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Piccioni A, Baroni S, Manca F, Sarlo F, Savioli G, Candelli M, Bronzino A, Covino M, Gasbarrini A, Franceschi F. Multi-Marker Approach in Patients with Acute Chest Pain in the Emergency Department. J Pers Med 2024; 14:564. [PMID: 38929785 PMCID: PMC11204991 DOI: 10.3390/jpm14060564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 05/17/2024] [Accepted: 05/22/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND Chest pain is a prevalent reason for emergency room referrals and presents diagnostic challenges. The physician must carefully differentiate between cardiac and noncardiac causes, including various vascular and extracardiovascular conditions. However, it is crucial not to overlook serious conditions such as acute coronary syndrome (ACS). Diagnosis of acute myocardial infarction (AMI) and early discharge management become difficult when traditional clinical criteria, ECG, and troponin values are insufficient. Recently, the focus has shifted to a "multi-marker" approach to improve diagnostic accuracy and prognosis in patients with chest pain. METHODS This observational, prospective, single-center study involved, with informed consent, 360 patients presenting to the emergency department with typical chest pain and included a control group of 120 healthy subjects. In addition to routine examinations, including tests for hsTnI (Siemens TNIH kit), according to the 0-1 h algorithm, biochemical markers sST2 (tumorigenicity suppression-2) and suPAR (soluble urokinase plasminogen activator receptor) were also evaluated for each patient. A 12-month follow-up was conducted to monitor outcomes and adverse events. RESULTS We identified two groups of patients: a positive one (112 patients) with high levels of hsTnI, sST2 > 24.19 ng/mL, and suPAR > 2.9 ng/mL, diagnosed with ACS; and a negative one (136 patients) with low levels of hsTnI, suPAR < 2.9 ng/mL, and sST2 < 24.19 ng/mL. During the 12-month follow-up, no adverse events were observed in the negative group. In the intermediate group, patients with hsTnI between 6 ng/L and the ischemic limit, sST2 > 29.1 ng/mL and suPAR > 2.9 ng/mL, showed the highest probability of adverse events during follow-up, while those with sST2 < 24.19 ng/mL and suPAR < 2.9 ng/mL had a better outcome with no adverse events at 12 months. CONCLUSION Our data suggest that sST2 and suPAR, together with hsTnI, may be useful in the prognosis of cardiovascular patients with ACS, providing additional information on endothelial damage. These biomarkers could guide the clinical decision on further diagnostic investigations. In addition, suPAR and sST2 emerge as promising for event prediction in patients with chest pain. Their integration into the standard approach in PS could facilitate more efficient patient management, allowing safe release or timely admission based on individual risk.
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Affiliation(s)
- Andrea Piccioni
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli-IRCCS, 00168 Roma, Italy; (F.M.); (M.C.); (A.B.); (M.C.); (F.F.)
| | - Silvia Baroni
- Unit of Chemistry, Biochemistry and Clinical Molecular Biology, Department of Laboratory and Hematological Sciences, Fondazione Policlinico Universitario Agostino Gemelli-IRCCS, Università Cattolica del Sacro Cuore, 00168 Roma, Italy; (S.B.); (F.S.)
| | - Federica Manca
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli-IRCCS, 00168 Roma, Italy; (F.M.); (M.C.); (A.B.); (M.C.); (F.F.)
| | - Francesca Sarlo
- Unit of Chemistry, Biochemistry and Clinical Molecular Biology, Department of Laboratory and Hematological Sciences, Fondazione Policlinico Universitario Agostino Gemelli-IRCCS, Università Cattolica del Sacro Cuore, 00168 Roma, Italy; (S.B.); (F.S.)
| | - Gabriele Savioli
- Departement of Emergency, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy;
| | - Marcello Candelli
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli-IRCCS, 00168 Roma, Italy; (F.M.); (M.C.); (A.B.); (M.C.); (F.F.)
| | - Alessandra Bronzino
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli-IRCCS, 00168 Roma, Italy; (F.M.); (M.C.); (A.B.); (M.C.); (F.F.)
| | - Marcello Covino
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli-IRCCS, 00168 Roma, Italy; (F.M.); (M.C.); (A.B.); (M.C.); (F.F.)
| | - Antonio Gasbarrini
- Medical and Surgical Science Department, Fondazione Policlinico Universitario Agostino Gemelli-IRCCS, Università Cattolica del Sacro Cuore, 00168 Roma, Italy;
| | - Francesco Franceschi
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli-IRCCS, 00168 Roma, Italy; (F.M.); (M.C.); (A.B.); (M.C.); (F.F.)
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Kadaster AK, Schears MR, Schears RM. Difficult Patients: Malingerers, Feigners, Chronic Complainers, and Real Imposters. Emerg Med Clin North Am 2024; 42:181-195. [PMID: 37977749 DOI: 10.1016/j.emc.2023.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Malingering is the intentional production of false or grossly exaggerated symptoms motivated by internal and external incentives. The true incidence of malingering in the emergency department is unknown because of the difficulty of identifying whether patients are fabricating their symptoms. Malingering is considered a diagnosis of exclusion; a differential diagnosis framework is described to guide emergency physicians. Several case studies are presented and analyzed from a medical ethics perspective. Practical recommendations include use of the NEAL (neutral, empathetic, and avoid labeling) strategy when caring for patients suspected of malingering.
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Affiliation(s)
| | - Markayle R Schears
- University of Wisconsin School of Medicine and Public Health, 750 Highland Avenue, Madison, WI 53705, USA.
| | - Raquel M Schears
- University of Central Florida, 400 Central Florida Boulevard, Orlando, FL 32816, USA
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3
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Alam MJ, Chen JDZ. Non-invasive neuromodulation: an emerging intervention for visceral pain in gastrointestinal disorders. Bioelectron Med 2023; 9:27. [PMID: 37990288 PMCID: PMC10664460 DOI: 10.1186/s42234-023-00130-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 10/24/2023] [Indexed: 11/23/2023] Open
Abstract
Gastrointestinal (GI) disorders, which extend from the esophagus to the anus, are the most common diseases of the GI tract. Among these disorders, pain, encompassing both abdominal and visceral pain, is a predominant feature, affecting the patients' quality of life and imposing a substantial financial burden on society. Pain signals originating from the gut intricately shape brain dynamics. In response, the brain sends appropriate descending signals to respond to pain through neuronal inhibition. However, due to the heterogeneous nature of the disease and its limited pathophysiological understanding, treatment options are minimal and often controversial. Consequently, many patients with GI disorders use complementary and alternative therapies such as neuromodulation to treat visceral pain. Neuromodulation intervenes in the central, peripheral, or autonomic nervous system by alternating or modulating nerve activity using electrical, electromagnetic, chemical, or optogenetic methodologies. Here, we review a few emerging noninvasive neuromodulation approaches with promising potential for alleviating pain associated with functional dyspepsia, gastroparesis, irritable bowel syndrome, inflammatory bowel disease, and non-cardiac chest pain. Moreover, we address critical aspects, including the efficacy, safety, and feasibility of these noninvasive neuromodulation methods, elucidate their mechanisms of action, and outline future research directions. In conclusion, the emerging field of noninvasive neuromodulation appears as a viable alternative therapeutic avenue for effectively managing visceral pain in GI disorders.
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Affiliation(s)
- Md Jahangir Alam
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, 48109, USA.
| | - Jiande D Z Chen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, 48109, USA.
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4
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Chen J, Oshima T, Kondo T, Tomita T, Fukui H, Shinzaki S, Miwa H. Non-cardiac Chest Pain in Japan: Prevalence, Impact, and Consultation Behavior - A Population-based Study. J Neurogastroenterol Motil 2023; 29:446-454. [PMID: 37814435 PMCID: PMC10577468 DOI: 10.5056/jnm22184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 01/05/2023] [Accepted: 01/25/2023] [Indexed: 10/11/2023] Open
Abstract
Background/Aims Non-cardiac chest pain (NCCP) is defined as recurring angina-like retrosternal chest pain of non-cardiac origin. Information about the epidemiology of NCCP in Japan is lacking. We aim to determine the prevalence and characteristics of NCCP in the Japanese general population. Methods Two internet-based surveys were conducted among the general population in March 2017. Questions investigated the characteristics of symptoms associated with chest pain and consultation behavior. Quality of life, anxiety, depression, and gastroesophageal reflux disease were analyzed. Results Five percent of the survey respondents reported chest pain. Subjects with chest pain showed higher frequencies of anxiety and depression and lower quality of life. Among subjects with chest pain, approximately 30% had sought medical attention for their symptoms. Among all consulters, 70% were diagnosed with NCCP. Females were less likely to seek consultations for chest pain than males. Further, severity and frequency of chest pain, lower physical health component summary score, and more frequent gastroesophageal reflux disease were associated with consultation behavior. Subjects with NCCP and cardiac chest pain experienced similar impacts on quality of life, anxiety, and depression. Among subjects with NCCP, 82% visited a primary-care physician and 15% were diagnosed with reflux esophagitis. Conclusions The prevalence of chest pain in this sample of a Japanese general population was 5%. Among all subjects with chest pain, less than one-third consulted physicians, approximately 70% of whom were diagnosed with NCCP. Sex and both the severity and frequency of chest pain were associated with consultation behavior.
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Affiliation(s)
- Junji Chen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Tadayuki Oshima
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Takashi Kondo
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Toshihiko Tomita
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Hirokazu Fukui
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Shinichiro Shinzaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Hiroto Miwa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo Medical University, Nishinomiya, Hyogo, Japan
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5
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Chen W, Wang JP, Wang ZM, Hu PC, Chen Y. Association between sleep duration and chest pain in US adults: A cross-sectional study. Front Public Health 2022; 10:952075. [PMID: 36062107 PMCID: PMC9437346 DOI: 10.3389/fpubh.2022.952075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 07/29/2022] [Indexed: 01/24/2023] Open
Abstract
Objective Herein, we purposed to explore the association of sleep duration with chest pain among adults in US. Methods This research work enrolled 13,274 subjects in the National Health and Nutrition Examination Survey (NHANES) from 2011 to 2018. The association of sleep duration with chest pain among adults in US was evaluated by Multivariable logistic regression. Results To elucidate the association, we made adjustments for gender, BMI, diabetes, smoking status, drinking status, race, marital status, annual family income, hyperlipoidemia, Hypertension. Chest pain incidence decreased by 5% [OR = 0.95 (0.93, 0.98), p = 0.0004] for an increase in sleep duration by 1 h. A generalized additive model (GAM) was used to reseal a U-shaped relationship of sleep duration with incident chest pain. When duration of sleep was <6.5 h, chest pain incidence negatively correlated to sleep duration [OR = 0.77 (0.72, 0.82) P < 0.0001]. However, when sleep duration was ≥6.5 h, chest pain incidence rose with escalating sleep duration [OR = 1.07 (1.03, 1.11) p = 0.0014]. Conclusions Duration of sleep was established to be independently linked with an increase in the occurrence of chest pain. Excessive sleep, as much as insufficient sleep, increases the risk of chest pain. Both excessive sleep and insufficient sleep are associated with an increased risk of chest pain.
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Affiliation(s)
- Wei Chen
- Department of Thoracic Surgery, Taizhou First People's Hospital, Taizhou, China
| | - Ji-ping Wang
- Department of Thoracic Surgery, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, China
| | - Zi-min Wang
- Department of Thoracic Surgery, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, China
| | - Peng-Cheng Hu
- Department of Ophthalmology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing Medical University, Chongqing, China,*Correspondence: Peng-Cheng Hu
| | - Yu Chen
- Department of Thoracic Surgery, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, China,Yu Chen
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Rogers J, Collins G, Husain M, Docherty M. Identifying and managing functional cardiac symptoms. Clin Med (Lond) 2021; 21:37-43. [PMID: 33479066 DOI: 10.7861/clinmed.2020-0934] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Recurring chest pain and other cardiac symptoms that cannot be adequately explained by organic pathology are common and can be associated with substantial disability, distress and high healthcare costs. Common mental disorders such as depression and anxiety frequently co-occur with these symptoms and, in some cases, account for their presentation, although they are not universally present. Due to the frequency of functional cardiac presentations and risks of iatrogenic harm, physicians should be familiar with strategies to identify, assess and communicate with patients about these symptoms. A systematic and multidisciplinary approach to diagnosis and management is often needed. Health beliefs, concerns and any associated behaviours should be elicited and addressed throughout. Psychiatric comorbidities should be concurrently identified and treated. For those with persistent symptoms, psychosocial outcomes can be poor, highlighting the need for further research and investment in diagnostic and therapeutic approaches and multidisciplinary service models.
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Affiliation(s)
- Jonathan Rogers
- University College London, London, UK and specialty registrar in general adult and old age psychiatry, South London and Maudsley NHS Foundation Trust, London, UK
| | - George Collins
- University College London, London, UK and specialty registrar in cardiology, Barts Health NHS Trust, London, UK
| | - Mujtaba Husain
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Mary Docherty
- South London and Maudsley NHS Foundation Trust, London, UK
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7
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Is cervical region tightness related to vagal function and stomach symptoms? Med Hypotheses 2020; 142:109819. [PMID: 32408072 DOI: 10.1016/j.mehy.2020.109819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 04/19/2020] [Accepted: 05/05/2020] [Indexed: 11/21/2022]
Abstract
The vagal nerve is a cranial nerve that carries mainly parasympathetic fibers (average 75%) with both sensory and motor functions. The vagal nerve contains a complex neuro-endocrine-immune network. The majority, at least 66%, of the gastric myenteric neurons receive direct cholinergic excitatory stimulation from the pre-enteric vagal nerve. Changes in vagal function may cause stomach problems, although the mechanisms that change the vagal function have not yet been fully illuminated. Considering the course of the vagal nerve in the cervical region, it is thought that conditions such as stiffness, tightness and decreased elasticity in this region may compress the vagal nerve andmay affect vagal function. According to this hypothesis, neuroinflammation and hyperalgesia may occur in the vagal nerve under mechanical pressure, resulting in increased complaints of pain and burning in the stomach increases. However, as the vagal nerve has various effects on the motility of the stomach and vagal dysfunction affects the motor function of the stomach, relaxation techniques applied to the soft tissues of the cervical region will provide mechanical relief in the nerve. Thus, the vagal nerve will be decompressed and be able to function optimally. According to our clinical observations, in patients whose soft tissues in the cervical region are relaxed, gastric symptoms are decreased. Based on research results and clinical experience, cervical region tightness can be considered to cause stomach problems through the vagal nerve, and soft tissue relaxation of the cervical region can be a promising treatment method for stomach symptoms.
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8
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Fass R, Shibli F, Tawil J. Diagnosis and Management of Functional Chest Pain in the Rome IV Era. J Neurogastroenterol Motil 2019; 25:487-498. [PMID: 31587539 PMCID: PMC6786446 DOI: 10.5056/jnm19146] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 08/07/2019] [Indexed: 12/13/2022] Open
Abstract
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.
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Affiliation(s)
- Ronnie Fass
- The Esophageal and Swallowing Center, MetroHealth Medical Center and Case Western Reserve University, Cleveland, OH, USA
| | - Fahmi Shibli
- The Esophageal and Swallowing Center, MetroHealth Medical Center and Case Western Reserve University, Cleveland, OH, USA
| | - Jose Tawil
- Departamento de Trastornos Funcionales Digestivos, Gedyt-Gastroenterología Diagnóstica y Terapéutica, BuenosAires, Argentina
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Park JY, Oh S, Han YM, Lee J, Kim JS, Jung HC, Hong KS. There might be a distinctive clinical phenotype of constipation with non-cardiac chest pain which responds to combination laxatives: A retrospective, longitudinal symptom analysis. Medicine (Baltimore) 2019; 98:e15884. [PMID: 31261496 PMCID: PMC6617427 DOI: 10.1097/md.0000000000015884] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Proton pump inhibitor (PPI)-refractory non-cardiac chest pain (NCCP) is often resolved when constipation was relieved. This study aimed to investigate the clinical features of patients with both NCCP and constipated functional bowel disorders (FBD).Among 692 consecutive patients diagnosed with functional constipation or irritable bowel syndrome with constipation and underwent anorectal manometry (ARM) in our hospital, PPI-refractory NCCP was present in 37. The clinical course of various torso symptoms including NCCP and ARM findings were retrospectively evaluated.The mean age was lower in the NCCP than in the non-NCCP group (57.4 vs 61.3 years, respectively, P = .042). Back pain (16.2% vs 2.0%, P < .001) and sharp abdominal pain (13.5% vs 0.9%, P < .001) were more common in the NCCP group. Increased resting pressure (16.2% vs 6.9%, P = .036) and squeezing pressure (62.2% vs 50.7%, P = .049) of the anal sphincter, increased urgency volume (40.5% vs 23.2%, P = .004), and maximal volume (25.7% vs 15.0%, P = .032) for rectal sensation were more frequently observed in the NCCP group. After taking laxatives for 1 to 3 months, 81.1% of patients with NCCP reported improvement.Subjects with NCCP showed decreased rectal sensation more frequently at anorectal manometry. Majority of patients with NCCP reported improvement of symptom upon relief of constipation. Constipation might be a therapeutic target in patients with NCCP related to constipated functional bowel disorders.
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Affiliation(s)
- Jae Yong Park
- Department of Internal Medicine, Chung-Ang University Hospital
| | - Sooyeon Oh
- Chaum Life Center, CHA Medical University
| | - Yoo Min Han
- Department of Internal Medicine, Healthcare Research Institute, Seoul National University Hospital Healthcare System Gangnam Center
| | - Jooyoung Lee
- Department of Internal Medicine, Healthcare Research Institute, Seoul National University Hospital Healthcare System Gangnam Center
| | - Joo Sung Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul
| | - Hyun Chae Jung
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul
| | - Kyoung Sup Hong
- Department of Gastroenterology, Mediplex Sejong Hospital, Incheon, South Korea
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Wertli MM, Dangma TD, Müller SE, Gort LM, Klauser BS, Melzer L, Held U, Steurer J, Hasler S, Burgstaller JM. Non-cardiac chest pain patients in the emergency department: Do physicians have a plan how to diagnose and treat them? A retrospective study. PLoS One 2019; 14:e0211615. [PMID: 30707725 PMCID: PMC6358153 DOI: 10.1371/journal.pone.0211615] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 01/17/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Non-cardiac chest pain is common and there is no formal recommendation on what diagnostic tests to use to identify underlying diseases after an acute coronary syndrome has been ruled out. OBJECTIVE To evaluate the diagnostic tests, treatment recommendations and initiated treatments in patients presenting with non-cardiac chest pain to the emergency department (ED). METHODS Single-center, retrospective medical chart review of patients presenting to the ED. Included were all medical records of patients aged 18 years and older presenting to the ED with chest pain and a non-cardiac discharge diagnosis between January 1, 2009 and December 31, 2011. Information on the diagnosis, diagnostic tests performed, treatment initiated and recommendation for further diagnostic testing or treatment were extracted. The primary outcomes of interest were the final diagnosis, diagnostic tests, and treatment recommendations. A formal ACS rule out testing was defined as serial three troponin testing. RESULTS In total, 1341 ED admissions for non-cardiac chest pain (4.2% of all ED admissions) were analyzed. Non-specific chest pain remained the discharge diagnosis in 44.7% (n = 599). Identified underlying diseases included musculoskeletal chest pain (n = 602, 44.9%), pulmonary (n = 30, 2.2%), GI-tract (n = 35, 2.6%), or psychiatric diseases (n = 75, 5.6%). In 81.4% at least one troponin test and in 89% one ECG were performed. A formal ACS rule out troponin testing was performed in 9.2% (GI-tract disease 14.3%, non-specific chest pain 14.0%, pulmonary disease 10.0%, musculoskeletal chest pain 4.7%, and psychiatric disease 4.0%). Most frequently analgesics were prescribed (51%). A diagnostic test with proton pump inhibitor (PPI) was prescribed in 20% (mainly in gastrointestinal diseases). At discharge, over 72 different recommendations were given, ranging from no further measures to extensive cardiac evaluation. CONCLUSION In this retrospective study, a formal work-up to rule out ACS was found in a minority of patients presenting to the ED with chest pain of non-cardiac origin. A wide variation in diagnostic processes and treatment recommendations reflect the uncertainty of clinicians on how to approach patients after a cardiac cause was considered unlikely. Panic and anxiety disorders were rarely considered and a useful PPI treatment trial to diagnose gastroesophageal reflux disease was infrequently recommended.
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Affiliation(s)
- Maria M. Wertli
- Division of General Internal Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
- Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich, Zurich, Switzerland
- * E-mail:
| | - Tenzin D. Dangma
- Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich, Zurich, Switzerland
| | - Sarah E. Müller
- Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich, Zurich, Switzerland
| | - Laura M. Gort
- Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich, Zurich, Switzerland
| | - Benjamin S. Klauser
- Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich, Zurich, Switzerland
| | - Lina Melzer
- Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich, Zurich, Switzerland
| | - Ulrike Held
- Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich, Zurich, Switzerland
| | - Johann Steurer
- Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich, Zurich, Switzerland
| | - Susann Hasler
- Kantonsspital Winterthur, Department of General Internal Medicine Outpatient Clinic, Winterthur, Switzerland
| | - Jakob M. Burgstaller
- Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich, Zurich, Switzerland
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Abstract
Noncardiac chest pain is an angina-type discomfort without indication of ischemia. Diagnosis can be difficult because of its heterogeneous nature. Classification varies by specialty; gastroenterology uses the terminology gastroesophageal reflux disease related versus non-gastroesophageal reflux disease related. Other disciplines recognize noncardiac chest pain etiologies as having gastrointestinal, musculoskeletal, psychiatric, or pulmonary/other as underlying etiologies. Diagnostics yield a specific cause for effective treatment, which is aimed at the underlying etiology, but it is not always possible. Some patients with noncardiac chest pain have comorbidities and ongoing pain that lead to decreased quality of life and continued health care use.
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Affiliation(s)
- Sharron Rushton
- Duke University School of Nursing, DUMC Box 3322, Durham, NC 27710, USA.
| | - Margaret J Carman
- Georgetown University School of Nursing and Health Studies, St. Mary's Hall, 3700 Reservoir Road Northwest, Washington, DC 20007, USA
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12
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Abstract
Background Non-cardiac chest pain (NCCP) is recurrent angina pectoris-like pain without evidence of coronary heart disease in conventional diagnostic evaluation. The prevalence of NCCP is up to 70% and may be detected (in this order) at all levels of the medical health care system (general practitioner, emergency department, chest pain unit, coronary care). Reduction of quality of life due to NCCP is comparable, and partially even higher, to that caused by cardiac chest pain. Reasons for psychological strain are symptom recurrence in approximately 50%, nonspecific diagnosis with resulting uncertainty, and insufficient integration of other medical disciplines in the diagnostic workup. Methods and Results The management of patients with chest pain has to be multidisciplinary because non-cardiac causes may be frequently encountered. Especially gastroenterological expertise is required since the cause of chest pain is gastroesophageal reflux disease (GERD) in 50-60%, hypercontractile esophageal motility disorders with nutcracker/jackhammer esophagus or diffuse esophageal spasm or achalasia in 15-18%, and other esophageal alterations (e.g., infectious esophageal inflammation, drug-induced ulcers, rings, webs, eosinophilic esophagitis) in 32-35%. Conclusion This review highlights the importance of regular interdisciplinary ward rounds and management of chest pain units.
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Affiliation(s)
- Thomas Frieling
- Department of Gastroenterology, Hepatology, Infectiology, Neurogastroenterology, Hematology, Oncology, and Palliative Medicine, HELIOS-Clinic Krefeld, Krefeld, Germany
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13
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Ribolsi M, Balestrieri P, Biasutto D, Emerenziani S, Cicala M. Role of Mixed Reflux and Hypomotility with Delayed Reflux Clearance in Patients with Non-cardiac Chest Pain. J Neurogastroenterol Motil 2016; 22:606-612. [PMID: 27095707 PMCID: PMC5056569 DOI: 10.5056/jnm15182] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Revised: 02/06/2016] [Accepted: 03/05/2016] [Indexed: 12/13/2022] Open
Abstract
Background/Aims Gastroesophageal reflux disease (GERD) is the most common cause of non-cardiac chest pain (NCCP). Currently available data reveal a weak relationship between NCCP and dysmotility. Moreover, it is unclear why some refluxes are perceived as heartburn and others as NCCP. We aimed to evaluate the role of the reflux pattern and the esophageal motility in patients with NCCP. Methods Forty-eight patients with NCCP (Group 1) and 50 only typical GERD symptoms (Group 2) were included and underwent high-resolution manometry (HRM) and multichannel intraluminal impedance-pH monitoring. Results Impaired peristalsis was found in 60% of patients with NCCP and in 24% of patients with typical symptoms (P < 0.05). In patients belonging to Group 1, the majority of reflux episodes associated with chest pain were acid and mixed. The proportion of mixed refluxes was higher than that in Group 2. In Group 1, the reflux clearing time at 5, 9, and 15 cm, measured in reflux episodes associated to NCCP was longer than in reflux episodes associated to typical symptoms (mean ± 95% CI: 27.2 ± 5.6, 23.3 ± 4.4, and 14.6 ± 2.3 seconds vs 18.3 ± 3.5, 13.3 ± 2.2, and 11.1 ± 1.8 seconds; P < 0.01). Conclusions The presence of gas in the refluxate seems to be associated with NCCP. The impaired motility observed in NCCP patients may play a relevant role in delaying reflux clearing, hence increasing the time of contact between refluxate and esophageal mucosa.
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Affiliation(s)
- Mentore Ribolsi
- Digestive Disease Unit, Campus Bio Medico University, Rome, Italy
| | | | - Dario Biasutto
- Digestive Disease Unit, Campus Bio Medico University, Rome, Italy
| | - Sara Emerenziani
- Digestive Disease Unit, Campus Bio Medico University, Rome, Italy
| | - Michele Cicala
- Digestive Disease Unit, Campus Bio Medico University, Rome, Italy
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15
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Min YW, Rhee PL. Esophageal hypersensitivity in noncardiac chest pain. Ann N Y Acad Sci 2016; 1380:27-32. [DOI: 10.1111/nyas.13182] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 06/13/2016] [Accepted: 06/20/2016] [Indexed: 12/18/2022]
Affiliation(s)
- Yang Won Min
- Department of Medicine, Samsung Medical Center; Sungkyunkwan University School of Medicine; Seoul Korea
| | - Poong-Lyul Rhee
- Department of Medicine, Samsung Medical Center; Sungkyunkwan University School of Medicine; Seoul Korea
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16
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Lee K, Kwon HJ, Kim IY, Yoo KH, Lee S, Min YW, Rhee PL. Esophageal Mast Cell Infiltration in a 32-Year-Old Woman with Noncardiac Chest Pain. Gut Liver 2016; 10:152-5. [PMID: 26087786 PMCID: PMC4694748 DOI: 10.5009/gnl14294] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Revised: 11/30/2014] [Accepted: 01/02/2015] [Indexed: 12/13/2022] Open
Abstract
Noncardiac chest pain (NCCP) is one of the most common esophageal symptoms and lacks a clearly defined mechanism. The most common cause of NCCP is gastroesophageal reflux disease (GERD). One of the accepted mechanisms of NCCP in a patient without GERD has been altered visceral sensitivity. Mast cells may play a role in visceral hypersensitivity in irritable bowel syndrome. In this case, a patient with NCCP and dysphagia who was unresponsive to proton pump inhibitor treatment had an increased esophageal mast cell infiltration and responded to 14 days of antihistamine and antileukotriene treatment. We suggest that there may be a relationship between esophageal symptoms such as NCCP and esophageal mast cell infiltration.
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Affiliation(s)
- Keol Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Hee Jin Kwon
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - In Young Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Kwai Han Yoo
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Seulkee Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Yang Won Min
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Poong-Lyul Rhee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul,
Korea
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17
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Min YW, Choi K, Pyo JH, Son HJ, Rhee PL. Impaired Esophageal Mucosal Integrity May Play a Causative Role in Patients With Nongastroesophageal Reflux Disease-Related Noncardiac Chest Pain. Medicine (Baltimore) 2015; 94:e2295. [PMID: 26705212 PMCID: PMC4697978 DOI: 10.1097/md.0000000000002295] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Baseline impedance (BI) measurement can be used to evaluate the status of the esophageal mucosa integrity. We hypothesized that impaired esophageal mucosal integrity may play a causative role in patients with nongastroesophageal reflux disease (non-GERD)-related noncardiac chest pain (NCCP). This retrospective study analyzed 24-hour multichannel intraluminal impedance-pH testing data from 77 patients with NCCP and 5 healthy volunteers. BI was calculated at 3 cm (distal esophagus) and 17 cm (proximal esophagus) above the lower esophageal sphincter. GERD was defined by the presence of pathologic acid exposure or reflux esophagitis. Among the 77 patients with NCCP, 16 (20.8%) were classified into the GERD-related NCCP group and 61 (79.2%) into the non-GERD-related NCCP group. BI (median, interquartile range) of the non-GERD-related NCCP group was lower than the control group at the proximal esophagus (2507 Ω, 2156-3217 vs 3855 Ω, 3238-4182, P = 0.001) but was similar at the distal esophagus. The GERD-related NCCP group showed lower BI than the control group at both the distal and proximal esophagus (2024 Ω, 1619-2308 vs 3203 Ω, 2366-3774, P = 0.007 and 2272 Ω, 1896-2908 vs 3855 Ω, 3238-4182, P = 0.003, respectively). At the distal esophagus, BI was lower in the GERD-related NCCP group than the non-GERD-related NCCP group (P = 0.002), whereas it did not differ between the 2 groups at the proximal esophagus. In conclusion, the mucosal integrity is impaired at the proximal esophagus in patients with non-GERD-related NCCP, which might be the pathogenic mechanism of NCCP.
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Affiliation(s)
- Yang Won Min
- From the Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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18
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Moukaddam N, AufderHeide E, Flores A, Tucci V. Shift, Interrupted: Strategies for Managing Difficult Patients Including Those with Personality Disorders and Somatic Symptoms in the Emergency Department. Emerg Med Clin North Am 2015; 33:797-810. [PMID: 26493524 DOI: 10.1016/j.emc.2015.07.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Difficult patients are often those who present with a mix of physical and psychiatric symptoms, and seem refractory to usual treatments or reassurance. such patients can include those with personality disorders, those with somatization symptoms; they can come across as entitled, drug-seeking, manipulative, or simply draining to the provider. Such patients are often frequent visitors to Emergency Departments. Other reasons for difficult encounters could be rooted in provider bias or countertransference, rather than sole patient factors. Emergency providers need to have high awareness of these possibilities, and be prepared to manage such situations, otherwise workup can be sub-standard and dangerous medical mistakes can be made.
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Affiliation(s)
- Nidal Moukaddam
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, 1502 Taub Loop, NPC Building 2nd Floor, Houston, TX 77030, USA.
| | - Erin AufderHeide
- Section of Emergency Medicine, Baylor College of Medicine, 1504 Taub Loop, Houston, TX 77030, USA
| | - Araceli Flores
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, 1502 Taub Loop, NPC Building 2nd Floor, Houston, TX 77030, USA
| | - Veronica Tucci
- Section of Emergency Medicine, Baylor College of Medicine, 1504 Taub Loop, Houston, TX 77030, USA
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Bahremand M, Moradi G, Saeidi M, Mohammadi S, Komasi S. Reducing Irrational Beliefs and Pain Severity in Patients Suffering from Non-Cardiac Chest Pain (NCCP): A Comparison of Relaxation Training and Metaphor Therapy. Korean J Pain 2015; 28:88-95. [PMID: 25852829 PMCID: PMC4387467 DOI: 10.3344/kjp.2015.28.2.88] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Revised: 02/13/2015] [Accepted: 02/27/2015] [Indexed: 11/05/2022] Open
Abstract
Background Patients suffering from non-cardiac chest pain (NCCP) can interpret their chest pain wrongly despite having received a correct diagnosis. The objective of this study was to compare the efficacy of the relaxation method with metaphor therapy for reducing irrational beliefs and pain severity in patients with NCCP. Methods Using a randomized controlled trial, 33 participants were randomly divided into a relaxation training group (n= 13), a metaphor therapy group (n = 10), and a control group (n = 10), and were studied for 4 weeks. The two tools used in this research were the Brief Pain Inventory (BPI) index for determining the degree of pain and the short version of the Jones Irrational Belief Test. Metaphor therapy and a relaxation technique based on Öst's treatment were used as the interventions. The collected data were analyzed with a multivariate analysis of covariance (MANCOVA), a Chi-square test, and the Bonferroni procedure of post-hoc analysis. Results The relaxation training method was significantly more effective than both metaphor therapy and the lack of treatment in reducing the patients' beliefs of hopelessness in the face of changes and emotional irresponsibility, as well as the pain severity. Metaphor therapy was not effective on any of these factors. In fact, the results did not support the effectiveness of metaphor therapy. Conclusions Regarding the effectiveness of the relaxation method as compared with metaphor therapy and the lack of treatment in the control group, this study suggests that relaxation should be paid greater attention as a method for improving the status of patients. In addition, more studies are needed to determine the effectiveness of metaphor therapy in this area.
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Affiliation(s)
- Mostafa Bahremand
- Interventional Cardiologist, Assistant Professor at Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Gholamreza Moradi
- Cardiac Anesthesiologist, Assistant Professor at Kermanshah University of Medical Sciences, Imam Ali Hospital, University of Medical Sciences, Kermanshah, Iran
| | - Mozhgan Saeidi
- Master of Clinical Psychology, Cardiac Rehabilitation Center, Imam Ali Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Samira Mohammadi
- Pharmacy Student at Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Saeid Komasi
- Master of Clinical Psychology, Cardiac Rehabilitation Center, Imam Ali Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
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ZAPOROWSKA-STACHOWIAK IWONA, GORZELIŃSKA LIDIA, SOPATA MACIEJ, ŁUCZAK JACEK. Treatment of acute, severe epigastric/chest pain in a patient with stomach cancer following gastrectomy: A case report. Oncol Lett 2015; 9:1412-1416. [PMID: 25663923 PMCID: PMC4315054 DOI: 10.3892/ol.2015.2886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2014] [Accepted: 11/13/2014] [Indexed: 11/12/2022] Open
Abstract
The treatment of acute chest pain can be a challenge in palliative care. Firstly, because acute chest pain is a symptom of a paucity of diseases, which makes diagnosis difficult and time consuming, while there is also a time constraint, due to the extreme suffering of the patient. Secondly, the condition of a patient with advanced cancer disease and co-morbidities does not always allow for required diagnostic procedures. The present report describes a case of acute, severe epigastric/chest pain in a patient with dynamic disease progression, who was receiving palliative care. This study also demonstrates that the pathophysiology of pain in a terminal patient may determine the treatment strategy. The patient in the present case was a 41-year-old male, who had previously undergone gastrectomy for stomach cancer, followed by postoperative chemotherapy. The patient was treated with palliative chemotherapy for metastases to the lungs, liver and lymph nodes, which led to the development of iatrogenic peripheral neuropathy. The patient was subsequently admitted to the Palliative Medicine In-patient Unit of the University Hospital of Lord’s Transfiguration (Poznan, Poland) with the complaint of acute epigastric and chest pain. An electrocardiogram, echocardiogram, chest and abdomen computerized tomography scan, esophagoduodenoscopy and laboratory analyses were performed to determine the source of the pain. The patient was treated with morphine sulfate, metoclopramide, midazolam, diazepam, acetaminophen, ketamine, hyoscine butylbromide, propofol, dexamethasone and amoxycillin, and received parenteral nutrition. As the source of pain remained unclear, a second esophagoduodenoscopy was performed to determine a diagnosis, resulting in pain relief. Thus, in the present case, esophagoduodenoscopy was diagnostic and therapeutic. Furthermore, although the treatment of acute chest pain may be a challenge in palliative care, the present study indicates that pain treatment should be adjusted to anatomical, pathophysiological and pharmacological factors, and may pose risks due to the unavoidable parenteral co-administration of multiple agents with strong therapeutic effects.
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Min YW, Rhee PL. Noncardiac Chest Pain: Update on the Diagnosis and Management. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2015; 65:76-84. [DOI: 10.4166/kjg.2015.65.2.76] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Yang Won Min
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Poong-Lyul Rhee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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22
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Lee G, Dix S, Mitra B, Coleridge J, Cameron P. The efficacy and safety of a chest pain protocol for short stay unit patients: A one year follow-up. Eur J Cardiovasc Nurs 2014; 14:416-22. [PMID: 24867877 DOI: 10.1177/1474515114537944] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Accepted: 05/11/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND The Alfred Emergency Short Stay Unit initiated a chest pain protocol for patients presenting with chest pain to risk stratify for acute coronary syndrome (ACS). A 30-day follow-up of patients discharged with low-or-intermediate risk of ACS demonstrated no deaths or ACS. AIMS The purpose of this study was to evaluate the long-term safety of the chest pain protocol, a one year follow-up was undertaken. METHODS A questionnaire was designed for the one-year follow-up and it was administered via a telephone interview by emergency nurses to document adverse cardiac events and health care utilisation. RESULTS From 297 patients, 224 (75%) were contacted 12 months following discharge. There was one death from stroke (0.4%; 95% confidence interval (CI): 0.01-2.5%) and another from an unknown cause. Five patients had been diagnosed with atrial fibrillation (2.2%; 95% CI: 0.7-5.1%), two patients had an acute myocardial infarction (0.9%; 95% CI: 0.03-2.1%) and four were diagnosed with angina (1.8%; 95% CI: 0.9-3.2%). Nearly half (n=103, 46%; 95% CI: 39.5-52.5%) had returned to the emergency department (ED) for various conditions including 42 patients with further chest pain. Ninety-six patients (43%; 95% CI: 39.3-52.7%) had specialist referrals and 124 investigations were performed. Thirty-four patients had cardiology referrals (15%; 95% CI: 10.7-20.5%) and 25 patients had gastroenterology referrals (11%; 95% CI: 7.3-16.0%). Diagnostic cardiac tests were performed on 38 patients: coronary angiography (n=10), 24-hour Holter monitoring (n=17), 24-hour blood pressure (BP) monitoring (n=4), thallium scans (n=5), exercise stress test (n=1) and CT scan (n=1). CONCLUSION Patients had a low risk of adverse events 12 months after discharge but substantial continuing health care utilization was observed. Complete assessment by health care professionals prior to discharge may help mitigate representations.
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Giral A, Kurt R, Yeğin EG, Yeğin K. Signal detection theory approach to gastroesophageal reflux disease: a new method for symptom analysis of impedance-pH data. Dis Esophagus 2014; 27:206-13. [PMID: 23795569 DOI: 10.1111/dote.12093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
An accurate reflux-symptom relationship analysis method is an unmet need in gastroesophageal reflux disease (GERD) diagnosis. The aim of this study was to adapt signal detection theory (SDT) approach to reflux-symptom relationship analysis to develop a new diagnosis method. Patients with predominant symptoms of heartburn and regurgitation were enrolled. Proton pump inhibitor (PPI)-responsive and PPI-unresponsive groups were created via interview and PPI trial. Patients then underwent stationary esophageal manometry and 24-hour multichannel intraluminal impedance-pH monitoring. SDT measurement parameters (discriminability: d' and criterion: c) were calculated using empirically selected time windows (0.5, 1, 2, 3, 4 and 5 minutes). The time window that provided the highest d' value was selected as the optimal time window. A cut-off d' value that optimally separates two groups was found using receiver operating characteristics analysis. Sixty-three patients completed the study (45 PPI responsive). Optimal time window and cut-off d' value were found as 1 and 0.767 minute, respectively. Symptom association probability (SAP) index values showed good correlation (rS = 0.7182, P < 0.0001) with d' values. SDT approach to reflux-symptom relationship analysis showed sensitivity (89% vs. 78%) and negative predictive values (75% vs. 60%) favorable over SAP index analysis. SDT approach using 1-minute time window and 0.767 cut-off d' value provides us a new and more accurate measure of reflux-symptom relationship than SAP index analysis.
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Affiliation(s)
- A Giral
- Department of Gastroenterology, Medical Faculty of Marmara University, Istanbul, Turkey
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24
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Vanuytsel T, Bisschops R, Farré R, Pauwels A, Holvoet L, Arts J, Caenepeel P, De Wulf D, Mimidis K, Rommel N, Tack J. Botulinum toxin reduces Dysphagia in patients with nonachalasia primary esophageal motility disorders. Clin Gastroenterol Hepatol 2013; 11:1115-1121.e2. [PMID: 23591282 DOI: 10.1016/j.cgh.2013.03.021] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Revised: 02/21/2013] [Accepted: 03/01/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Endoscopic injection of botulinum toxin (BTX) has shown benefits for patients with diffuse esophageal spasm (DES) and nutcracker esophagus (NE) in small uncontrolled trials. We investigated the effect of BTX on symptoms of patients with DES or NE and assessed manometry findings in a prospective, double-blind, randomized, controlled study. METHODS We assessed 22 patients with dysphagia-predominant, manometry-confirmed DES or NE (6 men; age, 63 ± 2 y) at a tertiary care medical center. Patients were given injections of BTX (8 × 12.5 U) or saline (8 × 0.5 mL) in 4 quadrants, at 2 and 7 cm above the esophagogastric junction. After 1 month, patients crossed over between groups and received endoscopic injections of BTX or saline. When the study began and 4 weeks after each injection, the patients were assessed by esophageal manometry and completed a symptom questionnaire (to determine solid and liquid dysphagia, chest pain, and regurgitation and heartburn; all scored 0-4). Responders were defined based on modified Vantrappen criteria for achalasia. RESULTS After BTX injections, patients had significant decreases in total symptom scores (sum of solid and liquid dysphagia and chest pain; from 7.6 ± 0.7 to 4.8 ± 0.8; P = .01); this decrease was not observed in patients who received saline injections. Moreover, BTX injection stabilized unintentional weight loss (weight gain of 0.3 ± 0.3 after BTX injection vs further weight loss of 1.6 ± 0.5 kg after saline injection; P = .01). Fifty percent of patients had a response 1 month after BTX injection, compared with 10% after saline injection (P = .04); 30% still had a response 1 year after BTX injection. BTX injection also caused a significant decrease in the mean esophagogastric junction pressure, compared with baseline (15.8 ± 1.7 vs 24.0 ± 2.8 mm Hg; P = .02). CONCLUSIONS In a prospective controlled study of patients with DES and NE, injections of BTX reduced symptoms and stabilized unintentional weight loss. TRIAL REGISTRY http://www.targid.eu, ML2669, ML6294.
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Affiliation(s)
- Tim Vanuytsel
- Translational Research Center for Gastrointestinal Disorders, University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium
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25
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da Silva RCV, de Sá CC, Pascual-Vaca ÁO, de Souza Fontes LH, Herbella Fernandes FAM, Dib RA, Blanco CR, Queiroz RA, Navarro-Rodriguez T. Increase of lower esophageal sphincter pressure after osteopathic intervention on the diaphragm in patients with gastroesophageal reflux. Dis Esophagus 2013; 26:451-6. [PMID: 22676647 DOI: 10.1111/j.1442-2050.2012.01372.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The treatment of gastroesophageal reflux disease may be clinical or surgical. The clinical consists basically of the use of drugs; however, there are new techniques to complement this treatment, osteopathic intervention in the diaphragmatic muscle is one these. The objective of the study is to compare pressure values in the examination of esophageal manometry of the lower esophageal sphincter (LES) before and immediately after osteopathic intervention in the diaphragm muscle. Thirty-eight patients with gastroesophageal reflux disease - 16 submitted to sham technique and 22 submitted osteopathic technique - were randomly selected. The average respiratory pressure (ARP) and the maximum expiratory pressure (MEP) of the LES were measured by manometry before and after osteopathic technique at the point of highest pressure. Statistical analysis was performed using the Student's t-test and Mann-Whitney, and magnitude of the technique proposed was measured using the Cohen's index. Statistically significant difference in the osteopathic technique was found in three out of four in relation to the group of patients who performed the sham technique for the following measures of LES pressure: ARP with P= 0.027. The MEP had no statistical difference (P= 0.146). The values of Cohen d for the same measures were: ARP with d= 0.80 and MEP d= 0.52. Osteopathic manipulative technique produces a positive increment in the LES region soon after its performance.
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26
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Lee H, Park JC, Shin SK, Lee SK, Lee YC. 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. J Gastroenterol Hepatol 2012; 27:1192-9. [PMID: 22413883 DOI: 10.1111/j.1440-1746.2012.07110.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Hyuk Lee
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
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Gill RS, Collins JS, Talley NJ. Management of noncardiac chest pain in women. ACTA ACUST UNITED AC 2012; 8:131-43; quiz 144-5. [PMID: 22375717 DOI: 10.2217/whe.12.3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Noncardiac chest pain (NCCP) is very prevalent in the community. Although mortality remains low, morbidity and the financial implications are high. Women, especially those of middle age, should be thoroughly investigated as per current guidelines for coronary artery disease before labeling their chest pain as NCCP. Gastroesophageal reflux disease is the most common cause of NCCP; however other esophageal pathology including esophageal hypersensitivity, neuromuscular disease and eosinophilic esophagitis may also cause NCCP. Proton pump inhibitors are commonly used initially to manage NCCP, although patients who do not respond to this therapy require further investigation and differing treatment regimes. This article will focus on current knowledge regarding GI tract-related NCCP management strategies.
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Affiliation(s)
- Raghubinder S Gill
- Gosford Hospital, Division of Gastroenterology, New South Wales, Australia
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Abstract
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.
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Affiliation(s)
- T Hershcovici
- The Neuroenteric Clinical Research Group, Southern Arizona VA Health Care System, Tucson, AZ 85723-0001, USA
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Fass R, Achem SR. Noncardiac chest pain: epidemiology, natural course and pathogenesis. J Neurogastroenterol Motil 2011; 17:110-23. [PMID: 21602987 PMCID: PMC3093002 DOI: 10.5056/jnm.2011.17.2.110] [Citation(s) in RCA: 123] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2011] [Revised: 03/17/2011] [Accepted: 03/28/2011] [Indexed: 12/24/2022] Open
Abstract
Noncardiac chest pain is defined as recurrent chest pain that is indistinguishable from ischemic heart pain after a reasonable workup has excluded a cardiac cause. Noncardiac chest pain is a prevalent disorder resulting in high healthcare utilization and significant work absenteeism. However, despite its chronic nature, noncardiac chest pain has no impact on patients' mortality. The main underlying mechanisms include gastroesophageal reflux, esophageal dysmotility and esophageal hypersensitivity. Gastroesophageal reflux disease is likely the most common cause of noncardiac chest pain. Esophageal dysmotility affects only the minority of noncardiac chest pain patients. Esophageal hypersensitivity may be present in non-GERD-related noncardiac chest pain patients regardless if esophageal dysmotility is present or absent. Psychological co-morbidities such as panic disorder, anxiety, and depression are also common in noncardiac chest pain patients and often modulate patients' perception of disease severity.
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Affiliation(s)
- Ronnie Fass
- Section of Gastroenterology, Department of Medicine, Southern Arizona VA Health Care System, Tucson, Arizona, USA.
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Kim BJ, Choi SC, Kim JJ, Rhee JC, Rhee PL. Pathological bolus exposure plays a significant role in eliciting non-cardiac chest pain. J Gastroenterol Hepatol 2010; 25:1855-60. [PMID: 21091997 DOI: 10.1111/j.1440-1746.2010.06415.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND AIM Pathological bolus exposure is defined in the present study as cases in which all reflux percentage times are above 1.4% of the total reflux number, as revealed by impedance-pH monitoring. The role of pathological bolus exposure in the pathogenesis of non-cardiac chest pain (NCCP) is poorly known. We aimed to classify and characterize NCCP using combined impedance-pH monitoring. METHODS Seventy-five consecutive patients with NCCP were prospectively enrolled from January 2006 to October 2008. All the patients underwent upper endoscopy, esophageal manometry, and 24-h multichannel intraluminal impedance (MII)-pH metering. RESULTS Sixteen patients (21.3%) had esophageal erosion upon endoscopy. Upon esophageal manometry, 37 patients (49.3%) had esophageal dysmotility. When the patients were classified based on MII-pH metering, 16 (21.3%) showed pathological acid exposure, and 40 (53.3%) showed pathological bolus exposure. The DeMeester score of patients with pathological acid exposure was higher than that of patients with pathological bolus exposure (P = 0.002). There was no significant difference in age, sex, typical esophageal symptoms, presence of esophageal erosion, esophageal dysmotility, improvement with proton pump inhibitor medication, symptom index ≥ 50%, percentage of time clearance pH below 4 ≥ 4%, and all reflux time ≥ 1.4% in the fasting period between the two groups. When the patients were divided into gastroesophageal reflux disease (GERD)-related NCCP and non-GERD-related NCCP groups based on MII-pH metering and upper endoscopy, there was no difference between the two groups. CONCLUSIONS Combined impedance-pH monitoring improves the detection and characterization of NCCP. This study suggests that pathological bolus exposure plays a major role in eliciting NCCP.
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Affiliation(s)
- Beom Jin Kim
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
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Budzyński J, Pulkowski G, Kłopocka M, Augustyńska B, Sinkiewicz A, Suppan K, Fabisiak J, Majer M, Świątkowski M. Treatment with double dose of omeprazole increases β-endorphin plasma level in patients with coronary artery disease. Arch Med Sci 2010; 6:201-7. [PMID: 22371748 PMCID: PMC3281341 DOI: 10.5114/aoms.2010.13896] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2009] [Revised: 01/17/2009] [Accepted: 01/22/2009] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION The proton pump inhibitor empirical trial, besides the analysis of symptoms, is the main method in the diagnosis of gastro-oesophageal reflux disease-related chest pain. β-Endorphin acts as an endogenous analgesia system. The aim of the study was verify whether β-endorphin plasma level is affected by omeprazole administration and influences the severity of anginal symptoms and outcome of the "omeprazole test" in patients with coronary artery disease (CAD) and chest pain of suspected non-cardiac origin. MATERIAL AND METHODS Omeprazole was administered to 48 patients with CAD in a randomized, placebo-controlled, crossover study design. At the beginning of the study, and again after the 14-day omeprazole and placebo treatment, the β-endorphin plasma concentration was determined. RESULTS The level of plasma β-endorphin after the administration of omeprazole was significantly greater than at the start of the study and following the placebo. Responders to omeprazole had an average lower β-endorphin plasma concentration than subjects who failed to respond to this therapy. Subjects with symptoms in class III (according to the Canadian Cardiovascular Society classification) after omeprazole administration had a greater β-endorphin plasma level than subjects in class II for anginal symptom severity. CONCLUSIONS Fourteen-day therapy with a double omeprazole dose significantly increases the β-endorphin plasma concentration in patients with CAD. Circulating β-endorphin does not seem to be involved in the mechanism for the "omeprazole test" outcome, although an individually different effect on pain threshold cannot be excluded.
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Affiliation(s)
- Jacek Budzyński
- Department of Gastroenterology, Vascular Diseases and Internal Medicine, Nicolaus Copernicus University in Toruń, Collegium Medicum in Bydgoszcz, Poland
| | - Grzegorz Pulkowski
- Clinical Ward of Vascular Diseases and Internal Medicine, Doctor Jan Biziel University Hospital no. 2, Bydgoszcz, Poland
| | - Maria Kłopocka
- Department of Gastroenterology, Vascular Diseases and Internal Medicine, Nicolaus Copernicus University in Toruń, Collegium Medicum in Bydgoszcz, Poland
| | - Beata Augustyńska
- Department of Psychiatric Nursing, Nicolaus Copernicus University in Toruń, Collegium Medicum in Bydgoszcz, Poland
| | - Anna Sinkiewicz
- The Outpatient Phoniatrics Department, Doctor Jan Biziel University Hospital no. 2 in Bydgoszcz, Poland
| | - Karol Suppan
- Department of Gastroenterology, Vascular Diseases and Internal Medicine, Nicolaus Copernicus University in Toruń, Collegium Medicum in Bydgoszcz, Poland
| | - Jacek Fabisiak
- Department of Gastroenterology, Vascular Diseases and Internal Medicine, Nicolaus Copernicus University in Toruń, Collegium Medicum in Bydgoszcz, Poland
| | - Marcin Majer
- Clinical Ward of Vascular Diseases and Internal Medicine, Doctor Jan Biziel University Hospital no. 2, Bydgoszcz, Poland
| | - Maciej Świątkowski
- Department of Gastroenterology, Vascular Diseases and Internal Medicine, Nicolaus Copernicus University in Toruń, Collegium Medicum in Bydgoszcz, Poland
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Domingues GRDS, Moraes-Filho JPP. [Non-cardiac chest pain]. ARQUIVOS DE GASTROENTEROLOGIA 2009; 46:233-40. [PMID: 19918693 DOI: 10.1590/s0004-28032009000300018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2009] [Accepted: 04/15/2009] [Indexed: 11/21/2022]
Abstract
CONTEXT Non-cardiac chest pain or functional chest pain is a syndrome with high prevalence in occidental world. Findings on 15%-30% of coronary angiograms performed in patients with chest pain are normal. Causes significant impact in quality of life of patients and is associated with increased use of the health care facilities. DATA SOURCES To this review the following data base were accessed: Medline, the Cochrane Library, LILACS. The limit was the last 5 years publications and were selected relevant original articles, reviews, consensus, guidelines and meta-analysis. RESULTS Forty-four papers were selected, 28 original articles, 12 reviews, 2 guidelines, 1 consensus and 1 meta-analysis. CONCLUSIONS Exclusion of cardiac disease is of crucial importance. On the other hand non-cardiac chest pain could be related to gastrointestinal, muscular and respiratory causes and/or psychological disturbances. Treatment aims to attack mechanism generator in order to relieve or to eliminate symptoms. Drugs are the cornerstone of treatment, exception to achalasia patients because those have better response to dilation of the esophagus or surgery, and to those who need intensive psychological therapy. The most important drugs used are proton pump inhibitors and tricyclic antidepressants, the latter, to modulate central signal process (visceral hypersensitivity) and autonomic response. Recently, new diagnostic facilities, and also therapeutic modalities, such as esophageal botulin toxin injection and hypnosis are under investigations. In the near future, maybe some of them would take a place in the therapeutic scenario of these patients.
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Wesselmann U, Baranowski AP, Börjesson M, Curran NC, Czakanski PP, Giamberardino MA, Ness TJ, Robbins MT, Traub RJ. EMERGING THERAPIES AND NOVEL APPROACHES TO VISCERAL PAIN. ACTA ACUST UNITED AC 2009; 6:89-95. [PMID: 21243067 DOI: 10.1016/j.ddstr.2009.05.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Ursula Wesselmann
- The University of Alabama at Birmingham, Department of Anesthesiology/Division of Pain Treatment, Birmingham, AL 35294, USA
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Evaluation and management of patients with noncardiac chest pain. Gastroenterol Res Pract 2009; 2008:708218. [PMID: 19390646 PMCID: PMC2672159 DOI: 10.1155/2008/708218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2008] [Accepted: 11/25/2008] [Indexed: 12/20/2022] Open
Abstract
Up to a third of patients undergoing coronary angiography for angina-like chest pain are found to have normal coronary arteries and a substantial proportion of these individuals continue to consult and even attend emergency departments. Initially, these patients are usually seen by cardiologists but with accumulating evidence that the pain might have a gastrointestinal origin, it may be more appropriate for them to be cared for by the gastroenterologist once a cardiological cause has been excluded. This review covers the assessment and management of this challenging condition, which includes a combination of education, reassurance, and pharmacotherapy. For the more refractory cases, behavioral treatments, such as cognitive behavioral therapy or hypnotherapy, may have to be considered.
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Gasiorowska A, Navarro-Rodriguez T, Dickman R, Wendel C, Moty B, Powers J, Willis MR, Koenig K, Ibuki Y, Thai H, Fass R. Clinical trial: the effect of Johrei on symptoms of patients with functional chest pain. Aliment Pharmacol Ther 2009; 29:126-34. [PMID: 18945261 DOI: 10.1111/j.1365-2036.2008.03859.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Patients with functional chest pain (FCP) represent a therapeutic challenge for practising physicians. AIM To determine the efficacy of Johrei as compared to wait-list in improving symptoms of FCP patients. METHODS Patients with chest pain of noncardiac origin for at least 3 months were enrolled into the study. All patients had to have negative upper endoscopy, pH testing and oesophageal manometry prior to randomization. Subsequently, patients were randomized to either Johrei or wait-list control. Patients received 18 Johrei sessions from a Johrei practitioner for 6 weeks. RESULTS A total of 21 FCP patients enrolled into the Johrei group and 18 into the wait-list group. There was no difference in symptom intensity score between Johrei group and wait-list group at baseline (20.28 vs. 23.06, P = N.S.). However, there was a significant pre- and post-treatment reduction in symptom intensity in the Johrei group (20.28 vs. 7.0, P = 0.0023). There was no significant reduction in symptom intensity score between baseline and at the end of the study in the wait-list group (23.06 vs. 20.69, P = N.S.). CONCLUSION This pilot study shows that Johrei may have a role in improving FCP symptoms; however, future studies are needed to compare Johrei treatment with sham Johrei or supportive care.
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Affiliation(s)
- A Gasiorowska
- The Neuroenteric Clinical Research Group, Section of Gastroenterology, Department of Medicine, Southern Arizona VA Health Care System and University of Arizona Health Sciences Center, Tucson, AZ, USA
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Abstract
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.
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Affiliation(s)
- Jeanetta Walters Frye
- Division of Gastroenterology and Hepatology, Vanderbilt University Medical Center, 1660 TVC, Nashville, TN 37232-5280, USA
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