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Hosaka H, Kuribayashi S, Kawamura O, Itoi Y, Sato K, Hashimoto Y, Kasuga K, Tanaka H, Kusano M, Uraoka T. The relationship between manometric subtype and symptom details in achalasia. Esophagus 2023; 20:761-768. [PMID: 37093537 DOI: 10.1007/s10388-023-01008-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 04/17/2023] [Indexed: 04/25/2023]
Abstract
BACKGROUND Although dysphagia and chest pain are the two most common symptoms in patients with achalasia, the mechanism of evoking symptoms is still unknown. The aim of this study was to reveal the relationship between symptoms and the subtypes of achalasia defined by the Chicago classification. METHODS A total of 71consecutive patients with newly diagnosed achalasia were enrolled between March 2009 and December 2017. Esophageal motility was assessed by high-resolution manometry (HRM) with the Chicago classification v 3.0. and esophagograms. Their symptoms were evaluated with structured self-reported questionnaires focused on dysphagia and chest pain. Symptom profiles and radiographic findings according to the manometric subtypes were investigated. RESULTS Among the total 71 patients, 69 patients (97%) had dysphagia and 39 patients (54%) had chest pain. Regarding dysphagia, type II patients reported dysphagia in the throat the most, while types I and III patients mostly felt it in the epigastrium. Type II patients often felt dysphagia at the time of swallowing (41%), but this was reported in only 8.7% of Type I and 33% of Type III patients (p = 0.02). Concerning chest pain, Type I patients rarely had pain during meals (14%), but more often while sleeping (43%) and in early morning (43%), while type III patients often had pain during meals (67%). Type III patients reported that solid food caused pain more often than other types (I/II/III 0/10/33%, p = 0.09). CONCLUSIONS Detailed symptoms of achalasia, such as its site and timing, varied by subtypes. The status of the esophageal body might induce those differences in symptoms.
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Affiliation(s)
- Hiroko Hosaka
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, 3-39-15 Showa-Machi Maebashi, Gunma, 371-8511, Japan.
| | - Shiko Kuribayashi
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, 3-39-15 Showa-Machi Maebashi, Gunma, 371-8511, Japan
| | - Osamu Kawamura
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, 3-39-15 Showa-Machi Maebashi, Gunma, 371-8511, Japan
| | - Yuki Itoi
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, 3-39-15 Showa-Machi Maebashi, Gunma, 371-8511, Japan
| | - Keigo Sato
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, 3-39-15 Showa-Machi Maebashi, Gunma, 371-8511, Japan
| | - Yu Hashimoto
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, 3-39-15 Showa-Machi Maebashi, Gunma, 371-8511, Japan
| | - Kengo Kasuga
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, 3-39-15 Showa-Machi Maebashi, Gunma, 371-8511, Japan
| | - Hirohito Tanaka
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, 3-39-15 Showa-Machi Maebashi, Gunma, 371-8511, Japan
| | - Motoyasu Kusano
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, 3-39-15 Showa-Machi Maebashi, Gunma, 371-8511, Japan
| | - Toshio Uraoka
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, 3-39-15 Showa-Machi Maebashi, Gunma, 371-8511, Japan
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Kamal AN, Clarke JO, Oors JM, Bredenoord AJ. The role of ambulatory 24-hour esophageal manometry in clinical practice. Neurogastroenterol Motil 2020; 32:e13861. [PMID: 32391594 PMCID: PMC7583476 DOI: 10.1111/nmo.13861] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 03/19/2020] [Accepted: 03/30/2020] [Indexed: 12/13/2022]
Abstract
High-resolution manometry revolutionized the assessment of esophageal motility disorders and upgraded the classification through the Chicago Classification. A known disadvantage of standard HRM, however, is the inability to record esophageal motility function for an extended time interval; therefore, it represents only a more snapshot view of esophageal motor function. In contrast, ambulatory esophageal manometry measures esophageal motility over a prolonged period and detects motor activity during the entire circadian cycle. Furthermore, ambulatory manometry has the ability to measure temporal correlations between symptoms and motor events. This article aimed to review the clinical implications of ambulatory esophageal manometry for various symptoms, covering literature on the manometry catheter, interpretation of findings, and relevance in clinical practice specific to the evaluation of non-cardiac chest pain, chronic cough, and rumination syndrome.
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Affiliation(s)
- Afrin N. Kamal
- Division of Gastroenterology and HepatologyStanford University School of MedicineStanfordCAUSA
| | - John O. Clarke
- Division of Gastroenterology and HepatologyStanford University School of MedicineStanfordCAUSA
| | - Jac M. Oors
- Department of Gastroenterology and HepatologyAmsterdam University Medical CentreAmsterdamThe Netherlands
| | - Albert J. Bredenoord
- Department of Gastroenterology and HepatologyAmsterdam University Medical CentreAmsterdamThe Netherlands
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Gómez-Escudero O, Coss-Adame E, Amieva-Balmori M, Carmona-Sánchez R, Remes-Troche J, Abreu-Abreu A, Cerda-Contreras E, Gómez-Castaños P, González-Martínez M, Huerta-Iga F, Ibarra-Palomino J, Icaza-Chávez M, López-Colombo A, Márquez-Murillo M, Mejía-Rivas M, Morales-Arámbula M, Rodríguez-Chávez J, Torres-Barrera G, Valdovinos-García L, Valdovinos-Díaz M, Vázquez-Elizondo G, Villar-Chávez A, Zavala-Solares M, Achem S. The Mexican consensus on non-cardiac chest pain. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2019. [DOI: 10.1016/j.rgmxen.2019.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Gómez-Escudero O, Coss-Adame E, Amieva-Balmori M, Carmona-Sánchez RI, Remes-Troche JM, Abreu Y Abreu AT, Cerda-Contreras E, Gómez-Castaños PC, González-Martínez MA, Huerta-Iga FM, Ibarra-Palomino J, Icaza-Chávez ME, López-Colombo A, Márquez-Murillo MF, Mejía-Rivas M, Morales-Arámbula M, Rodríguez-Chávez JL, Torres-Barrera G, Valdovinos-García LR, Valdovinos-Díaz MA, Vázquez-Elizondo G, Villar-Chávez AS, Zavala-Solares M, Achem SR. The Mexican consensus on non-cardiac chest pain. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2019; 84:372-397. [PMID: 31213326 DOI: 10.1016/j.rgmx.2019.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 04/22/2019] [Accepted: 05/16/2019] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Non-cardiac chest pain is defined as a clinical syndrome characterized by retrosternal pain similar to that of angina pectoris, but of non-cardiac origin and produced by esophageal, musculoskeletal, pulmonary, or psychiatric diseases. AIM To present a consensus review based on evidence regarding the definition, epidemiology, pathophysiology, and diagnosis of non-cardiac chest pain, as well as the therapeutic options for those patients. METHODS Three general coordinators carried out a literature review of all articles published in English and Spanish on the theme and formulated 38 initial statements, dividing them into 3 main categories: (i)definitions, epidemiology, and pathophysiology; (ii)diagnosis, and (iii)treatment. The statements underwent 3rounds of voting, utilizing the Delphi system. The final statements were those that reached >75% agreement, and they were rated utilizing the GRADE system. RESULTS AND CONCLUSIONS The final consensus included 29 statements. All patients presenting with chest pain should initially be evaluated by a cardiologist. The most common cause of non-cardiac chest pain is gastroesophageal reflux disease. If there are no alarm symptoms, the initial approach should be a therapeutic trial with a proton pump inhibitor for 2-4weeks. If dysphagia or alarm symptoms are present, endoscopy is recommended. High-resolution manometry is the best method for ruling out spastic motor disorders and achalasia and pH monitoring aids in demonstrating abnormal esophageal acid exposure. Treatment should be directed at the pathophysiologic mechanism. It can include proton pump inhibitors, neuromodulators and/or smooth muscle relaxants, psychologic intervention and/or cognitive therapy, and occasionally surgery or endoscopic therapy.
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Affiliation(s)
- O Gómez-Escudero
- Clínica de Gastroenterología, Endoscopia Digestiva y Motilidad Gastrointestinal «Endoneurogastro», Hospital Ángeles Puebla, Puebla, Puebla, México
| | - E Coss-Adame
- Departamento de Gastroenterología y Laboratorio de Motilidad Gastrointestinal, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Ciudad de México, México.
| | - M Amieva-Balmori
- Laboratorio de Fisiología Digestiva y Motilidad Gastrointestinal, Instituto de Investigaciones Médico Biológicas, Universidad Veracruzana, Veracruz, Veracruz, México
| | - R I Carmona-Sánchez
- Unidad de Medicina Ambulatoria Christus Muguerza, San Luis Potosí, S.L.P., México
| | - J M Remes-Troche
- Laboratorio de Fisiología Digestiva y Motilidad Gastrointestinal, Instituto de Investigaciones Médico Biológicas, Universidad Veracruzana, Veracruz, Veracruz, México
| | - A T Abreu Y Abreu
- Gastroenterología y Fisiología Digestiva, Hospital Ángeles del Pedregal, Ciudad de México, México
| | - E Cerda-Contreras
- Medicina Interna, Gastroenterología y Motilidad Gastrointestinal, Hospital Médica Sur, Profesor de Medicina ITESM, Ciudad de México, México
| | | | - M A González-Martínez
- Departamento de Endoscopia, Laboratorio de Motilidad Gastrointestinal, Hospital de Especialidades CMN Siglo XXI IMSS, Ciudad de México, México
| | - F M Huerta-Iga
- Jefe de Endoscopia y Fisiología Digestiva, Hospital Ángeles Torreón, Torreón, Coahuila, México
| | - J Ibarra-Palomino
- Laboratorio de Motilidad Gastrointestinal, Área de Gastroenterología, Hospital Ángeles del Carmen, Guadalajara, Jalisco, México
| | - M E Icaza-Chávez
- Hospital Star Médica de Mérida, Profesora de Gastroenterología de la UNIMAYAB, Mérida, Yucatán, México
| | - A López-Colombo
- Dirección de Educación e Investigación en Salud, UMAE Hospital de Especialidades del Centro Médico Nacional «Manuel Ávila Camacho», Instituto Mexicano del Seguro Social, Puebla, Puebla, México
| | - M F Márquez-Murillo
- Cardiólogo Electrofisiólogo, Departamento de Electrocardiología, Instituto Nacional de Cardiología «Ignacio Chávez», Ciudad de México, México
| | - M Mejía-Rivas
- Gastroenterología, Endoscopia, Neurogastroenterología, Hospital «Vivien Pellas», Managua, Nicaragua
| | | | - J L Rodríguez-Chávez
- Gastroenterología y Neurogastroenterología, Hospital Puerta de Hierro, Guadalajara, Jalisco, México
| | - G Torres-Barrera
- Departamento de Gastroenterología, Hospital Universitario, Universidad Autónoma de Nuevo León, Profesor de cátedra, ITESM, Monterrey, Nuevo León, México
| | - L R Valdovinos-García
- Departamento de Gastroenterología y Laboratorio de Motilidad Gastrointestinal, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Ciudad de México, México
| | - M A Valdovinos-Díaz
- Departamento de Gastroenterología y Laboratorio de Motilidad Gastrointestinal, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Ciudad de México, México
| | - G Vázquez-Elizondo
- Escuela de Medicina y Ciencias de la Salud, Tecnológico de Monterrey, OnCare Group, Monterrey, Nuevo León, México
| | - A S Villar-Chávez
- Gastroenterología y Motilidad Gastrointestinal, Hospital Ángeles Acoxpa, Ciudad de México, México
| | - M Zavala-Solares
- Unidad de Motilidad Gastrointestinal, Servicio de Gastroenterología, Hospital General de México «Dr. Eduardo Liceaga», Ciudad de México, México
| | - S R Achem
- Profesor de Medicina Interna y Gastroenterología, Facultad de Medicina, Mayo College of Medicine, Mayo Clinic, Jacksonville, Florida, Estados Unidos de América
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Heinrich H, Sweis R. The role of oesophageal physiological testing in the assessment of noncardiac chest pain. Ther Adv Chronic Dis 2018; 9:257-267. [PMID: 30719270 PMCID: PMC6348533 DOI: 10.1177/2040622318791392] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 05/14/2018] [Indexed: 12/15/2022] Open
Abstract
Oesophageal physiology testing plays an important role in the diagnosis of noncardiac chest pain (NCCP) after cardiac, structural and mucosal abnormalities have been ruled out. Endoscopy can establish the presence of structural causes of chest pain such as cancer, oesophageal webs and diverticula. Even if macroscopically normal, eosinophilic oesophagitis is a common cause of chest pain and needs to be ruled out with an adequate biopsy regimen. In the remaining cases, diagnosis is focused on the identification of often subtle mechanisms that lead to NCCP. The most common oesophageal aetiologies for NCCP are gastro-oesophageal reflux disease (GORD), oesophageal dysmotility and functional chest pain. Ambulatory pH studies (with or without impedance or wireless measurements) can establish the presence of GORD, nonerosive reflux as well any association with symptoms of chest pain. High-resolution manometry, particularly with the inclusion of adjunctive testing, can rule out major motility disorders such as spasm, hypercontraction or achalasia. The EndoFLIP device can help define disorders with reduced distensibility, not easily appreciated with endoscopy or manometry. When all tests remain negative, a diagnosis of oesophageal hypersensitivity is normally made and therapy is shifted from targeting a disease to treating symptoms and patient affect.
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Affiliation(s)
- Henriette Heinrich
- University Hospital Zuerich, Department for Gastroenterology and Hepatology, Zuerich, Switzerland St Claraspital, Bauchzentrum, Basel, Switzerland
| | - Rami Sweis
- GI Services, University College London Hospital, Ground floor west, 250 Euston Road, London, NW1 2 PG, London, UK
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Gomez Cifuentes J, Lopez R, Thota PN. Factors predictive of gastroesophageal reflux disease and esophageal motility disorders in patients with non-cardiac chest pain. Scand J Gastroenterol 2018; 53:643-649. [PMID: 29848163 DOI: 10.1080/00365521.2018.1452975] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Patients with non-cardiac chest pain (NCCP) are referred for esophageal motility testing and pH monitoring since gastroesophageal reflux disease (GERD) and esophageal motility disorders are frequently encountered in these patients. Our aim was to determine the prevalence and distribution of these disorders and to identify predictors of abnormal esophageal function testing. METHODS We performed a retrospective study of NCCP patients who presented after a negative cardiac evaluation and underwent esophageal manometry, esophageal pH monitoring and upper endoscopy from January 2010 to January 2017. KEY RESULTS In a total of 177 patients, esophageal motility disorders were diagnosed in 31% and GERD in 35% of the patients. The most common diagnoses were ineffective esophageal motility (IEM) in 14.1%, jackhammer esophagus in 6.8%, diffuse esophageal spasm in 5.1% and achalasia in 2.3% patients. Older age [for every 5-year increment, odds ratio (OR) 1.2 (95% confidence intervals (CI) 1.00-1.3) p = .047] and dysphagia [OR 3.8 (95% CI, 1.9-7.5) p < .001] were predictors of esophageal motility disorders. Older age [for every 5-year increment, OR 1.2 (95% CI, 1.01-1.3) p = .032] was predictive of GERD. Abnormal esophageal testing was associated with male gender [OR 2.2 (95% CI, 1.04-4.6) p = .039], older age [for every 5-year increment, OR 1.2 (95% CI, 1.03-1.3) p = .016] and Caucasian race [OR 3.1 (95% CI, 1.1-8.7) p < .029]. CONCLUSIONS Approximately two thirds of patients presenting with NCCP have GERD or esophageal motility disorders. Esophageal function testing in NCCP should be considered in older patients, men, Caucasians and those presenting with dysphagia.
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Affiliation(s)
| | - Rocio Lopez
- b Quantitative Health Sciences Department , Cleveland Clinic , Cleveland , OH , USA
| | - Prashanthi N Thota
- c Digestive Disease and Surgery Institute , Cleveland Clinic , Cleveland , OH , USA
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Determinants of the Association between Non-Cardiac Chest Pain and Reflux. Am J Gastroenterol 2017; 112:1671-1677. [PMID: 29016562 DOI: 10.1038/ajg.2017.288] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 08/08/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Gastroesophageal reflux is considered to be the most common gastrointestinal cause of non-cardiac chest pain (NCCP). It remains unclear why some reflux episodes in the same patient cause chest pain while others do not. To understand more about the mechanisms by which reflux elicits chest pain, we aimed to identify factors which are important in triggering chest pain. METHODS In this multicenter study, 120 patients with NCCP were analyzed using 24-h pH-impedance monitoring. In the patients with a positive association between reflux and chest pain, the characteristics of the reflux episodes which were followed by a chest pain episode were compared with chest pain-free reflux episodes. RESULTS Using 24-h pH-impedance monitoring, 40% of the NCCP patients were identified as having reflux as a possible cause of their chest pain. Reflux episodes that were associated with chest pain had a higher proximal extent (P=0.007), a higher volume clearance time (P=0.030), a higher 15-minute acid burden (P=0.041), were more often acidic (P=0.011), had a lower nadir pH (P=0.044), and had a longer acid duration time (P=0.027) than reflux episodes which were not followed by chest pain. Patients who experienced typical reflux symptoms were more likely to have reflux as the cause of their chest pain (52 vs. 31.4%, P=0.023). CONCLUSIONS The presence of a larger volume of acid refluxate for a longer period of time appears to be an important determinant of perceiving a reflux episode as chest pain. 24-h pH-impedance monitoring is an important tool in identifying gastroesophageal reflux as a potential cause of symptoms in patients with NCCP.
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Abstract
PURPOSE OF REVIEW Noncardiac chest pain (NCCP) has been defined as recurrent chest pain that is indistinguishable from ischemic heart pain after excluding a cardiac cause. NCCP is a common and highly challenging clinical problem in Gastrointestinal practice that requires targeted diagnostic assessment to identify the underlying cause of the symptoms. Treatment is tailored according to the cause of NCCP: gastroesophageal reflux disease (GERD), esophageal dysmotility or functional chest pain. The purpose of this review is to discuss the current diagnosis and treatment of NCCP. RECENT FINDINGS Utilization of new diagnostic techniques such as pH-impedance and high-resolution esophageal manometry, and the introduction of a new definition for functional chest pain have helped to better diagnose the underlying mechanisms of NCCP. A better therapeutic approach toward GERD-related NCCP, the introduction of new interventions for symptoms due to esophageal spastic motor disorders and the expansion of the neuromodulator armamentarium for functional chest pain have changed the treatment landscape of NCCP. SUMMARY GERD is the most common esophageal cause of NCCP, followed by functional chest pain and esophageal dysmotility. The proton pump inhibitor test, upper endoscopy, wireless pH capsule and pH-impedance are used to identify GERD-induced NCCP. High-resolution esophageal manometry is the main tool to identify esophageal motor disorder in non-GERD-related NCCP. Negative diagnostic assessment suggests functional chest pain. Potent antireflux treatment is offered to patients with GERD-related NCCP; medical, endoscopic or surgical interventions are considered in esophageal dysmotility; and neuromodulators are prescribed for functional chest pain. Assessment and treatment of psychological comorbidity should be considered in all NCCP patients.
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Huang L, Pimentel M, Rezaie A. Do Jackhammer contractions lead to achalasia? A longitudinal study. Neurogastroenterol Motil 2017; 29. [PMID: 27660053 DOI: 10.1111/nmo.12953] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 08/25/2016] [Indexed: 01/21/2023]
Abstract
BACKGROUND Jackhammer esophagus (JE) is a rare esophageal motility disorder defined in the Chicago Classification of Esophageal Motility by presence of excessively high distal contractile integral (DCI) on high-resolution manometry (HRM), with unknown natural manometric course. We examined the development of achalasia over time in patients with JE. METHODS Through a retrospective longitudinal design, patients with Jackhammer contractions who had more than one HRM between 2005 and 2015 were identified. Any change in manometric finding was assessed for the presence of achalasia. Demographic and manometric risk factors for this progression were then sought in univariate analysis. KEY RESULTS Of 3363 HRM studies, 229 subjects had multiple manometries, accounting for 528 studies. Twelve subjects met our inclusion criteria for JE on any of the multiple tests, represented by 27 studies for a total of 347 patient-months of manometric follow-up. Subjects with JE whose manometry included impedance demonstrated consistent esophageal bolus clearance. Of 12 subjects with Jackhammer contractions, three subjects progressed to type III achalasia, over a mean of 24 months (range: 19-31 months). At the time of diagnosis with JE, impaired esophago-gastric junction relaxation was seen in all three subjects and was the only risk factor that could predict progression to achalasia (P<.01). CONCLUSIONS & INFERENCES In this unique study of the natural course of JE, we have shown that JE can progress to achalasia. Manometric findings at the time of JE diagnosis might predict this progression.
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Affiliation(s)
- L Huang
- Department of Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - M Pimentel
- GI Motility Program, Cedars-Sinai Medical Center, Los Angeles, California
| | - A Rezaie
- GI Motility Program, Cedars-Sinai Medical Center, Los Angeles, California
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