Antidepressant treatment of patients with diffuse esophageal spasm: a psychosomatic approach

Comparison of the efficacy of diltiazem versus fluoxetine in the treatment of distal esophageal spasm: A randomized-controlled-trial

BACKGROUND AND STUDY AIM

Distal esophageal spasm is an uncommon esophageal motility disorder presenting with non-cardiac chest pain and dysphagia. The main goal of therapy is symptom relief with pharmacologic, endoscopic, and surgical therapies. Pharmacologic treatment is less invasive and is the preferred method of choice. The purpose of this study was to compare the effectiveness of diltiazem versus fluoxetine in the treatment of distal esophageal spasm.

PATIENTS AND METHODS

A total of 125 patients with distal esophageal spasm diagnosed using endoscopy, barium esophagogram, and manometry were evaluated. Patients were divided into diltiazem and fluoxetine groups and received a 2-month trial of diltiazem + omeprazole or fluoxetine + omeprazole, respectively. Of 125 patients, 55 were lost to follow up and 70 were eligible for final analysis. Clinical signs and symptoms were assessed before and after therapy using four validated questionnaires: Eckardt score, short form-36, heartburn score, and the hospital anxiety and depression scale.

RESULTS

Both regimens significantly relieved symptoms (a decrease in mean Eckardt score of 2.57 and 3.18 for diltiazem and fluoxetine groups, respectively; and a decrease in mean heartburn score by 0.89 and 1.03 for diltiazem and fluoxetine groups, respectively). Patients' quality of life improved based on short form-36 (an increase in mean score of 2.37 and 3.95 for fluoxetine and diltiazem groups, respectively). There was no relationship between patients' improvement and severity of symptoms. Psychological findings based on the hospital anxiety and depression scale were inconsistent (a decrease in mean of 0.143 and 0.57 for fluoxetine and diltiazem groups, respectively; p > 0.05).

CONCLUSION

Fluoxetine and diltiazem were effective for clinical symptom relief in patients with distal esophageal spasm, but were not promising for improving psychological symptoms. Neither regimen was superior in terms of efficacy. Consequently, it is key to consider side effects and comorbidities when choosing a therapy.

Diagnosis and Management of Functional Chest Pain in the Rome IV Era

Functional chest pain accounts for about a third of the patients with noncardiac chest pain. It is a very common functional esophageal disorder that remains even today a management challenge to the practicing physician. Based on the definition offered by the Rome IV criteria, diagnosis of functional chest pain requires a negative workup of noncardiac chest pain patients that includes, proton pump inhibitor test or empirical proton pump inhibitor trial, endoscopy with esophageal mucosal biopsies, reflux testing, and esophageal manometry. The mainstay of treatment are neuromodulators that are primarily composed of anti-depressants. Alternative medicine and psychological interventions may be provided alone or in combination with other therapeutic modalities.

Recent Advances in the Pharmacological Management of Gastroesophageal Reflux Disease

The management of proton pump inhibitor-refractory GERD (rGERD) is a challenge in clinical practice. Since up to one-third of patients with typical GERD symptoms (heartburn and/or acid regurgitation) are not satisfied with proton pump inhibitor (PPI) therapy, new drug development targeting different pathophysiologies of GERD is imperative. At present, no other drugs serve as a more potent acid suppression agent than PPIs. As an add-on therapy, histamine type-2 receptor antagonists, alginates, prokinetics and transient lower esophageal sphincter relaxation inhibitors have some impact on the subgroups of rGERD, but greater effectiveness and fewer adverse effects for widespread use are required. Visceral hypersensitivity also contributes to the perception of GERD symptoms, and neuromodulators including antidepressants play a role in this category. Esophageal pH-impedance monitoring helps to distinguish functional heartburn from true GERD, and psychologic medication and cognitive behavior therapy are further therapy options instead of PPIs.

Dronabinol increases pain threshold in patients with functional chest pain: a pilot double-blind placebo-controlled trial

Noncardiac chest pain is associated with poor quality of life and high care expenditure. The majority of noncardiac chest pain is either gastresophageal reflux disease related or due to esophageal motility disorders, and the rest are considered functional chest pain (FCP) due to central and peripheral hypersensitivity. Current treatment of FCP improves 40-50% of patients. Cannabinoid receptors 1 (CB1) and 2 (CB2) modulate release of neurotransmitters; CB1 is located in the esophageal epithelium and reduces excitatory enteric transmission and potentially could reduce esophageal hypersensitivity. We performed a prospective study to evaluate its effects on pain threshold, frequency, and intensity in FCP. Subjects with FCP received dronabinol (5 mg, twice daily; n = 7; average age, 44 years; mean body mass index, 26.7) or placebo (n = 6; average age, 42 years; mean body mass index, 25.9) for 28 days (4 weeks). Chest pain, general health, and anxiety/depression questionnaires were assessed at baseline and at 4 weeks. Subjects underwent an esophageal balloon distention test prior to treatment and on last day of the study. Dronabinol increased pain thresholds significantly (3.0 vs. 1.0; P = 0.03) and reduced pain intensity and odynophagia compared to placebo (0.18 vs. 0.01 and 0.12 vs. 0.01, respectively, P = 0.04). Depression and anxiety scores did not differ between the groups at baseline or after treatment. No significant adverse effects were observed. In this novel study, dronabinol increased pain threshold and reduced frequency and intensity of pain in FCP. Further, large scale studies are needed to substantiate these findings.

Current treatment options for esophageal diseases

Exciting new developments-pharmacologic, endoscopic, and surgical-have arisen for the treatment of many esophageal diseases. Refractory gastroesophageal reflux disease presents a therapeutic challenge, and several new options have been proposed to overcome an insufficient effectiveness of proton pump inhibitors. In patients with distal esophageal spasm, drugs and endoscopic treatments are the current mainstays of the therapeutic approach. Treatment with proton pump inhibitors (or antireflux surgery) should be considered in patients with Barrett's esophagus, since a recent meta-analysis demonstrated a 71% reduction in risk of neoplastic progression. Endoscopic resection combined with radiofrequency ablation is the standard of care in patients with early esophageal adenocarcinoma. Mucosal squamous cancer may also be treated endoscopically, preferably with endoscopic submucosal dissection. Patients with upper esophageal cancer often refrain from surgery. Robot-assisted, thoracolaparoscopic, minimally invasive esophagectomy may be an appropriate option for these patients, as the robot facilitates a good overview of the upper mediastinum. Induction chemoradiotherapy is currently considered as standard treatment for patients with advanced squamous cell carcinoma, while the role of neoadjuvant therapy for adenocarcinoma remains controversial. A system for defining and recording perioperative complications associated with esophagectomy has been recently developed and may help to find predictors of mortality and morbidity.

Psychological interventions for symptomatic management of non-specific chest pain in patients with normal coronary anatomy

BACKGROUND

Recurrent chest pain in the absence of coronary artery disease is a common problem which sometimes leads to excess use of medical care. Although many studies have examined the causes of pain in these patients, few clinical trials have evaluated treatment. This is an update of a Cochrane review originally published in 2005 and last updated in 2010. The studies reviewed in this paper provide an insight into the effectiveness of psychological interventions for this group of patients.

OBJECTIVES

To assess the effects of psychological interventions for chest pain, quality of life and psychological parameters in people with non-specific chest pain.

SEARCH METHODS

We searched the Cochrane Library (CENTRAL, Issue 4 of 12, 2014 and DARE Issue 2 of 4, 2014), MEDLINE (OVID, 1966 to April week 4 2014), EMBASE (OVID, 1980 to week 18 2014), CINAHL (EBSCO, 1982 to April 2014), PsycINFO (OVID, 1887 to April week 5 2014) and BIOSIS Previews (Web of Knowledge, 1969 to 2 May 2014). We also searched citation lists and contacted study authors.

SELECTION CRITERIA

Randomised controlled trials (RCTs) with standardised outcome methodology that tested any form of psychotherapy for chest pain with normal anatomy. Diagnoses included non-specific chest pain (NSCP), atypical chest pain, syndrome X or chest pain with normal coronary anatomy (as either inpatients or outpatients).

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, extracted data and assessed quality of studies. We contacted trial authors for further information about the included RCTs.

MAIN RESULTS

We included two new papers, one of which was an update of a previously included study. Therefore, a total of 17 RCTs with 1006 randomised participants met the inclusion criteria, with the one new study contributing an additional 113 participants. There was a significant reduction in reports of chest pain in the first three months following the intervention: random-effects relative risk = 0.70 (95% CI 0.53 to 0.92). This was maintained from three to nine months afterwards: relative risk 0.59 (95% CI 0.45 to 0.76). There was also a significant increase in the number of chest pain-free days up to three months following the intervention: mean difference (MD) 3.00 (95% CI 0.23 to 5.77). This was associated with reduced chest pain frequency (random-effects MD -2.26, 95% CI -4.41 to -0.12) but there was no evidence of effect of treatment on chest pain frequency from three to twelve months (random-effects MD -0.81, 95% CI -2.35 to 0.74). There was no effect on severity (random-effects MD -4.64 (95% CI -12.18 to 2.89) up to three months after the intervention. Due to the nature of the main interventions of interest, it was impossible to blind the therapists as to whether the participant was in the intervention or control arm. In addition, in three studies the blinding of participants was expressly forbidden by the local ethics committee because of issues in obtaining fully informed consent . For this reason, all studies had a high risk of performance bias. In addition, three studies were thought to have a high risk of outcome bias. In general, there was a low risk of bias in the other domains. However, there was high heterogeneity and caution is required in interpreting these results. The wide variability in secondary outcome measures made it difficult to integrate findings from studies.

AUTHORS' CONCLUSIONS

This Cochrane review suggests a modest to moderate benefit for psychological interventions, particularly those using a cognitive-behavioural framework, which was largely restricted to the first three months after the intervention. Hypnotherapy is also a possible alternative. However, these conclusions are limited by high heterogeneity in many of the results and low numbers of participants in individual studies. The evidence for other brief interventions was less clear. Further RCTs of psychological interventions for NSCP with follow-up periods of at least 12 months are needed.

The role of pain modulators in esophageal disorders - no pain no gain

Pain modulators have been primarily used for the management of functional esophageal disorders. Recently, these drugs have also been used for the management of other esophageal disorders, such as non-erosive reflux disease, the hypersensitive esophagus, and heartburn that is not responsive to proton pump inhibitor treatment. Several etiologies have been identified in patients with functional esophageal disorders, and these include esophageal hypersensitivity due to peripheral and/or central sensitisation, altered central processing of peripheral stimuli, altered autonomic activity, and psychological comorbidity such as depression and anxiety. Different antidepressants have been used as pain modulators and have demonstrated a beneficial effect on patients with the aforementioned esophageal disorders. Tricyclic antidepressants are the most commonly used class of drugs in clinical practice. Other antidepressants that have been used, some with more clinical success than others, include selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and trazodone. Other medications that have been used as pain modulators in esophageal disorders include adenosine antagonists, serotonin agonists, antiepileptics, and medications that ameliorate peripheral neuropathy. The mechanism by which many of the pain modulators confer their visceral analgesic effect remains to be fully elucidated. Regardless, their role and value in treating esophageal disorders have markedly increased in the last decade.

Proton pump inhibitor resistance, the real challenge in gastro-esophageal reflux disease

Gastro-esophageal reflux disease (GERD) is one of the most prevalent chronic diseases. Although proton pump inhibitors (PPIs) represent the mainstay of treatment both for healing erosive esophagitis and for symptom relief, several studies have shown that up to 40% of GERD patients reported either partial or complete lack of response of their symptoms to a standard PPI dose once daily. Several mechanisms have been proposed as involved in PPIs resistance, including ineffective control of gastric acid secretion, esophageal hypersensitivity, ultrastructural and functional changes in the esophageal epithelium. The diagnostic evaluation of a refractory GERD patients should include an accurate clinical evaluation, upper endoscopy, esophageal manometry and ambulatory pH-impedance monitoring, which allows to discriminate non-erosive reflux disease patients from those presenting esophageal hypersensitivity or functional heartburn. Treatment has been primarily based on doubling the PPI dose or switching to another PPI. Patients with proven disease, not responding to PPI twice daily, are eligible for anti-reflux surgery.

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.

[Updated guidelines 2012 for gastroesophageal reflux disease]

In 2010, a Korean guideline for the management of gastroesophageal reflux disease (GERD) was made by the Korean Society of Neurogastroenterology and Motility, in which the definition and diagnosis of GERD were not included. The aim of this guideline was to update the clinical approach to the diagnosis and management of GERD in adult patients. This guideline was developed by the adaptation process of the ADAPTE framework. Twelve guidelines were retrieved from initial queries through the Appraisal of Guidelines for Research & Evaluation II process. Twenty-seven statements were made as a draft and revised by modified Delphi method. Finally, 24 consensus statements for the definition (n=4), diagnosis (n=7) and management (n=13) of GERD were developed. Multidisciplinary experts participated in the development of the guideline, and the external review of the guideline was conducted at the finalization phase.

Step-by-step management of refractory gastresophageal reflux disease

Up to a third of the patients who receive proton pump inhibitor (PPI) once daily will demonstrate lack or partial response to treatment. There are various mechanisms that contribute to PPI failure and they include residual acid reflux, weakly acidic and weakly alkaline reflux, esophageal hypersensitivity, and psychological comorbidity, among others. Some of these underlying mechanisms may coincide in the same patient. Evaluation for proper compliance and adequate dosing time of PPIs should be the first management step before ordering invasive diagnostic tests. Doubling the PPI dose or switching to another PPI is the second step of management. Upper endoscopy and pH testing appear to have limited diagnostic value in patients who failed PPI treatment. In contrast, esophageal impedance with pH testing (multichannel intraluminal impedance MII-pH) on therapy appears to provide the most insightful information about the subsequent management of these patients (step 3). In step 4, treatment should be tailored to the specific underlying mechanism of patient's PPI failure. For those who demonstrate weakly acidic or weakly alkaline reflux as the underlying cause of their residual symptoms, transient lower esophageal sphincter relaxation reducers, endoscopic treatment, antireflux surgery and pain modulators should be considered. In those with functional heartburn, pain modulators are the cornerstone of therapy.

Selective serotonin reuptake inhibitors for the treatment of hypersensitive esophagus: a randomized, double-blind, placebo-controlled study

OBJECTIVES

Ambulatory 24-h pH-impedance monitoring can be used to assess the relationship of persistent symptoms and reflux episodes, despite proton pump inhibitor (PPI) therapy. Using this technique, we aimed to identify patients with hypersensitive esophagus and evaluate the effect of selective serotonin reuptake inhibitors (SSRIs) on their symptoms.

METHODS

Patients with normal endoscopy and typical reflux symptoms (heartburn, chest pain, and regurgitation), despite PPI therapy twice daily, underwent 24-h pH-impedance monitoring. Distal esophageal acid exposure (% time pH <4) was measured and reflux episodes were classified into acid or non-acid. A positive symptom index (SI) was declared if at least half of the symptom events were preceded by reflux episodes. Patients with a normal distal esophageal acid exposure time, but with a positive SI were classified as having hypersensitive esophagus and were randomized to receive citalopram 20 mg or placebo once daily for 6 months.

RESULTS

A total of 252 patients (150 females (59.5%); mean age 55 (range 18-75) years) underwent 24-h pH-impedance monitoring. Two hundred and nineteen patients (86.9%) recorded symptoms during the study day, while 105 (47.9%) of those had a positive SI (22 (20.95%) with acid, 5 (4.76%) with both acid and non-acid, and 78 (74.29%) with non-acid reflux). Among those 105 patients, 75 (71.4%) had normal distal esophageal acid exposure time and were randomized to receive citalopram 20 mg (group A, n=39) or placebo (group B, n=36). At the end of the follow-up period, 15 out of the 39 patients of group A (38.5%) and 24 out of the 36 patients of group B (66.7%) continue to report reflux symptoms (P=0.021).

CONCLUSIONS

Treatment with SSRIs is effective in a select group of patients with hypersensitive esophagus.

Esophageal motility disorders (distal esophageal spasm, nutcracker esophagus, and hypertensive lower esophageal sphincter): modern management

The group of hypercontractile esophageal motility disorders includes distal esophageal spasm (DES), nutcracker esophagus (NE), and hypertensive lower esophageal sphincter (LES). The clinical relevance of these abnormalities identified during esophageal manometry is debated, and their management can be challenging. Hypercontractile esophageal motility abnormalities are defined through specific manometric criteria. Current pathophysiologic concepts for these abnormalities include defects in the nitronergic neural pathways and imbalances between the cholinergic and nitronergic pathway. Proposed treatments for NE, DES, and hypertensive LES include proton-pump inhibitors, nitrates, calcium channel blockers, phosphodiasterase inhibitors, and tricyclic antidepressants or serotonin reuptake inhibitors. Small case series reported benefits after botulinum toxin injections, dilatations, and myotomies. The optional management of esophageal spasm, NE, and hypertensive LES is still debated. Treatment recommendations are based on controlled studies with small numbers of patients or on case series. Medical treatment, including acid suppression, smooth muscle relaxants, and visceral analgesics, should be tried first. In nonresponding patients, botulinum toxin injections or balloon dilatations can be tried. Pneumatic dilatations or myotomies should be regarded as last-option treatments for nonresponding patients.

Psychological interventions for symptomatic management of non-specific chest pain in patients with normal coronary anatomy

BACKGROUND

Recurrent chest pain in the absence of coronary artery disease is a common problem that sometimes leads to excess use of medical care. Although many studies examine the causes of pain in these patients, few clinical trials have evaluated treatment. The studies reviewed in this paper provide an insight into the effectiveness of psychological interventions for this group of patients.

OBJECTIVES

To update the previously published systematic review.

SEARCH METHODS

We searched the Cochrane LIbrary (CENTRAL and DARE) (Issue 3 of 4 2011), MEDLINE (1966 to August Week 5, 2011), CINAHL (1982 to Sept 2011) EMBASE (1980 to Week 35 2011), PsycINFO (1887 to Sept Week 1, 2011), and Biological Abstracts (January 1980 to Sept 2011). We also searched citation lists and approached authors.

SELECTION CRITERIA

Randomised controlled trials (RCTs) with standardised outcome methodology that tested any form of psychotherapy for chest pain with normal anatomy. Diagnoses included non-specific chest pain (NSCP), atypical chest pain, syndrome X, or chest pain with normal coronary anatomy (as either inpatients or outpatients).

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies for inclusion, extracted data and assessed quality of studies. The authors contacted trial authors for further information about the RCTs included.

MAIN RESULTS

Six new RCTs were located and added to the existing trials, therefore, a total of 15 RCTs (803 participants) were included. There was a significant reduction in reports of chest pain in the first three months following the intervention; fixed-effect relative risk = 0.68 (95% CI 0.57 to 0.81). This was maintained from three to nine months afterwards; relative risk = 0.59 (95% CI 0.45 to 0.76). There was also a significant increase in the number of chest pain free days up to three months following the intervention; mean difference = 2.81 (95% CI 1.28 to 4.34). This was associated with reduced chest pain frequency (random-effects mean difference = -2.26 95% CI -4.41 to -0.12) but there was no evidence of effect of treatment on chest pain frequency from three to twelve months (random-effects mean difference -0.81 95% CI -2.35, 0.74). There was no effect on severity (random-effects mean difference = -4.64 (95% CI -12.18 to 2.89) up to three months after the intervention. Overall there was generally a low risk of bias, however, there was high heterogeneity and caution is required in interpreting these results. Wide variability in outcome measures made integration of studies for secondary outcome measures difficult to report on.

AUTHORS' CONCLUSIONS

This review suggests a modest to moderate benefit for psychological interventions, particularly those using a cognitive-behavioural framework, which was largely restricted to the first three months after the intervention. Hypnotherapy is also a possible alternative. The evidence for brief interventions was less clear. Further RCTs of psychological interventions for NSCP with follow-up periods of at least 12 months are needed.

Therapeutic options for refractory gastroesophageal reflux disease

Refractory gastroesophageal reflux disease may affect up to one-third of the patients that consume proton pump inhibitor (PPI) once daily. Treatment in clinical practice has been primarily focused on doubling the PPI dose, despite lack of evidence of its value. In patients who failed PPI twice daily, medical treatment has been primarily focused on reducing transient lower esophageal sphincter relaxation rate or attenuating esophageal pain perception using visceral analgesics. In patients with evidence of reflux as the direct trigger of their symptoms, endoscopic treatment or antireflux surgery may be helpful in remitting symptoms. The role of psychological interventions, as well as non-traditional therapeutic strategies remains to be further elucidated.

Presentation, diagnosis, and treatment of oesophageal motility disorders

Whilst the current treatment of achalasia is well understood, the management of other oesophageal disorders is still debated, as these are rare and the literature on their clinical presentation and management is scarce. The following review describes the clinical presentation of oesophageal motility disorders, gives an overview of their diagnosis in light of the new advances in oesophageal motility testing, and provides an evidence-based approach to their management with different forms of treatment (medical, endoscopic, and minimally invasive).

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.

New pharmacologic approaches in gastroesophageal reflux disease

This article highlights current and emerging pharmacological treatments for gastroesophageal reflux disease (GERD), opportunities for improving medical treatment, the extent to which improvements may be achieved with current therapy, and where new therapies may be required. These issues are discussed in the context of current thinking on the pathogenesis of GERD and its various manifestations and on the pharmacologic basis of current treatments.

Selective-serotonin reuptake inhibitors for the treatment of hypersensitive esophagus

In patients with proton-pump inhibitor (PPI) resistant reflux symptoms, ambulatory 24 h pH impedance monitoring can be used to assess whether a relationship exists between symptoms and reflux episodes. Using this technique it has been suggested that patients with typical reflux symptoms and a normal upper endoscopy should be subclassified as follows: normal endoscopy and abnormal distal acid esophageal exposure (patients with acid reflux); normal endoscopy, with normal distal acid esophageal exposure and a positive symptom association for either acid or nonacid reflux (patients with hypersensitive esophagus); and normal endoscopy, normal distal acid esophageal exposure and a negative symptom association for acid and nonacid reflux (patients with functional heartburn). Although for patients with a normal endoscopy and abnormal distal acid esophageal exposure more aggressive acid suppression can be recommended, managing patients with hypersensitive esophagus and functional heartburn remains a real challenge.Therefore, investigators have evaluated the role of tricyclic antidepressants or selective-serotonin reuptake inhibitors (SSRIs) in influencing esophageal perception. Imipramine has been shown to decrease pain perception in healthy male volunteers and improve symptoms of patients with chest pain and normal coronary angiograms. Trazodone improved symptoms in patients with esophageal contraction abnormalities, while administration of SSRIs lowered chemical and mechanical sensitivity and benefited patients with diffuse esophageal spasm. Furthermore, in a recent study conducted by our group, citalopram administered once daily for 6 months was effective in a select group of patients with hypersensitive esophagus, suggesting that there is a role for SSRIs in the treatment of this disorder.

[Guidelines for the treatment of gastroesophageal reflux disease]

Gastroesophageal reflux disease (GERD) is defined as a condition that develops when the reflux of stomach contents causes troublesome symptoms and/or complications. In the last decade, GERD has been increasing in Korea. Seventeen consensus statements for the treatment of GERD were developed using the modified Delphi approach. Acid suppression treatments, such as proton pump inhibitors (PPIs), histmine-2 receptor antagonists and antacids are effective in the control of GERD-related symptoms. Among them, PPIs are the most effective medication. Standard dose PPI is recommended as the initial treatment of erosive esophagitis (for 8 weeks) and non-erosive reflux disease (at least for 4 weeks). Long-term continuous PPI or on-demand therapy is required for the majority of GERD patients after the initial treatment. Anti-reflux surgery can be considered in well selected patients. Prokinetic agents and mucosal protective drugs have limited roles. Twice daily PPI therapy can be tried to control extra-esophageal symptoms of GERD. For symptomatic patients with Barrett's esophagus, long-term treatment with PPI is required. Further studies are strongly needed to develop better treatment strategies for Korean patients with GERD.

Advances in drug therapy for gastroesophageal reflux disease

The incidence of gastroesophageal reflux disease (GERD) is increasing drastically in China. GERD could probably cause reflux esophagitis, chronic cough, asthma, Barrett's esophagus and adenocarcinoma, and frequently affects health-related quality of life. The use of proton pump inhibitors (PPIs) provides effective symptomatic relief in most patients; however, some patients appear refractory to the treatment with PPIs. The long term use of PPIs might also cause adverse effects, such as interstitial nephritis, fracture and small intestinal bacterial overgrowth. Many new drugs for GERD have emerged recently. This article reviews the advances in drug therapy for GERD.

Pharmacological management of GERD: where does it stand now?

Gastroesophageal reflux disease (GERD) is very common and advances in drug development over recent years have markedly improved GERD management. A wide range of medications are currently used in GERD treatment, including antacids, Gaviscon, sucralfate, histamine-2 receptor antagonists and prokinetics. However, proton pump inhibitors (PPIs) remain the mainstay of treatment for GERD owing to their profound and consistent inhibitory effect on acid secretion. Despite the presence of a wide armamentarium of therapeutic modalities for GERD, many areas of unmet needs remain. Drug development has focused primarily on improving PPI efficacy, reducing the transient lower esophageal sphincter relaxation rate, attenuating esophageal sensitivity and developing esophageal mucosal protectants.

An algorithm for diagnosis and treatment of refractory GERD

Patients with gastro-esophageal reflux disease (GERD) who are not responding to proton pump inhibitors (PPIs) given once daily are very common. These therapy-resistant patients have become the new face of GERD in clinical practice in the last decade. Upper endoscopy appears to have a limited diagnostic value. In contrast, esophageal impedance with pH testing on therapy appears to provide the most insightful information about the subsequent management of these patients. Commonly, doubling the PPI dose or switching to another PPI will be offered to patients who failed PPI once daily. Failure of such therapeutic strategies is commonly followed by assessment for weakly or residual acidic reflux. There is growing information about the potential value of compounds that can reduce transient lower esophageal sphincter relaxation rate. Esophageal pain modulators are commonly offered to patients with functional heartburn although supportive clinical studies are still missing.

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.

New pharmacologic approaches in gastroesophageal reflux disease

This article highlights current and emerging pharmacological treatments for gastroesophageal reflux disease (GERD), opportunities for improving medical treatment, the extent to which improvements may be achieved with current therapy, and where new therapies may be required. These issues are discussed in the context of current thinking on the pathogenesis of GERD and its various manifestations and on the pharmacologic basis of current treatments.

The role of weakly acidic reflux in proton pump inhibitor failure, has dust settled?

Patients that do not respond satisfactorily to standard proton pump inhibitor (PPI) treatment have become the most common presentation of gastro-esophageal reflux disease (GERD) in third referral gastrointestinal practices. The causes of refractory GERD include lack of compliance with treatment, residual acid reflux and weakly acidic reflux, esophageal hypersensitivity and persistent symptoms not associated with reflux. A role for weakly acidic reflux in symptom generation has been proposed since the availability of impedance-pH monitoring. The possible mechanisms by which persistent weakly acidic reflux might contribute to persistent symptoms in patients under PPI treatment may include esophageal distension by increased reflux volume, persistent impaired mucosal integrity (ie, dilation of intercellular spaces) and/or esophageal hypersensitivity to weakly acidic reflux events. To establish a definite role of weakly acidic reflux in refractory GERD, outcome studies targeting this type of reflux are still lacking. Treatment strategies to reduce the number or effect of weakly acidic reflux could involve drugs that decrease transient lower esophageal sphincter relaxations (ie, baclofen or similar), improve oesophageal mucosa resistance or visceral pain modulators. Finally, anti-reflux surgery can be considered, only if a clear symptom-weakly acidic reflux association was demonstrated.

Management of gastroesophageal reflux disease that does not respond well to proton pump inhibitors

PURPOSE OF REVIEW

Patients with gastroesophageal reflux disease (GERD) who are not responding to proton pump inhibitors (PPIs) given once daily are very common. These therapy-resistant patients have become the new face of GERD in clinical practice in the last decade and presently pose a significant therapeutic challenge to the practicing physician. We reviewed newly accumulated information about the management of PPI failure that has been published over the past 2 years.

RECENT FINDINGS

There are diverse mechanisms that contribute to the failure of PPI treatment in GERD patients and they are not limited to residual reflux. Some of the causes of PPI failure may coincide in the same patient. Upper endoscopy appears to have limited diagnostic value. In contrast, esophageal impedance with pH testing on therapy appears to provide the most insightful information about the subsequent management of these patients. Commonly, doubling the PPI dose or switching to another PPI will be offered to patients who failed PPI once daily. Failure of such therapeutic strategies is commonly followed by assessment for residual reflux. There is growing information about the potential value of compounds that can reduce transient lower esophageal sphincter relaxations. Esophageal pain modulators are commonly offered to patients with functional heartburn, although supportive clinical studies are still missing.

SUMMARY

Management of refractory GERD patients remains an important clinical challenge. Recent studies have cemented the value of impedance-pH testing in pursuing proper treatment. Presently, the most promising therapeutic development for this patient population is transient lower esophageal sphincter relaxation reducers.

Psychological interventions for symptomatic management of non-specific chest pain in patients with normal coronary anatomy

BACKGROUND

Recurrent chest pain in the absence of coronary artery disease is a common problem that sometimes leads to excess use of medical care. Although many studies examine the causes of pain in these patients, few clinical trials have evaluated treatment. The studies reviewed in this paper provide an insight into the effectiveness of psychological interventions for this group of patients.

OBJECTIVES

To investigate psychological treatments for non-specific chest pain (NSCP) with normal coronary anatomy.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2008, Issue 4), MEDLINE (1966 to December 2008), CINAHL (1982 to December 2008) EMBASE (1980 to December 2008), PsycINFO (1887 to December 2008), the Database of Abstracts of Reviews of Effectiveness (DARE) and Biological Abstracts (January 1980 to December 2008). We also searched citation lists and approached authors.

SELECTION CRITERIA

Randomised controlled trials (RCTs) with standardised outcome methodology that tested any form of psychotherapy for chest pain with normal anatomy. Diagnoses included non-specific chest pain, atypical chest pain, syndrome X, or chest pain with normal coronary anatomy (as either inpatients or outpatients).

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies for inclusion, extracted data and assessed quality of studies. The authors contacted trial authors for further information about the RCTs included.

MAIN RESULTS

Ten RCTs (484 participants) were included. There was a significant reduction in reports of chest pain in the first three months following the intervention; fixed effects relative risk = 0.68 (95% CI 0.57 to 0.81). This was maintained from 3 to 9 months afterwards; relative risk = 0.59 (95% CI 0.45 to 0.76). There was also a significant increase in the number of chest pain free days up to three months following the intervention; mean difference = 2.81 (95% CI 1.28 to 4.34). This was associated with reduced chest pain frequency (mean difference = -1.73 (95% CI -2.21 to -1.26)) and severity (mean difference = -6.86 (95% CI -10.74 to -2.97)). However, there was high heterogeneity and caution is required in interpreting these results. Wide variability in outcome measures made integration of studies for secondary outcome measures difficult to report on.

AUTHORS' CONCLUSIONS

This review suggests a modest to moderate benefit for psychological interventions, particularly those using a cognitive-behavioural framework, which was largely restricted to the first three months after the intervention. Hypnotherapy is also a possible alternative. The evidence for brief interventions was less clear. Further RCTs of psychological interventions for NSCP with follow-up periods of at least 12 months are needed.

Proton pump inhibitor failure--what are the therapeutic options?

Proton pump inhibitor (PPI) failure is very common and may affect up to one-third of the PPI consumers. Identifying the underlying mechanisms for PPI failure in each individual patient is essential for treatment success. For residual acid reflux, increasing the PPI dose to twice daily; switching to another PPI, or adding an histamine 2 receptor antagonist could be a successful therapeutic strategy. In patients with duodenogastroesophageal reflux, weak acidic/alkaline reflux and hypersensitivity to acid reflux, therapeutic modalities that reduce transient lower esophageal sphincter relaxation or visceral pain could be entertained. Treatment of PPI failure due to delayed gastric emptying should be focused on improving gastric motor activity. Psychological management may supplement any medical or surgical approach toward PPI failure.

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.

A Questionnaire Study to Assess Long-Term Outcome in Patients with Abnormal Esophageal Manometry

Patients with unexplained chest pain or dysphagia are often referred for esophageal manometric studies to further investigate their symptoms. Four main manometric abnormalities have been described: achalasia, diffuse esophageal spasm, "nutcracker" (hypercontracting) esophagus, and hypocontracting esophagus. With the exception of achalasia, treatments are of limited benefit and the natural history of these conditions is largely unknown. We sent questionnaires to patients who were investigated at least three years before our study began. They repeated a DeMeester symptom questionnaire that they had completed at the time of their initial study. Questionnaires were sent to 137 patients with diffuse esophageal spasm, "nutcracker" (hypercontracting) esophagus, or hypocontracting esophagus. We also sent questionnaires to 57 patients with dysphagia or chest pain who had had normal esophageal manometry and pH studies. These patients acted as symptomatic controls. Responses were compared using the Wilcoxon signed ranks test. Seventy-two (53%) patients with diffuse esophageal spasm, "nutcracker" esophagus, or hypocontracting esophagus replied. An additional 8 (6%) patients died. Symptom scores in all three conditions had improved significantly over time (p < or = 0.01 for each condition, Wilcoxon signed ranks test). Patients with dysphagia or chest pain but normal esophageal studies had not improved. The significance of diffuse esophageal spasm, "nutcracker" esophagus, and hypocontracting esophagus found at esophageal manometry remains uncertain. Although treatment is often ineffective, these conditions typically run a benign course. Patients can be reassured that their symptoms are likely to improve with time.

Edrophonium provocative testing for the evaluation of upper gastrointestinal hypersensitivity in patients with nonulcer dyspepsia

The aim of this study was to examine if edrophonium provocative testing is useful for evaluating upper gastrointestinal hypersensitivity in patients with nonulcer dyspepsia (NUD). A questionnaire rating dyspeptic symptoms was done for 58 patients with NUD. The patients were then given an intravenous infusion of saline followed by 5 mg of edrophonium. Baseline esophageal manometry was also done. Patients whose usual symptoms were reproduced (48.3%) had significantly higher symptom scores (13.0 [8.5, 17.0] vs. 8.5 [6.0, 11.0]; P = 0.015) and a significantly higher number of symptoms (4.0 [2.5, 6.0] vs. 3.0 [1.0, 4.0]; P = 0.010) than patients whose usual symptoms were not reproduced. The presence of an esophageal motility disorder was not significantly different between the two groups. These findings suggest upper gastrointestinal hypersensitivity in the patients whose symptoms were reproduced. Edrophonium provocative testing might be useful for evaluating upper gastrointestinal hypersensitivity in patients with NUD.

Review article: oesophageal spasm - diagnosis and management

Oesophageal spasm is a common empiric diagnosis clinically applied to patients with unexplained chest pain. In contrast it is an uncommon manometric abnormality found in patients presenting with chest pain and/or dysphagia and diagnosed by >or=20% simultaneous oesophageal contractions during standardized motility testing. Using Medline we searched for diagnostic criteria and treatment options for oesophageal spasm. While the aetiology of this condition is unclear, studies suggest the culprit being a defect in the nitric oxide pathway. Well-known radiographic patterns have low sensitivities and specificities to identify intermittent simultaneous contractions. Recognizing that simultaneous contractions may result from gastro-oesophageal reflux this diagnosis should be investigated or treated first. Studies have documented improvements with proton-pump inhibitors, nitrates, calcium-channel blockers and tricyclic antidepressants or serotonin reuptake inhibitors. Small case series reported benefits after botulinium toxin injections, dilatations and myotomies. Uncertainties persist regarding the optimal management of oesophageal spasm and recommendations are based on controlled studies with small numbers of patients or on case series. Acid suppression, muscle relaxants and visceral analgetics should be tried first. Botulinium toxin injections should be reserved for patients who do not respond. Pneumatic dilatations or myotomies represent rather heroic approaches for non-responding patients.

Diagnosis and treatment of noncardiac chest pain

Chest pain is common: one in four of the population have an episode annually. Of those who present to hospital, nearly two-thirds have noncardiac chest pain. More than half of these cases might have gastroesophageal reflux disease. Opinion differs over what is the most appropriate application of current investigatory methods. Evidence suggests that, once cardiac disease is ruled unlikely, empiric use of a proton pump inhibitor is an option; if acid suppression fails, detailed investigations as clinically indicated can be considered. A range of esophageal investigations is available, including 24-hour or 48-hour esophageal pH testing and esophageal manometry, as well as provocative tests, but there is no consensus as to which methods are the most useful. Psychiatric evaluation is not routine, but psychiatric or psychological disorders are common. Musculoskeletal disorders are also common, but are frequently overlooked. It is possible to subject patients to a comprehensive set of investigations before empiric therapy, but recent studies have failed to demonstrate an improved outcome using this exhaustive approach. A new tactic is required, with less attention spent on absolute diagnostic accuracy and more emphasis on optimizing the long-term clinical outcome in patients with noncardiac chest pain. It is possible that the targeted use of multiple drug trials in a policy of 'therapy as investigation' might be a superior methodology.

Psychological interventions for symptomatic management of non-specific chest pain in patients with normal coronary anatomy

BACKGROUND

Recurrent chest pain in the absence of coronary artery disease is a common problem that sometimes leads to excess use of medical care. Although many studies examine the causes of pain in these patients, few clinical trails have evaluated treatment. The studies reviewed in this paper provide an insight into the effectiveness of psychological interventions for this group of patients.

OBJECTIVES

To investigate psychological treatments for non-specific chest pain (NSCP) with normal coronary anatomy.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2002, Issue 3), MEDLINE (1966 to 2002), CINAHL (1982 to 2002) EMBASE (1980 to 2002), PSYCH Info (1887 to 2002), the Database of Abstracts of Reviews of Effectiveness (DARE) and Biological Abstracts (January 1980 to 2002). We also searched citation lists and approached authors.

SELECTION CRITERIA

RCTs with standardised outcome methodology that tested any form of psychotherapy for chest pain with normal anatomy. Diagnoses included non-specific chest pain, atypical chest pain, syndrome X, or chest pain with normal coronary anatomy (as either inpatients or outpatients).

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies for inclusion, extracted data and assessed quality of studies. The authors contacted trial authors for further information about the RCTs included.

MAIN RESULTS

Eight studies involving 403 randomised participants were included. There was a significant reduction in reports of chest pain in the first three months following the intervention; fixed effects relative risk = 0.68 (95% CI 0.57 to 0.81). This was maintained from 3 to 9 months afterwards; relative risk = 0.58 (95% CI 0.45 to 0.76). There was also a significant increase in the number of chest pain free days up to three months following the intervention; the standardized mean difference = 0.85 (95% CI 0.38 to 1.31). However, there was high heterogeneity for this test. Wide variability in outcome measures made integration of studies for secondary outcome measures difficult.

AUTHORS' CONCLUSIONS

Review suggested a modest to moderate benefit for psychological interventions, particularly those using a cognitive-behavioural framework, which was largely restricted to the first three months after the intervention. The evidence for brief interventions was less clear. Further RCTs of psychological interventions for NSCP with follow-up periods of at least 12 months are needed.

Endoscopy-negative reflux disease: concepts and clinical practice

Endoscopy-negative reflux disease is used to describe a heterogeneous group of disorders with symptoms that mimic those of gastroesophageal reflux disease in the absence of visible esophageal injury at endoscopy. Compared with patients who have gastroesophageal reflux-related erosive esophagitis, those with endoscopy-negative disease are more likely to be younger, female, of lower body weight, and without a hiatal hernia. Approximately 50% of those with endoscopy-negative reflux have abnormal intraesophageal acid exposure and are considered to have nonerosive acid reflux disease. Those with symptoms of >12 consecutive or intermittent weeks' duration during the prior year, with normal acid exposure and without achalasia or other motility disorder with a recognized pathologic basis, are considered to have functional heartburn. In the absence of pathologic reflux, a number of etiologies may contribute to the symptoms of heartburn, including motor events, reflux of nonacidic gastric contents, minute changes in intraesophageal pH (pH <4), visceral hypersensitivity, and emotional or psychological abnormalities. Although persons with endoscopy-negative reflux disease experience decrements in their quality of life that are similar to those for individuals with erosive esophagitis, the response to traditional therapies for acid reflux may differ between the 2 groups. Studies have found that approximately 50% of patients with endoscopy-negative reflux disease experience complete symptom relief after 4 weeks of proton pump inhibitor treatment. In those with persistent heartburn symptoms, other structural or nonacid reflux etiologies for their symptoms should be explored.

Treatment of spastic esophageal motility disorders

Treatment of spastic motility disorders continues to be challenging. Therapeutic options remain limited due in part to our lack of understanding of the pathophysiology and significance of these disorders. Furthermore, most of therapeutic trials to date are hampered by the poorly designed nature of the study, including the small size of the trials and the lack of placebo arm. Most of the available information suggests that there seems to be an important dissociation between symptoms (chest pain/dysphagia) and esophageal dysmotility. Drug treatment aimed at visceral sensitivity seems more effective in relieving symptoms than spasmolytic medications. Recent trials with Botox, nitric oxide derivatives, and SSRIs offer promising results. Rigorous study design that includes large placebo-controlled trials is needed in this area.

Noncardiac chest pain: evaluation and treatment

Noncardiac chest pain is a heterogeneous condition for which diagnosis and treatment are challenging. Research is needed to streamline evaluation to minimize unnecessary invasive testing and costs. Chest pain clinics to assess chest pain patients are popular in the United States and may be of value in reassuring patients and reducing presentation to hospital; however, recently this has been contended [111]. Options for the effective treatment of NCCP are dependent on the risk of an adverse outcome and the cost-effectiveness of the management algorithm that is followed. Most (64%) of those presenting to the emergency department with chest pain are classified as having NCCP [112,113]. GERD is probably the most important cause and application of a test of acid suppression with a high-dose PPI for 1 to 2 weeks seems to be a useful diagnostic tool. In those patients with GERD-related NCCP, short-term and potentially long-term therapy with a PPI (commonly higher than standard dose) is required to alleviate symptoms. Esophageal dysmotility is relatively uncommon in patients with NCCP and evaluation by esophageal manometry might be limited to rule out achalasia. Chest wall syndromes are common but probably often missed. Many patients with NCCP have psychologic or psychiatric abnormalities, as either the cause or an effect of the chest pain, but diagnosis here depends on techniques not applied easily in the acute situation. Pain modulators seem to offer significant improvement in chest pain symptoms for non-GERD-related NCCP. Finally, trials of management strategies to deal with this problem are required urgently, because the earlier discharge of patients with NCCP may exacerbate the problem. Fig. 2 provides a flow chart for diagnosis and treatment of NCCP.

Esophageal motor disorders: achalasia and esophageal spasm

PURPOSE

To define the esophageal motor disorders of achalasia and esophageal spasms and describe their presentation in the clinical setting.

DATA SOURCES

Selected research-based articles, textbooks, and expert opinion. A case study is presented.

CONCLUSIONS

The presentation of esophageal motor disorders may not be clear, particularly when the presenting symptom is chest pain. Determining whether the pain is cardiac or digestive in origin is crucial.

IMPLICATIONS FOR PRACTICE

Progressive dysphagia for both solids and liquids is the major symptom of achalasia; other symptoms include regurgitation, chest pain, and nocturnal cough. Diffuse esophageal spasm typically causes substernal chest pain with nonprogressive dysphagia and odynophagia for both liquids and solids. Dysphagia related to esophageal motility is characterized by a sensation of swallowed food "sticking" in the throat or chest; there is no problem initiating the act of swallowing.

Practical approaches to dysphagia caused by Esophageal motor disorders

Dysphagia is a common symptom with which patients present. This review focuses primarily on the esophageal motor disorders that result in dysphagia. Following a brief description of the normal swallowing mechanisms and the messengers involved, more specific motor abnormalities are discussed. The importance of achalasia, as the only pathophysiologically defined esophageal motor disorder, is discussed in some detail, including recent developments in pathogenesis and treatment options. Other esophageal spastic disorders are described, with relevant manometric tracings included. In recent years, the importance of gastroesophageal reflux as a primary cause of esophageal dysmotility has been recognized, and this is also discussed. In addition, the motility disturbances that develop after surgical fundoplication are reviewed.

Esophageal motor disorders

Motor dysfunction is responsible for symptomatic illnesses both in the proximal skeletal muscle region and in the distal smooth muscle esophagus. Practical methods for diagnosing and treating oropharyngeal dysphagia continue to reach consensus. Achalasia, the most significant of the distal motor disorders, is of investigative interest because of the expanded armamentarium of treatment options. Minimally invasive surgical methods have taken an important foothold as a primary treatment of this disorder. Appreciation is growing for sensory dysfunction that accompanies distal motor disorders. Such dysfunction may help explain the observed discrepancies between symptoms and measurable motility abnormality.

Novel approaches to the treatment of nausea and vomiting

Nausea and vomiting are debilitating symptoms complicating many clinical conditions. Conventional antiemetic agents act as muscarinic, histamine, and dopamine receptor antagonists in the central nervous system. In a retrospective analysis, tricyclic antidepressant drugs demonstrated efficacy in long-term treatment of functional nausea. Some cases of vomiting result from impaired gastrointestinal motor activity. Agents which act on gastric serotonin (5-HT4), dopamine, and motilin receptors accelerate gastric emptying and relieve symptoms in gastroparesis. Recent investigations suggest that some patients with refractory gastroparesis may benefit from gastric electrical pacing. The treatment of acute chemotherapy-induced emesis was revolutionized by 5-HT3 receptor antagonists; however, these agents are less efficacious in delayed vomiting. Neurokinin (NK-1) receptor antagonists show promise in treating delayed chemotherapy-evoked emesis. Furthermore, animal studies indicate a broad spectrum of action for NK-1 antagonists in treating diverse causes of nausea and vomiting. The cyclic vomiting syndrome is characterized by discrete episodes of relentless vomiting separated by asymptomatic intervals and is associated with migraine headaches. Antimigraine therapies including the 5-HT1D receptor agonists sumatriptan reduce the severity of cyclic vomiting attacks. Investigations into these and other novel treatments may provide important advances in the care of difficult cases of nausea and vomiting resulting from disparate illnesses.