are available for the treating physician, although some patients with non-cardiac chest pain may require a multimodal therapeutic approach.

Unmet Needs in the Treatment of Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is a highly prevalent gastrointestinal disorder. Proton pump inhibitors have profoundly revolutionized the treatment of GERD. However, several areas of unmet need persist despite marked improvements in the ther-apeutic management of GERD. These include the advanced grades of erosive esophagitis, nonerosive reflux disease, main-tenance treatment of erosive esophagitis, refractory GERD, postprandial heartburn, atypical and extraesophageal manifestations of GERD, Barrett's esophagus, chronic protein pump inhibitor treatment, and post-bariatric surgery GERD. Consequently, any fu-ture development of novel therapeutic modalities for GERD (medical, endoscopic, or surgical), would likely focus on the afore-mentioned areas of unmet need.

Esophageal hypomotility and spastic motor disorders: current diagnosis and treatment

Esophageal hypomotility (EH) is characterized by abnormal esophageal peristalsis, either from a reduction or absence of contractions, whereas spastic motor disorders (SMD) are characterized by an increase in the vigor and/or propagation velocity of esophageal body contractions. Their pathophysiology is not clearly known. The reduced excitation of the smooth muscle contraction mediated by cholinergic neurons and the impairment of inhibitory ganglion neuronal function mediated by nitric oxide are likely mechanisms of the peristaltic abnormalities seen in EH and SMD, respectively. Dysphagia and chest pain are the most frequent clinical manifestations for both of these dysfunctions, and gastroesophageal reflux disease (GERD) is commonly associated with these motor disorders. The introduction of high-resolution manometry (HRM) and esophageal pressure topography (EPT) has significantly enhanced the ability to diagnose EH and SMD. Novel EPT metrics in particular the development of the Chicago Classification of esophageal motor disorders has enabled improved characterization of these abnormalities. The first step in the management of EH and SMD is to treat GERD, especially when esophageal testing shows pathologic reflux. Smooth muscle relaxants (nitrates, calcium channel blockers, 5-phosphodiesterase inhibitors) and pain modulators may be useful in the management of dysphagia or pain in SMD. Endoscopic Botox injection and pneumatic dilation are the second-line therapies. Extended myotomy of the esophageal body or peroral endoscopic myotomy (POEM) may be considered in highly selected cases but lack evidence.

Treatment of esophageal motility disorders based on the chicago classification

OPINION STATEMENT

The Chicago Classification divides esophageal motor disorders based on the recorded value of the integrated relaxation pressure (IRP). The first group includes those with an elevated mean IRP that is associated with peristaltic abnormalities such as achalasia and esophagogastric junction outflow obstruction. The second group includes those with a normal mean IRP that is associated with esophageal hypermotility disorders such as distal esophageal spasm, hypercontractile esophagus (jackhammer esophagus), and hypertensive peristalsis (nutcracker esophagus). The third group includes those with a normal mean IRP that is associated with esophageal hypomotility peristaltic abnormalities such as absent peristalsis, weak peristalsis with small or large breaks, and frequent failed peristalsis. The therapeutic options vary greatly between the different groups of esophageal motor disorders. In achalasia patients, potential treatment strategies comprise medical therapy (calcium channel blockers, nitrates, and phosphodiesterase 5 inhibitors), endoscopic procedures (botulinum toxin A injection, pneumatic dilation, or peroral endoscopic myotomy) or surgery (Heller myotomy). Patients with a normal IRP and esophageal hypermotility disorder are candidates for medical therapy (nitrates, calcium channel blockers, phosphodiesterase 5 inhibitors, cimetropium/ipratropium bromide, proton pump inhibitors, benzodiazepines, tricyclic antidepressants, trazodone, selective serotonin reuptake inhibitors, and serotonin-norepinephrine reuptake inhibitors), endoscopic procedures (botulinum toxin A injection and peroral endoscopic myotomy), or surgery (Heller myotomy). Lastly, in patients with a normal IRP and esophageal hypomotility disorder, treatment is primarily focused on controlling the presence of gastroesophageal reflux with proton pump inhibitors and lifestyle modifications (soft and liquid diet and eating in the upright position) to address patient's dysphagia.

Treatment efficacy for non-cardiovascular chest pain: a systematic review and meta-analysis

BACKGROUND

Non-cardiovascular chest pain (NCCP) leads to impaired quality of life and is associated with a high disease burden. Upon ruling out cardiovascular disease, only vague recommendations exist for further treatment.

OBJECTIVES

To summarize treatment efficacy for patients presenting with NCCP.

METHODS

Systematic review and meta-analysis. In July 2013, Medline, Web of Knowledge, Embase, EBSCOhost, Cochrane Reviews and Trials, and Scopus were searched. Hand and bibliography searches were also conducted. Randomized controlled trials (RCTs) evaluating non-surgical treatments in patients with NCCP were included. Exclusion criteria were poor study quality and small sample size (<10 patients per group).

RESULTS

Thirty eligible RCT's were included. Most studies assessed PPI efficacy for gastroesophageal reflux disorders (GERD, n = 10). Two RCTs included musculoskeletal chest pain, seven psychotropic drugs, and eleven various psychological interventions. Study quality was high in five RCTs and acceptable in 25. PPI treatment in patients with GERD (5 RCTs, 192 patients) was more effective than placebo [pooled OR 11.7 (95% CI 5.5 to 25.0, heterogeneity I2 = 6.1%)]. The pooled OR in GERD negative patients (4 RCTs, 156 patients) was 0.8 (95% CI 0.2 to 2.8, heterogeneity I2 = 50.4%). In musculoskeletal NCCP (2 RCTs, 229 patients) manual therapy was more effective than usual care but not than home exercise [pooled mean difference 0.5 (95% CI -0.3 to 1.3, heterogeneity I2 = 46.2%)]. The findings for cognitive behavioral treatment, serotonin reuptake inhibitors, tricyclic antidepressants were mixed. Most evidence was available for cognitive behavioral treatment interventions.

LIMITATIONS

Only a small number of studies were available.

CONCLUSIONS

Timely diagnostic evaluation and treatment of the disease underlying NCCP is important. For patients with suspected GERD, high-dose treatment with PPI is effective. Only limited evidence was available for most prevalent diseases manifesting with chest pain. In patients with idiopathic NCCP, treatments based on cognitive behavioral principles might be considered.

Treatment of esophageal (noncardiac) chest pain: an expert review

BACKGROUND & AIMS

Chest pain is a common and frightening symptom. Once cardiac disease has been excluded, an esophageal source is most likely. Pathophysiologically, gastroesophageal reflux disease, esophageal dysmotility, esophageal hypersensitivity, and anxiety disorders have been implicated. However, treatment remains a challenge. Here we examined the efficacy and safety of various commonly used modalities for treatment of esophageal (noncardiac) chest pain (ECP) and provided evidence-based recommendations.

METHODS

We reviewed the English language literature for drug trials evaluating treatment of ECP in PubMed, Cochrane, and MEDLINE databases from 1968-2012. Standard forms were used to abstract data regarding study design, duration, outcome measures and adverse events, and study quality.

RESULTS

Thirty-five studies comprising various treatments were included and grouped under 5 broad categories. 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. 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. Proton pump inhibitors, antidepressants, theophylline, and cognitive behavioral therapy 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.

The prevalence of gastroesophageal reflux disease among hospital employees

Quantitative estimate of the actual prevalence of the gastroesophageal reflux disease (GERD) is difficult to obtain because most of the patients with heartburn have intermittent symptoms. The aim of this study was to assess the frequency of typical and atypical symptoms suggesting GERD to investigate the association of habits and social conditions reported to lead to reflux in the employees of hospital. A total of 2037 collected forms were assessed. The prevalence of GERD was found to be 21.7% (442). The prevalence of symptoms other than heartburn in employees with and without GERD symptoms were 6.6% versus 3.4% (P < 0.05) for asthma, 27.6% versus 8.3% (P < 0.001) for night cough, 50% versus 19.5% (P < 0.001) for noncardiac chest pain. Dyspeptic complaints were found to be significantly higher among GERD patients (P < 0.001). By multiple logistic regression analysis, female gender (odds ratio [OR] 1.30, 95% confidence interval [CI] 1.03-1.60, P = 0.027), non-steroidal anti-inflammatory drug medication (OR 1.29, 95% CI 1.03-1.60, P = 0.021) and body mass index over 30 (OR 2.26, 95% CI 1.60-3.18, P < 0.001) were independent risk factors associated with GERD symptoms. GERD is a common health problem in Turkey, and its prevalence is similar to that of Western populations with different symptom profiles. Female gender, non-steroidal anti-inflammatory drug, and body mass index >30 kg/m(2) were independent risk factors associated with GERD symptoms. Age, alcohol, coffee, tea, and tobacco smoking do not seem to be risk factors for reflux.

Nonspecific motility disorders, irritable esophagus, and chest pain

This paper presents commentaries on whether Starling's law applies to the esophagus; whether erythromycin affects esophageal motility; the relationship between hypertensive lower esophageal sphincter and vigorous achalasia; whether ethnic- and gender-based norms affect diagnosis and treatment of esophageal motor disorders; health care and epidemiology of chest pain; whether normal pH excludes esophageal pain; the role of high-resolution manometry in noncardiac chest pain; whether pH-impedance should be included in the evaluation of noncardiac chest pain; whether there are there alternative therapeutic options to PPI for treating noncardiac chest pain; and the usefulness of psychological treatment and alternative medicine in noncardiac chest pain.

Diagnostic indicators of non-cardiovascular chest pain: a systematic review and meta-analysis

BACKGROUND

Non-cardiovascular chest pain (NCCP) has a high healthcare cost, but insufficient guidelines exist for its diagnostic investigation. The objective of the present work was to identify important diagnostic indicators and their accuracy for specific and non-specific conditions underlying NCCP.

METHODS

A systematic review and meta-analysis were performed. In May 2012, six databases were searched. Hand and bibliography searches were also conducted. Studies evaluating a diagnostic test against a reference test in patients with NCCP were included. Exclusion criteria were having <30 patients per group, and evaluating diagnostic tests for acute cardiovascular disease. Diagnostic accuracy is given in likelihood ratios (LR): very good (LR+ >10, LR- <0.1); good (LR + 5 to 10, LR- 0.1 to 0.2); fair (LR + 2 to 5, LR- 0.2 to 0.5); or poor (LR + 1 to 2, LR- 0.5 to 1). Joined meta-analysis of the diagnostic test sensitivity and specificity was performed by applying a hierarchical Bayesian model.

RESULTS

Out of 6,316 records, 260 were reviewed in full text, and 28 were included: 20 investigating gastroesophageal reflux disorders (GERD), 3 musculoskeletal chest pain, and 5 psychiatric conditions. Study quality was good in 15 studies and moderate in 13. GERD diagnosis was more likely with typical GERD symptoms (LR + 2.70 and 2.75, LR- 0.42 and 0.78) than atypical GERD symptoms (LR + 0.49, LR- 2.71). GERD was also more likely with a positive response to a proton pump inhibitor (PPI) test (LR + 5.48, 7.13, and 8.56; LR- 0.24, 0.25, and 0.28); the posterior mean sensitivity and specificity of six studies were 0.89 (95% credible interval, 0.28 to 1) and 0.88 (95% credible interval, 0.26 to 1), respectively. Panic and anxiety screening scores can identify individuals requiring further testing for anxiety or panic disorders. Clinical findings in musculoskeletal pain either had a fair to moderate LR + and a poor LR- or vice versa.

CONCLUSIONS

In patients with NCCP, thorough clinical evaluation of the patient's history, symptoms, and clinical findings can indicate the most appropriate diagnostic tests. Treatment response to high-dose PPI treatment provides important information regarding GERD, and should be considered early. Panic and anxiety disorders are often undiagnosed and should be considered in the differential diagnosis of chest pain.

Distal esophageal spasm: an update

Distal esophageal spasm (DES) is an esophageal motility disorder that presents clinically with chest pain and/or dysphagia and is defined manometrically as simultaneous contractions in the distal (smooth muscle) esophagus in ≥20% of wet swallows (and amplitude contraction of ≥30 mmHg) alternating with normal peristalsis. With the introduction of high resolution esophageal pressure topography (EPT) in 2000, the definition of DES was modified. The Chicago classification proposed that the defining criteria for DES using EPT should be the presence of at least two premature contractions (distal latency<4.5 s) in a context of normal EGJ relaxation. The etiology of DES remains insufficiently understood, but evidence links nitric oxide (NO) deficiency as a culprit resulting in a disordered neural inhibition. GERD frequently coexists in DES, and its role in the pathogenesis of symptoms needs further evaluation. There is some evidence from small series that DES can progress to achalasia. Treatment remains challenging due in part to lack of randomized placebo-controlled trials. Current treatment agents include nitrates (both short and long acting), calcium-channel blockers, anticholinergic agents, 5-phosphodiesterase inhibitors, visceral analgesics (tricyclic agents or SSRI), and esophageal dilation. Acid suppression therapy is frequently used, but clinical outcome trials to support this approach are not available. Injection of botulinum toxin in the distal esophagus may be effective, but further data regarding the development of post-injection gastroesophageal reflux need to be assessed. Heller myotomy combined with fundoplication remains an alternative for the rare refractory patient. Preliminary studies suggest that the newly developed endoscopic technique of per oral endoscopic myotomy (POEM) may also be an alternative treatment modality.

Acid-suppressive therapy with esomeprazole for relief of unexplained chest pain in primary care: a randomized, double-blind, placebo-controlled trial

OBJECTIVES

High-quality data regarding the efficacy of acid-suppressive treatment for unexplained chest pain are lacking. The aim of this study was to evaluate the efficacy of esomeprazole in primary-care treatment of patients with unexplained chest pain stratified for frequency of reflux/regurgitation symptoms.

METHODS

Patients with a ≥ 2-week history of unexplained chest pain (unrelated to gastroesophageal reflux) who had at least moderate pain on ≥ 2 of the last 7 days were stratified by heartburn/regurgitation frequency (≤ 1 day/week (stratum 1) vs. ≥ 2 days/week (stratum 2)) and randomized to 4 weeks of double-blind treatment with twice-daily esomeprazole 40 mg or placebo. Chest pain relief during the last 7 days of treatment (≤ 1 day with minimal symptoms assessed daily using a 7-point scale) was analyzed by stratum in keeping with the predetermined analysis plan.

RESULTS

Overall, 599 patients (esomeprazole: 297, placebo: 302) were randomized. In stratum 1, more esomeprazole than placebo recipients achieved chest pain relief (38.7% vs. 25.5%; P=0.018); no between-treatment difference was observed in stratum 2 (27.2% vs. 24.2%; P=0.54). However, esomeprazole was superior to placebo in a post-hoc analysis of the whole study population (combined strata; 33.1% vs. 24.9%; P=0.035).

CONCLUSIONS

A 4-week course of high-dose esomeprazole provided statistically significant relief of unexplained chest pain in primary-care patients who experienced infrequent or no heartburn/regurgitation, but there was no such significant reduction in patients with more frequent reflux symptoms.

Segmental changes in smooth muscle contraction as a predictive factor of the response to high-dose proton pump inhibitor treatment in patients with functional chest pain

BACKGROUND AND AIMS

High-dose proton pump inhibitor (PPI) treatment leads to relatively little symptomatic improvement in patients with functional chest pain (FCP). This study was to evaluate the use of smooth muscle segmental changes in esophageal contraction as measured by topographical plots of high resolution manometry (HRM) as predictive factors of the response to high-dose PPI treatment in FCP patients.

METHODS

Thirty patients diagnosed with FCP were treated with rabeprazole 20 mg twice daily for 2 weeks and classified as positive and negative responders based on symptom intensity score. HRM topographical plots were analyzed for segment lengths, maximal wave amplitudes, and pressure volumes of the proximal and distal smooth muscle segments.

RESULTS

A positive response was observed in 23.3% of the patients. While the pressure volume of the proximal segment was significantly higher in the positive responders than the negative responders (900.4 ± 91.5 mm Hg/cm per s vs. 780.5 ± 133.3 mm Hg/cm per s, P = 0.017), the pressure volume of the distal segment was significantly lower in the positive responders (1914.0 ± 159.8 mm Hg/cm per s vs. 2140.5 ± 276.2 mm Hg/cm per s, P = 0.014). A prominent shifting in pressure volume to the distal segment was observed in the negative responders compared with the positive responders (segmental ratio of pressure volume (SRPV): 2.9 ± 0.5 vs. 2.1 ± 0.1, P < 0.001), and 2.39 was found to be the SRPV that best differentiated positive and negative responders.

CONCLUSIONS

A low SRPV was associated with a positive response to high-dose PPI treatment in patients with FCP.

Noncardiac chest pain: diagnostic evaluation

Noncardiac chest pain (NCCP) is a common and challenging clinical problem. It is estimated that more than 70 million Americans (23% of the population) suffer from this condition yearly. Patients with NCCP represent a diagnostic dilemma. Their chest pain is often indistinguishable from cardiac pain leading to extensive and expensive evaluations. Once coronary artery disease and other cardiac and pulmonary sources of chest pain are excluded, patients are frequently referred to gastroenterologists to look primarily for esophageal sources of pain. A variety of diagnostic tests are available to the practicing clinician to identify the origin of pain, including ambulatory pH testing, esophageal motility, upper endoscopy, provocative testing and even therapeutic trials.

Evaluation of noncardiac chest pain: diagnostic approach, coping strategies and quality of life

BACKGROUND

Approximately 30% of coronary angiograms are negative for significant coronary artery disease and patients are classified as having noncardiac chest pain (NCCP). So far, no systematic diagnostic approach to patients with NCCP investigating for possible esophageal, psychiatric and musculoskeletal abnormalities exists. Furthermore, coping strategies and quality of life are poorly characterized in NCCP patients.

METHODS AND RESULTS

A simple diagnostic approach was applied to 37 consecutive patients (21 female, age 61+/-12 years) with angina-like chest pain and normal coronary angiograms. Twenty-one patients were found to suffer from psychiatric disorders (combined anxiety (A) and depression (D): n = 10, D: n = 5, panic disorder (P): n = 3, somatization (S): n = 3) based on their Symptom Check List 90 scores and according to DSM IV-R criteria. Sixteen patients had an improvement of their chest pain after oral esomeprazole (40 mg for 7 days) and were therefore diagnosed with gastroesophageal reflux disease (GERD). Musculoskeletal abnormalities including chostochondritis (n = 4), thoracic spondylodynia (n = 1), and fibromyalgia (n = 1) were found in six patients. Multiple diagnoses were confirmed in six patients with GERD (additional D n = 3, additional musculoskeletal disorders n = 3). Patients with psychiatric disorders showed a diminished quality of life (MOS-SF 36), more frequent chest pain, less treatment satisfaction (Seattle Angina Questionnaire) and more rumination (Trier Coping Scales) compared to GERD patients.

CONCLUSIONS

Immediate combined psychiatric and orthopedic evaluation as well as esomeprazole administration following exclusion of coronary artery disease may confirm the causes of noncardiac chest pain. Identification of psychiatric disorders seems especially warranted since these patients experience a reduced quality of life and exhibit pathologic coping strategies.

Systematic review: the treatment of noncardiac chest pain

BACKGROUND

Treatment of noncardiac chest pain (NCCP) remains a challenge. This is in part due to the heterogeneous nature of this disorder. Several conditions are associated with NCCP including gastro-oesophageal reflux disease (GERD), oesophageal dysmotility, oesophageal hypersensitivity as well as others.

AIM

To determine the currently available therapeutic modalities for NCCP.

METHODS

We performed a systematic review of the literature that was published between January, 1980 and March, 2011. We identified 734 studies; 68 of them met entry criteria.

RESULTS

Patients with GERD-related NCCP should receive proton pump inhibitors (PPI) twice daily for at least 8 weeks. Smooth muscle relaxants are only recommended for temporary relief of NCCP with motility disorders. Botulinum toxin injection of the distal oesophagus may be effective in the treatment of NCCP and spastic oesophageal motility disorders. Studies assessing the value of tricyclic antidepressants, trazodone and selective serotonin reuptake inhibitors in NCCP are relatively small, but suggest an oesophageal analgesic effect in NCCP patients that is limited by their side effects profile. The usage of theophylline to treat patients with non-GERD-related NCCP should be weighed against its potential toxicity. Use of complementary medicine has been scarcely studied in NCCP. Patients with coexisting psychological morbidity or those not responding to any medical therapy should be considered for psychological intervention. Cognitive behavioural therapy and hypnotherapy may be useful in the treatment of NCCP.

CONCLUSIONS

Patients with GERD-related noncardiac chest pain should be treated with at least double dose PPI. The primary treatment for non-GERD-related noncardiac chest pain, regardless if oesophageal dysmotility is present, is pain modulators.

Distal esophageal spasm in high-resolution esophageal pressure topography: defining clinical phenotypes

BACKGROUND

The manometric diagnosis of distal esophageal spasm (DES) uses "simultaneous contractions" as a defining criterion, ignoring the concept of short latency distal contractions as an important feature. Our aim was to apply standardized metrics of contraction velocity and latency to high-resolution esophageal pressure topography (EPT) studies to refine the diagnosis of DES.

METHODS

Two thousand consecutive EPT studies were analyzed for contractile front velocity (CFV) and distal latency to identify patients potentially having DES. Normal limits for CFV and distal latency were established from 75 control subjects. Clinical data of patients with reduced distal latency and/or rapid CFV were reviewed.

RESULTS

Of 1070 evaluable patients, 91 (8.5%) had a high CFV and/or low distal latency. Patients with only rapid contractions (n = 186 [17.4%] using conventional manometry criteria; n = 85 [7.9%] using EPT criteria) were heterogeneous in diagnosis and symptoms, with the majority ultimately categorized as weak peristalsis or normal. In contrast, 96% of patients with premature contraction had dysphagia, and all (n = 24; 2.2% overall) were ultimately managed as spastic achalasia or DES.

CONCLUSIONS

The current DES diagnostic paradigm focused on "simultaneous contractions" identifies a large heterogeneous set of patients, most of whom do not have a clinical syndrome suggestive of esophageal spasm. Incorporating distal latency into the diagnostic algorithm of EPT studies improves upon this by isolating disorders of homogeneous pathophysiology: DES with short latency and spastic achalasia. We hypothesize that prioritizing measurement of distal latency will refine the management of these disorders, recognizing that outcomes trials are necessary.

Botulinum toxin in the treatment of diffuse esophageal spasm

Diffuse esophageal spasm is a primary esophageal motility disorder. The prevalence is 3-10% in patients with dysphagia and treatment options are limited. This review summarizes the treatment of diffuse esophageal spasm, including pharmacotherapy, endoscopic treatment, and surgical treatment with a special focus on botulinum toxin injection. A PubMed search was performed to identify the literature using the search items diffuse esophageal spasm and treatment. Pharmacotherapy with smooth muscle relaxants, proton pump inhibitors, and antidepressants was suggested from small case series and uncontrolled clinical trials. Endoscopic injection of botulinum toxin is a well-studied treatment option and results in good symptomatic benefit in patients with diffuse esophageal spasm. Surgical treatment was reported in patients with very severe symptoms refractory to pharmacologic treatment. This article summarizes the present knowledge on the treatment of diffuse esophageal spasm with a special emphasis on botulinum toxin injection. Endoscopic injection of botulinum toxin is presently the best studied treatment option but many questions remain unanswered.

Guidelines for the diagnosis and management of gastroesophageal reflux disease: an evidence-based consensus

Gastroesophageal reflux disease (GERD) is one of the most common disorders in medical practice. A number of guidelines and recommendations for the diagnosis and management of GERD have been published in different countries, but a Brazilian accepted directive by the standards of evidence-based medicine is still lacking. As such, the aim of the Brazilian GERD Consensus Group was to develop guidelines for the diagnosis and management of GERD, strictly using evidence-based medicine methodology that could be clinically used by primary care physicians and specialists and would encompass the needs of physicians, investigators, insurance and regulatory bodies. A total of 30 questions were proposed. Systematic literature reviews, which defined inclusion and/or exclusion criteria, were conducted to identify and grade the available evidence to support each statement. A total of 11,069 papers on GERD were selected, of which 6,474 addressed the diagnosis and 4,595, therapeutics. Regarding diagnosis, 51 met the requirements for the analysis of evidence-based medicine: 19 of them were classified as grade A and 32 as grade B. As for therapeutics, 158 met the evidence-based medicine criteria; 89 were classified as grade A and 69 as grade B. In the topic Diagnosis, answers supported by publications grade A and B were accepted. In the topic Treatment only publications grade A were accepted: answers supported by publications grade B were submitted to the voting by the Consensus Group. The present publication presents the most representative studies that responded to the proposed questions, followed by pertinent comments. Follow examples. In patients with atypical manifestations, the conventional esophageal pH-metry contributes little to the diagnosis of GERD. The sensitivity, however, increases with the use of double-channel pH-metry. In patients with atypical manifestations, the impedance-pHmetry substantially contributes to the diagnosis of GERD. The examination, however, is costly and scarcely available in our country. The evaluation of the histological signs of esophagitis increases the diagnostic probability of GERD; hence, the observation of the dimensions of the intercellular space of the esophageal mucosa increases the probability of diagnostic certainty and also allows the analysis of the therapeutic response. There is no difference in the clinical response to the treatment with PPI in two separate daily doses when compared to a single daily dose. In the long term (>1 year), the eradication of H. pylori in patients with GERD does not decrease the presence of symptoms or the high recurrence rates of the disease, although it decreases the histological signs of gastric inflammation. It seems very likely that there is no association between the eradication of the H. pylori and the manifestations of GERD. The presence of a hiatal hernia requires larger doses of proton-pump inhibitor for the clinical treatment. The presence of permanent migration from the esophagogastric junction and the hernia dimensions (>2 cm) are factors of worse prognosis in GERD. In this case, hiatal hernias associated to GERD, especially the fixed ones and larger than 2 cm, must be considered for surgical treatment. The outcomes of the laparoscopic fundoplication are adequate.

Extraesophageal GERD

The manifestations of gastroesophageal reflux disease (GERD) have been classified into either esophageal or extraesophageal syndromes. Cough, reflux laryngitis, and asthma have been classified as extraesophageal syndromes, whereas reflux chest pain has been classified as a symptomatic syndrome of GERD. In extraesophageal syndromes, patients usually do not display the classic symptoms of reflux, such as heartburn and regurgitation. Upper gastrointestinal endoscopy and pH monitoring, when used to diagnose reflux in patients with symptoms not classic for GERD, have proved to have poor sensitivity and are often not diagnostically helpful. In contrast, an empiric trial of proton pump inhibitors is a well-established, cost-effective tool.

Noncardiac chest pain-treatment approaches

Treatment of noncardiac chest pain is often difficult because of the heterogeneous nature of the disorder. This condition can stem from gastroesophageal reflux, visceral hyperalgesia, esophageal motility disorders, psychiatric dysfunction, abnormal biomechanical properties of the esophageal wall, sustained esophageal contractions, abnormal cerebral processing of visceral stimulation, or disrupted autonomic activity. For a treatment to be successful, diagnosis of the underlying cause is essential. This article examines three decades of studies from around the world. It concludes that new research into additional mechanisms involved in visceral pain appears promising; but that future studies using improved selective adenosine receptor antagonists and other therapeutic interventions are needed.

Differential diagnosis of chest pain: point of view of a cardiologist and a rheumatologist

A terápia utóbbi évtizedekben bekövetkezett rohamos fejlődése a klinikum minden területén szükségessé teszi a mihamarabbi bajmegállapítást, mivel döntően ettől függ a terápiával elérhető eredmény. Ez a cardio- és cerebrovascularis események esetében különösen igaz. Célkitűzés: Tekintettel arra, hogy a mellkasban életveszélyes cardiovascularis és az életet kevésbé veszélyeztető egyéb történések egyaránt fájdalmat okoznak, a szerzők – elsősorban saját tapasztalataik, továbbá az irodalmi adatok alapján – áttekintést adnak a mellkasi fájdalom differenciáldiagnosztikájáról. Módszer: A szerzők a mellkasi fájdalom veszélyességét, gyakoriságát és topográfiáját figyelembe vevő sorrendben és csoportosításban tárgyalják a különböző okokat. Következtetés: A korszerű diagnosztikai és terápiás lehetőségek birtokában sem nélkülözhető, sőt még inkább szükséges a mellkasi fájdalom mint tünet minél részletesebb elemzése.

Clinical trial design in adult reflux disease: a methodological workshop

BACKGROUND

The development of well-tolerated acid suppressant drugs has stimulated substantial growth in the number of trials assessing therapy options for gastro-oesophageal reflux disease (GERD).

AIM

To develop consensus statements to inform clinical trial design in adult patients with GERD.

METHODS

Draft statements were developed employing a systematic literature review. A modified Delphi process including three rounds of voting was used to reach consensus. Between voting, statements were revised based on feedback from the Working Group and additional literature reviews. The final vote was at a face-to-face meeting that included discussion time. Voting was conducted using a six-point scale.

RESULTS

At the last vote, 93% of the final 102 statements achieved consensus (defined a priori as being supported by >or=75% of the votes). The Working Group strongly supported the development of validated patient-reported outcome instruments. Symptom assessments carried out by the investigator were considered unacceptable. There was agreement that exclusion from clinical trials should be minimized to improve generalizability, that prospective evaluation ideally requires electronic timed/dated methods and that endoscopists should be blinded to patient symptom status.

CONCLUSIONS

Implementation of the consensus statements will improve the quality and comparability of trials, and make them compatible with regulatory requirements.

Noncardiac chest pain

Noncardiac chest pain (NCCP) affects approximately 1 quarter of the adult population in the United States. The pathophysiology of the disorder remains to be fully elucidated. Identified underlying mechanisms for esophageal pain include gastroesophageal reflux disease (GERD), esophageal dysmotility, and visceral hypersensitivity. Aggressive antireflux treatment has been the main therapeutic strategy for GERD-related NCCP. NCCP patients with or without spastic esophageal motor disorders are responsive to pain modulators. The value of botulinum toxin injection, endoscopic treatment for GERD, and antireflux surgery in alleviating NCCP symptoms is limited.

Diffuse esophageal spasm

The purpose of this article is to review the clinical features, pathophysiology, diagnosis, and management of patients with diffuse esophageal spasm (DES). The PubMed database was searched with a focus on recent publications, using keywords "DES," plus "epidemiology," "prevalence," "diagnosis," "pathogenesis," "calcium channel blocker," "nitrates," "botulinum toxin," "antidepressants," "dilation," and "myotomy." The reference lists of papers identified in the initial PubMed search were reviewed for further relevant publications.

Non-achalasic motor disorders of the oesophagus

Motor abnormalities of the oesophagus are characterised by a chronic impairment of the neuromuscular structures that co-ordinate oesophageal function. The best-defined entity is achalasia, which is discussed in a separate chapter. Other motor disorders with clinical relevance include diffuse oesophageal spasm, oesophageal dysmotility associated with scleroderma, and ineffective oesophageal motility. These non-achalasic motor disorders have variable prevalence but they could be associated with invalidating symptoms such as dysphagia, chest pain and gastro-oesophageal reflux disease. New oesophageal diagnostic techniques, including high-resolution manometry, high-frequency intraluminal ultrasound and intraluminal impedance, allow (1) better definition of peristalsis and sphincter function, (2) assessment of changes in oesophageal wall thickness, and (3) evaluation of pressure gradients within the oesophagus and across the sphincters that can produce normal or abnormal patterns of bolus transport. This chapter discusses recent advances in physiology, pathophysiology, diagnosis and treatment of non-achalasic oesophageal motor disorders.

Prevalence of upper gastrointestinal tract findings in patients with noncardiac chest pain versus those with gastroesophageal reflux disease (GERD)-related symptoms: results from a national endoscopic database

BACKGROUND

Available data on the prevalence of esophageal and upper gut findings in patients with noncardiac chest pain (NCCP) are scarce and limited to one center's experience.

AIM

To determine the prevalence of esophageal and upper gut mucosal findings in patients undergoing upper endoscopy for NCCP only versus those with gastroesophageal reflux disease (GERD) symptoms only, using the national Clinical Outcomes Research Initiative (CORI) database.

METHODS

During the study period, the CORI database received endoscopic reports from a network of 76 community, university, and Veteran Administration Health Care System (VAHCS)/military practice sites. All adult patients who underwent an upper endoscopy for NCCP only or GERD-related symptoms only were identified. Demographic characteristics and prevalence of endoscopic findings were compared between the two groups.

RESULTS

A total of 3,688 consecutive patients undergoing an upper endoscopy for NCCP and 32,981 for GERD were identified. Normal upper endoscopy was noted in 44.1% of NCCP patients versus 38.8% of those with GERD (P<0.0001). Of the NCCP group, 28.6% had a hiatal hernia (HH), 19.4% erosive esophagitis (EE), 4.4% Barrett's esophagus (BE), and 3.6% stricture/stenosis. However, HH, EE, and BE were significantly more common in the GERD group as compared with the NCCP group (44.8%, 27.8%, and 9.1%, respectively, P<0.0001). In univariate analysis of patients with NCCP, male gender was a risk factor for BE (OR 1.86, 95% CI 1.35-2.55, P=0.0001) and being nonwhite was protective (OR 0.43, 95% CI 0.22-0.86, P=0.02). In this group, male gender was also a risk factor for EE (OR 1.31, 95% CI 1.11-1.54, P=0.001) and age>or=65 yr was protective (OR 0.73, 95% CI 0.6-0.89, P=0.002). The NCCP group had a significantly higher prevalence of peptic ulcer in the upper gastrointestinal tract as compared with the GERD group (2.0% vs 1.5%, P=0.01).

CONCLUSIONS

In this endoscopic prevalence study, most of the endoscopic findings in NCCP were GERD related, but less common as compared with GERD patients.

Theophylline improves esophageal chest pain--a randomized, placebo-controlled study

BACKGROUND/AIM

The treatment of esophageal (noncardiac) chest pain is unsatisfactory and there is no approved therapy. A previous uncontrolled study suggested that theophylline may be useful. Our aims were to investigate the effects of theophylline on esophageal sensorimotor function and chest pain.

METHODS

In a double-blind study, sensory and biomechanical properties of the esophagus were assessed using impedance planimetry in 16 patients with esophageal hypersensitivity, after intravenous theophylline or placebo. In a second, randomized 4-wk crossover study, oral theophylline and placebo were administered to 24 patients with esophageal hypersensitivity. Frequency, intensity, and duration of chest pain episodes were evaluated.

RESULTS

After IV theophylline, chest pain thresholds (P=0.027) and esophageal cross-sectional area (P=0.03) increased and the esophageal wall became more distensible (P=0.04) compared with placebo. After oral theophylline, the number of painful days (P=0.03) and chest pain episodes (P=0.025), pain duration (P=0.002), and its severity (P=0.031) decreased. Overall symptoms improved in 58% on theophylline and 6% on placebo (P<0.02). There was no order effect.

CONCLUSIONS

Theophylline relaxed the esophageal wall, decreased hypersensitivity, and improved chest pain. Theophylline is effective in the treatment of functional chest pain.

New frontiers for the treatment of noncardiac chest pain: the adenosine receptors

Emerging data suggest that noncardiac chest pain (NCCP) is a very common disorder of international proportions. In the United States alone, an estimated 69 million patients suffer from NCCP. The clinical spectrum of patients with NCCP being referred to gastroenterologists seems to be changing to those failing to respond acid inhibition therapy or those who may not have gastroesophageal reflux (GER) in the first place. For these individuals there is an important need to find effective therapeutic options. These patients are the subject of the study that appears in this issue of The American Journal of Gastroenterology (Rao et al.,). Rao et al. report data from their tertiary center on consecutive patients with recurrent NCCP failing an 8-wk therapeutic trial of double-dose PPI or lacking evidence of GER on 24-h pH testing. They found that theophylline--a nonspecific adenosine receptor antagonist--when compared with placebo, improved the biomechanical and sensory properties of the esophageal wall and chest pain frequency, severity, and duration. This study underscores the potential role of adenosine receptors in visceral pain.

Are there any differences between nutcracker esophagus with and without reflux?

"Nutcracker esophagus" (NE) is a primary esophageal motor disorder, first described in patients with noncardiac chest pain. In recent years NE has been associated with gastroesophageal reflux disease (GERD). In this study we compare patients with NE with and without GERD, as defined by pHmetry or endoscopy, with respect to clinical, endoscopic, radiologic, and manometric findings. Fifty-two patients with NE were studied. They were divided in two groups: GERD (17-32.6%) and non-GERD (35-67.4%) patients. Females predominated in both groups, with no significant difference in age (p>0.05). Chest pain was the chief complaint in both groups (p>0.05). Clinical findings in patients with and without reflux included chest pain (52.9% and 51.4%), dysphagia (58.8% and 42.8%), and heartburn (64.7% and 42.8%), followed by regurgitation, dyspepsia, ear, nose, and throat (ENT) complaints, respiratory symptoms, and odynophagia (p>0.05). Erosive esophagitis was found in three patients (5.7%). There were no differences between groups in the findings of barium swallow studies and all manometric findings were similar for both groups (p>0.05). We conclude that there were no differences in patients with NE with or without associated reflux disease. It is important to diagnose reflux properly so patients can be treated adequately.

Non-erosive reflux disease and atypical gastro-oesophageal reflux disease manifestations: treatment results

Gastro-oesophageal reflux disease (GERD) is a widespread complex disorder that may be responsible for a variety of different symptoms and clinical features. Despite the presence of symptoms, the majority of patients do not have endoscopic lesions of oesophagitis. Non-erosive reflux disease (NERD) is a chronic, relapsing condition that can adversely affect the quality of life despite the absence of mucosal breaks at endoscopy. In many patients GERD is associated with extra-oesophageal or atypical manifestations, including cough, asthma, laryngitis or non-cardiac chest pain. Acid suppression with proton pump inhibitors (PPI) remains the mainstay of GERD therapy. However, patients with NERD and extra-oesophageal manifestations are often poorly responsive to PPI therapy. Accurate diagnosis followed by adequate PPI dosage and compliance with therapy are essential for the successful control of NERD and extra-oesophageal manifestations. The better detection and characterization of acid and non-acid reflux episodes using developing technologies, such as combined pH-impedance monitoring, is extending our understanding of the pathophysiology of NERD and the extra-oesophageal manifestations of GERD, and will lead to the improved management of these often poorly responsive conditions. This article reviews the treatment results and outlines approaches to the evaluation, diagnosis and therapy of NERD and atypical GERD manifestations.