Treatment of non-cardiac chest pain: a controlled trial of hypnotherapy

The Role of Psychological Factors in Noncardiac Chest Pain of Esophageal Origin

Background/Aims

Noncardiac chest pain (NCCP) of esophageal origin is a challenging clinical problem of diverse etiology that affects more than 80 million Americans yearly. We assess the prevalence and impact of psychological disorders on NCCP of esophageal origin, describe possible mechanisms associated with this condition, and review psychological therapy options.

Methods

Online search using PubMed and Medline from January 1, 1966, to April 30, 2023.

Results

Psychological disorders have been reported in up to 79% of patients with NCCP of esophageal origin. Several psychological disturbances have been identified with this condition, including depression, anxiety, panic disorder, phobias, and obsessive-compulsive and somatoform disorders. It is unclear whether the psychological disorders trigger the chest pain or vice versa. Multiple psychological mechanisms have been linked to chest pain and may contribute to its pathogenesis and severity. These mechanisms include cardiophobia, poor coping strategies, negative social problem solving, stress and perceived control, hypervigilance to cardiopulmonary sensations, altered pain perception, and alexithymia. Psychological therapies for NCCP of esophageal origin include cognitive behavioral therapy, hypnotherapy, physical and relaxation training, breathing retraining, and alternative medicine. Among the therapeutic options, cognitive behavioral therapy has been shown to be an effective treatment for NCCP of esophageal origin.

Conclusion

This review raises awareness about the high prevalence of psychological disorders in NCCP of esophageal origin and highlights the need for clinical trials and trained therapists to address the management of this taxing clinical problem.

Hypnotherapy as a medical treatment: Evidence-based or pseudoscience?

BACKGROUND

Hypnotherapy continues to be a controversial practice in medicine. It is surrounded by myth and misuses that instill doubts about its legitimacy and usefulness.

PURPOSE

In this paper, we will distinguish pseudoscientific claims from evidence-based uses of hypnotherapy.

RESULTS

The use and acceptability of hypnotherapy has varied over history. Pseudoscientific uses, based on outdated theories that it can access the unconscious mind, have delegitimized hypnotherapy. Modern theories that hypnosis uses common social, emotional, and cognitive processes combined with evidence-based methods have re-established the use of hypnotherapy in many physical and mental health disorders and symptoms. Currently it is a widely accepted and recommended treatment for irritable bowel syndrome, with evidence building for many other applications.

CONCLUSION

Hypnotherapy, as a pseudoscience, can become unethical and cause distress for the patient and their families. Hypnotherapy, as an evidence-based treatment, can be used as a powerful tool to treat physical and psychological symptoms related to medical ailments.

Refractory Gastroesophageal Reflux Disease: Diagnosis and Management

Gastroesophageal reflux disease (GERD) is common, with increasing worldwide disease prevalence and high economic burden. A significant number of patients will remain symptomatic following an empiric proton pump inhibitor (PPI) trial. Persistent symptoms despite PPI therapy are often mislabeled as refractory GERD. For patients with no prior GERD evidence (unproven GERD), testing is performed off antisecretory therapy to identify objective evidence of pathologic reflux using criteria outlined by the Lyon consensus. In proven GERD, differentiation between refractory symptoms (persisting symptoms despite optimized antisecretory therapy) and refractory GERD (abnormal reflux metrics on ambulatory pH impedance monitoring and/or persistent erosive esophagitis on endoscopy while on optimized PPI therapy) can direct subsequent management. While refractory symptoms may arise from esophageal hypersensitivity or functional heartburn, proven refractory GERD requires personalization of the management approach, tapping from an array of non-pharmacologic, pharmacologic, endoscopic, and surgical interventions. Proper diagnosis and management of refractory GERD is critical to mitigate undesirable long-term complications such as strictures, Barrett's esophagus, and esophageal adenocarcinoma. This review outlines the diagnostic workup of patients presenting with refractory GERD symptoms, describes the distinction between unproven and proven GERD, and provides a comprehensive review of the current treatment strategies available for the management of refractory GERD.

Clinical efficacy of Kuanxiong aerosol for patients with prehospital chest pain: A randomized controlled trial

BACKGROUND

Kuanxiong Aerosol (KXA)(CardioVent®), consisting of Asarum sieboldii Miq. oil, Santalum album L. oil, Alpinia officinarum Hance oil, Piper longum L. oil and borneol, seems to relieve the symptoms of chest pain and serve as a supplementary treatment for prehospital chest pain in emergency department.

STYLE OF THE STUDY

This randomized controlled trial aimed to determine the clinical effect and safety of KXA for patients with prehospital chest pain.

METHODS

A total of 200 patients were recruited from Guangdong Provincial Hospital of Chinese Medicine and randomly divided into KXA group (n = 100) and Nitroglycerin Aerosol (NA) group (n = 100) by SAS 9.2 software. All patients were treated with standardized Western medicine according to the pre-hospital procedure. The experimental group and NA group was additionally treated with KXA and NA respectively. The primary outcome was the relieving time of prehospital chest pain (presented as relief rate) after first-time treatment. The secondary outcomes included the evaluation of chest pain (NRS scores, degree of chest pain, frequency of chest pain after first-time treatment), efficacy in follow-up time (the frequency of average aerosol use, emergency department visits, 120 calls, medical observations and hospitalization at 4 weeks, 8 weeks, 12 weeks), alleviation of chest pain (Seattle angina questionnaire, chest pain occurrence, and degree of chest pain at 12-weeks treatment) and the change of TCM symptoms before and after 12-weeks treatment. In addition, the safety of KXA was also assessed by the occurrence of adverse events. The database was created using Epidata software, and statistical analysis was conducted by SPSS 23.0 software.

RESULTS

A total of 194 participants finally completed the trial, the results showed that after first-time treatment, KXA had a higher relief rate (72.2%) of chest pain within 30 min than that of NA group (59.4%, p = 0.038), KXA group had a lower degree of chest pain (p = 0.005), lower NRS score (p = 0.011) and higher reduction of NRS score (p = 0.005) than the NA. In the follow-up period, KXA group decreased the frequency of 120 call better than that of NA group at 4 weeks (p = 0.040), but KXA had a similar efficacy as NA in the improvement on the of frequency of chest pain, aerosol use, emergency department visits, 120 call, medical observation and hospitalization at 4 weeks, 8 weeks and 12 weeks (p>0.05). There also had no difference between the two groups on the occurrence of chest pain, degree of chest pain, physical limitation, angina stability, treatment satisfaction, and disease perception between the two groups at 12 weeks (p>0.05). In addition, KXA and NA both improved the patient's chest pain, but not the TCM symptoms. In terms of safety, KXA showed similar safety as NA in this study.

CONCLUSIONS

KXA relieved prehospital chest pain faster than NA and had a better remission effect on the prehospital chest pain than that of the NA group in short-period. In long-period, KXA showed similar efficacy on the improvement of prehospital chest pain as NA. KXA may be a safe and reliable therapy for prehospital chest pain.

Efficacy of psychological therapies in people with inflammatory bowel disease: a systematic review and meta-analysis

BACKGROUND

There is increasing evidence for an influence of the gut-brain axis on the natural history of inflammatory bowel disease (IBD). Psychological therapies could, therefore, have beneficial effects in individuals with IBD, but data are conflicting. We aimed to update our previous systematic review and meta-analysis to assess whether the inclusion of more randomised controlled trials (RCTs) showed any beneficial effects and whether these effects varied by treatment modality.

METHODS

In this systematic review and meta-analysis, we searched MEDLINE, Embase, Embase Classic, PsychINFO, and the Cochrane Central Register of Controlled Trials from Jan 1, 2016, to April 30, 2023, for RCTs published in any language recruiting individuals aged 16 years or older with IBD that compared psychological therapy with a control intervention or treatment as usual. We pooled dichotomous data to obtain relative risks (RR) with 95% CIs of inducing remission in people with active disease or of relapse in people with quiescent disease at final follow-up. We pooled continuous data to estimate standardised mean differences (SMD) with 95% CIs in disease activity indices, anxiety scores, depression scores, stress scores, and quality-of-life scores at completion of therapy and at final follow-up. We pooled all data using a random-effects model. Trials were analysed separately according to whether they recruited people with clinically active IBD or predominantly individuals whose disease was quiescent. We conducted subgroup analyses by mode of therapy and according to whether trials recruited selected groups of people with IBD. We used the Cochrane risk of bias tool to assess bias at the study level and assessed funnel plots using the Egger test. We assessed heterogeneity using the I2 statistic.

FINDINGS

The updated literature search identified a total of 469 new records, 11 of which met eligibility criteria. 14 studies were included from our previous meta-analysis published in 2017. In total, 25 RCTs were eligible for this meta-analysis, all of which were at high risk of bias. Only four RCTs recruited patients with active IBD; there were insufficient data for meta-analysis of remission, disease activity indices, depression scores, and stress scores. In patients with active IBD, psychological therapy had no benefit compared with control for anxiety scores at completion of therapy (two RCTs; 79 people; SMD -1·04, 95% CI -2·46 to 0·39), but did have significant benefit for quality-of-life scores at completion of therapy (four RCTs; 309 people; 0·68, 0·09 to 1·26), although heterogeneity between studies was high (I2=82%). In individuals with quiescent IBD, RR of relapse of disease activity was not reduced with psychological therapy (ten RCTs; 861 people; RR 0·83, 95% CI 0·62 to 1·12), with moderate heterogeneity (I2=60%), and the funnel plot suggested evidence of publication bias or other small study effects (Egger test p=0·046). For people with quiescent IBD at completion of therapy, there was no difference in disease activity indices between psychological therapy and control (13 RCTs; 1015 people; SMD -0·01, 95% CI -0·13 to 0·12; I2=0%). Anxiety scores (13 RCTs; 1088 people; -0·23, -0·36 to -0·09; 18%), depression scores (15 RCTs; 1189 people; -0·26, -0·38 to -0·15; 2%), and stress scores (11 RCTs; 813 people; -0·22, -0·42 to -0·03; 47%) were significantly lower, and quality-of-life scores (16 RCTs; 1080 people; 0·31, 0·16 to 0·46; 30%) were significantly higher, with psychological therapy versus control at treatment completion. Statistically significant benefits persisted up to final follow-up for depression scores (12 RCTs; 856 people; -0·16, -0·30 to -0·03; 0%). Effects were strongest in RCTs of third-wave therapies and in RCTs that recruited people with impaired psychological health, fatigue, or reduced quality of life at baseline.

INTERPRETATION

Psychological therapies have beneficial, short-term effects on anxiety, depression, stress, and quality-of-life scores, but not on disease activity. Further RCTs in selected groups are needed to establish the place for such therapies in IBD care.

FUNDING

None.

Hypnotherapy in Pediatric Gastroenterology

In several countries, gut-directed hypnotherapy is becoming an established and evidence-based treatment in pediatric gastroenterology. This article describes what hypnotherapy is, offers an overview of its effect in gut-brain disorders and explains its potential mode of action. Moreover, the use of hypnotherapy in other areas of pediatric gastroenterology, as a supportive tool to reduce pain, stress, depression, and anxiety and improve quality of life, will be also discussed. Guidance toward implementing hypnotherapy in clinical practice is provided, including examples of how you can explain hypnosis to patients with gastroenterological symptoms.

The Clinical value of brain-gut behavioral therapies for functional esophageal disorders and symptoms

Functional esophageal disorders (functional chest pain, functional heartburn, reflux hypersensitivity, globus, and functional dysphagia) are the disorders of gut-brain interactions (DGBI) and present with esophageal symptoms not associated with a structural, major motility or underlying inflammatory condition. Notably, many patients with the latter conditions may still experience esophageal symptoms beyond what could be attributed to their underlying disorders. Esophageal visceral hypersensitivity and hypervigilance are the two pathways which drive functional esophageal disorders and symptoms. These functional esophageal symptoms may be severe, leaving patients with impaired quality of life and inadequate treatment outcomes. Neuromodulators are the foundation of the pharmacologic approach of many of the functional esophageal disorders and symptoms, modulating both peripheral and central hyperalgesia. There is also emerging evidence for brain-gut behavioral therapies (BGBT) such as gut-directed hypnotherapy and cognitive behavior therapy for the treatment of a variety of DGBIs. In this issue of Neurogastroenterology and Motility, Hurtte et al. add to the literature on the effectiveness of BGBT in treating functional esophageal symptoms, showing multimodal therapy with pharmacologic and non-pharmacologic approaches led to improvement in health-related quality of life. In this review, we outline the mechanistic underpinnings of BGBT and review the existing evidence for BGBT for functional esophageal disorders and symptoms. We also highlight the future research directions and challenges for scaling these therapies.

The clinical value of psycho-gastroenterological interventions for functional esophageal symptoms

BACKGROUND

Disorders of gut-brain interaction (DGBI) are associated with high symptom burden and poor quality of life. We evaluated the clinical value of multimodal therapy with psycho-gastroenterological interventions in patients with refractory functional symptoms.

METHODS

Of 80 DGBI patients managed over a 12-month period, 26 patients undergoing multimodal therapy (median age 60.0 years, 73.1%F) were compared to 54 patients (median age 56.0 years, 68.5%F) managed using conventional approaches. Psycho-gastroenterological multimodal therapy was individualized and included relaxation training (diaphragmatic breathing, passive muscle relaxation) and gut-direct hypnotherapy/guided imagery. All patients completed documentation of symptom frequency and severity using a 100 mm visual analog scale (VAS) and assessment of health-related quality of life (BEST score) before and following therapy. Data were analyzed to determine comparative change in symptom burden between the two cohorts.

KEY RESULTS

Baseline demographics and symptom burden were similar between the two treatment subgroups. While patients improved with both multimodal and conventional therapies, BEST score demonstrated greater improvement with multimodal therapy (p = 0.03). Physician perception of symptom burden at baseline and on follow-up did not correspond to self-reported questionnaire data. On multivariable analysis, multimodal therapy (OR 7.9, 95% CI 1.8-34.6, p = 0.006) and functional esophageal disorders (OR 17.6, 95% CI 2.6-121.1, p = 0.004) predicted >50% improvement in BEST score, while the presence of psychiatric disease was a negative predictor (OR 0.22, CI 0.05-0.94, p = 0.04).

CONCLUSIONS & INFERENCES

Psychological intervention using multimodal therapy provides clinical value to the management of functional esophageal symptoms among patients refractory to conventional therapy.

Hypnotherapy for irritable bowel syndrome: patient expectations and perceptions

INTRODUCTION

Numerous studies have shown that hypnotherapy (HT) is effective in irritable bowel syndrome (IBS) using traditional symptom severity end points. However, there is now interest in capturing the patient's perception of their illness and treatment because what patients expect from their treatment may differ from that of their healthcare provider.

OBJECTIVE

To record patient perceptions and expectations of hypnotherapy as well as their symptom response.

METHODS

150 consecutive IBS patients (116 females, 34 males, aged 16-81 years) receiving hypnotherapy completed questionnaires recording IBS symptom severity, quality of life, noncolonic symptoms, anxiety and depression levels before and after treatment. Their expectations and perceptions of HT were also recorded, including a free text reflection.

RESULTS

121 patients (81%) responded to treatment consistent with our previous experience. Symptom severity scores, noncolonic symptoms, quality of life, anxiety and depression significantly all improved after HT (p < 0.001). Expectancy of an improvement with hypnotherapy was greater in those who did not respond to treatment (63%) than those who did (57%, p < 0.001). Scepticism and apprehension were common before treatment and replaced with enthusiasm afterwards. Free text responses after treatment were overwhelmingly positive. Patients also reported a variety of other benefits and even 20 of 29 symptom nonresponders (70%) still considered treatment worthwhile.

CONCLUSION

Although initially perceived negatively, hypnotherapy improved symptoms and resulted in a wide range of additional benefits. Expectation did not necessarily influence outcome. Recording IBS symptoms alone does not fully capture the patient's experience of treatment and needs to be considered in future research.

Functional Chest Pain and Esophageal Hypersensitivity: A Clinical Approach

Functional chest pain, functional heartburn, and reflux hypersensitivity are 3 functional esophageal disorders defined by the Rome IV criteria. Specific criteria, combining symptoms and the results of objective testing, allow for an accurate diagnosis of these conditions. Management may include medications targeted at optimizing acid suppression or neuromodulation, as well as a host of complementary or alternative treatment options. Psychological and behavioral interventions, such as cognitive behavioral therapy and hypnotherapy, have displayed substantial benefits in the treatment of functional chest pain and functional heartburn. Acid suppression and focused neuromodulation are key evidence-based treatment options for reflux hypersensitivity.

Nurse's knowledge and perceptions on communicative hypnosis: an observational study

Background and aim of the study.

Much evidence shows that hypnotic communication can have a pain-relieving effect and reduce complications such as anxiety, insomnia and depression. Whenever this technique was applied, the use of pharmaceuticals was reduced, there were fewer side effects, shorter hospitalization times frames and lower treatment costs. The aim of this study is to evaluate the knowledge and perceptions of nurses about hypnotic communication and the causes for which this technique is not frequently used. A secondary objective pointed to measuring the effectiveness of an educational event on hypnosis.

Method.

The evaluation was done by directly administering an anonymous and voluntary survey created ad hoc, in a pre-test and post-test modality, to nurses subscribed to a four-hour formative event on hypnotic communication organized in 2019 by the Nursing Order, Province of Ravenna.

Results.

78 nurses (85.7%) participated in the study. The analysis of the pre-test results shows a gap of knowledge regarding hypnotic communication. The variation of answers between the pre-test and post-test (T-Student) has shown a radical difference in knowledge (95%-100% correct answers). The main causes were found regarding the lack of use for hypnotic communication: stereotypes and prejudices related to this technique and insufficient university education.

Conclusions.

The implementation of this technique, effective and efficient under various aspects, requires a preliminary creation of culture regarding this theme, capable of surpassing the stereotypes and resistances brought by a lack of theoretical elements.

Guidelines for reasonable and appropriate care in the emergency department (GRACE): Recurrent, low-risk chest pain in the emergency department

This first Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-1) from the Society for Academic Emergency Medicine is on the topic: Recurrent, Low-risk Chest Pain in the Emergency Department. The multidisciplinary guideline panel used The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding eight priority questions for adult patients with recurrent, low-risk chest pain and have derived the following evidence based recommendations: (1) for those >3 h chest pain duration we suggest a single, high-sensitivity troponin below a validated threshold to reasonably exclude acute coronary syndrome (ACS) within 30 days; (2) for those with a normal stress test within the previous 12 months, we do not recommend repeat routine stress testing as a means to decrease rates of major adverse cardiac events at 30 days; (3) insufficient evidence to recommend hospitalization (either standard inpatient admission or observation stay) versus discharge as a strategy to mitigate major adverse cardiac events within 30 days; (4) for those with non-obstructive (<50% stenosis) coronary artery disease (CAD) on prior angiography within 5 years, we suggest referral for expedited outpatient testing as warranted rather than admission for inpatient evaluation; (5) for those with no occlusive CAD (0% stenosis) on prior angiography within 5 years, we recommend referral for expedited outpatient testing as warranted rather than admission for inpatient evaluation; (6) for those with a prior coronary computed tomographic angiography within the past 2 years with no coronary stenosis, we suggest no further diagnostic testing other than a single, normal high-sensitivity troponin below a validated threshold to exclude ACS within that 2 year time frame; (7) we suggest the use of depression and anxiety screening tools as these might have an effect on healthcare use and return emergency department (ED) visits; and (8) we suggest referral for anxiety or depression management, as this might have an impact on healthcare use and return ED visits.

Gut-focused hypnotherapy for children and adolescents with irritable bowel syndrome

OBJECTIVE

Severe irritable bowel syndrome (IBS) in school children and adolescents often leads to stigmatisation, social withdrawal, disrupted education and psychological distress. While there are few effective treatment options for IBS in this age group, gut-focused hypnotherapy (GFH) has shown promise in several trials. Unfortunately, GFH is not widely available, and clinical data outside of trials are scarce. Here, we evaluated outcomes from GFH in patients with IBS, aged ≤18 years, from a tertiary referral centre.

DESIGN/METHOD

Consecutive patients aged ≤18 years with severe IBS received 12 sessions of GFH, at weekly intervals, using the Manchester Protocol. Clinical outcomes data, including IBS Symptom Severity Score (IBS-SSS), Hospital Anxiety and Depression Scale (HADS), Non-colonic Symptom Score and Quality-of-Life (QoL) score, were collected prospectively, and compared pre-GFH and post-GFH. Clinical response was defined as ≥50 point reduction in IBS-SSS.

RESULTS

32 young patients fulfilling Rome III diagnostic criteria for IBS (median age 16 (range 8-18) years, n=23/32 (72%) female individuals) completed GFH. At baseline, the mean duration of IBS was 5.9±0.9 years, and the mean IBS-SSS was 313±14. After GFH, 28/32 (88%) responded, with a mean overall reduction in IBS-SSS -159±16 (p<0.0001), and 24/32 (75%) achieved ≥30% reduction in abdominal pain scores. GFH also improved: non-colonic symptoms (p<0.0001), HADS-anxiety (p<0.0001), HADS-depression (p=0.0002) and QoL Scores (p<0.0001).

CONCLUSION

GFH is highly effective in children and adolescents with IBS. Early intervention with GFH in childhood IBS may reduce the subsequent burden of this problem in adults.

Hypnotic intervention in people with fibromyalgia: A randomized controlled trial

Fibromyalgia affects the quality of life of the patients, as well as their family. It also affects their social, labor, physical, and psychological dynamics. We aimed to evaluate the effectiveness of audio-recorded hypnosis in ameliorating fibromyalgia symptoms. We enrolled 97 individuals with fibromyalgia (mean age: 45 years) and randomly distributed them to two groups (48 in the experimental group and 47 in the control group). Individuals in both groups maintained their standard pharmacological treatment and continued their usual physical or psychological activities. The experimental group received an audio-recorded hypnosis intervention in the first session; subsequently, they received another audio hypnosis session to use for daily practice for a month. We evaluated the pre- and post-intervention pain intensity, pain interference, fatigue intensity, fatigue interference, depressive symptomatology, and satisfaction with life. We found that the self-administered audio-recorded hypnotic intervention significantly decreased the intensity and interference of pain and fatigue, as well as the depressive symptomatology. Audio-recorded clinical hypnosis techniques could provide an effective, practical, and economical alternative for reducing fibromyalgia-related symptoms.

Hypnosis and Cognitive Behavioral Therapies for the Management of Gastrointestinal Disorders

PURPOSE OF REVIEW

To review the nature, current evidence of efficacy, recent developments, and future prospects for cognitive behavioral therapy (CBT) and gut-directed hypnotherapy, the two best established psychological interventions for managing gastrointestinal (GI) disorders.

RECENT FINDINGS

New large randomized controlled trials are showing that cost-effective therapy delivery formats (telephone-based, Internet-based, fewer therapist sessions, or group therapy) are effective for treating GI disorders. CBT and hypnotherapy can produce substantial improvement in the digestive tract symptoms, psychological well-being, and quality of life of GI patients. However, they have long been hampered by limited scalability and significant cost, and only been sufficiently tested for a few GI health problems. Through adoption of more cost-effective therapy formats and teletherapy, and by expanding the scope of efficacy testing to additional GI treatment targets, these interventions have the potential to become widely available options for improving clinical outcomes for patients with hard-to-treat GI disorders.

The Efficacy of Hypnotherapy in the Treatment of Functional Dyspepsia

BACKGROUND

Functional dyspepsia (FD) is one of the most frequent functional gastrointestinal disorders and is defined using the Rome IV criteria as any combination of the following symptoms: postprandial fullness, early satiety, epigastric pain, and epigastric burning that are severe enough to interfere with the usual activities and occur at least 3 days per week over the past 3 months with an onset of at least 6 months before the presentation. The purpose of this systematic review is to analyze all the relevant studies in the literature that investigate the efficiency of hypnotherapy in FD.

AREAS OF UNCERTAINTY

FD refractory to conservative treatment is a therapeutic challenge, and alternative treatment options are needed. Gut-oriented hypnotherapy has been reported an effective treatment for irritable bowel syndrome, but poorly tested in FD.

DATA SOURCES

We performed a search in 6 bibliographic databases (PubMed, Embase, Cochrane Library, Web of Science, Scopus, and LILACS) using customized search strategies for each engine. The search strategy included the following terms: (hypnosis, hypnotherapy, hypnotherapies, hypnogenesis, hypnotism, hypnotist, hypnotical suggestion, suggestion, and mesmerism) and {[functional and (dyspepsia or dyspeptic)] or FD}.

RESULTS

Taking the aforementioned criteria into account, the result was a review of 4 articles analyzing the efficacy of hypnotherapy in the treatment of FD, published in the past 20 years. The initial search identified 398 articles, of which 37 potentially appropriate articles were reviewed. Of these 37 articles, 4 articles were included in the review. The benefits observed by numerous studies go beyond the field of digestive pathology, patients describing a general improvement in physical and mental health.

CONCLUSIONS

Current studies analyzing the efficacy of hypnotherapy in FD provide encouraging data, but additional randomized controlled trials are needed before a firm position on the effectiveness of hypnosis in FD.

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

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

Gut-focused hypnotherapy for Functional Gastrointestinal Disorders: Evidence-base, practical aspects, and the Manchester Protocol

BACKGROUND

Despite their high prevalence and advances in the field of neurogastroenterology, there remain few effective treatment options for functional gastrointestinal disorders (FGIDs). It is recognized that approximately 25% of sufferers will have symptoms refractory to existing therapies, causing significant adverse effects on quality of life and increased healthcare utilization and morbidity. Gut-focused hypnotherapy, when delivered by trained therapists, has been shown to be highly effective in severe refractory FGIDs. However, hypnotherapy continues to be surrounded by much misunderstanding and skepticism.

PURPOSE

The purpose of this review is to provide a contemporary overview of the principles of gut-focused hypnotherapy, its effects on gut-brain interactions, and the evidence-base for its efficacy in severe FGIDs. As supplementary material, we have included a hypnotherapy protocol, providing the reader with an insight into the practical aspects of delivery, and as a guide, an example of a script of a gut-focused hypnotherapy session.

The Mexican consensus on non-cardiac chest pain

INTRODUCTION

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

AIM

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

METHODS

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

RESULTS AND CONCLUSIONS

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

Oesophageal dysphagia: a stepwise approach to diagnosis and management

Dysphagia is a common symptom in the general population. Incidence varies depending on the specific definition used. A good medical history is vital for distinguishing true oesophageal dysphagia from oropharyngeal dysphagia or other causes. Oesophageal dysphagia is a so-called red flag alarm symptom requiring oesophagogastroduodenoscopy. However, even after investigations including oesophagogastroduodenoscopy (with biopsy), barium swallow, and oesophageal manometry, no obstructive cause may be found. This Review suggests an algorithm of history-taking and investigation to allow the causes of non-obstructive dysphagia to be identified, including functional dysphagia. The Review then discusses management strategies and outcomes for functional dysphagia.

Proton pump inhibitor-refractory gastroesophageal reflux disease: challenges and solutions

A significant percentage of patients with gastroesophageal reflux disease (GERD) will not respond to proton pump inhibitor (PPI) therapy. The causes of PPI-refractory GERD are numerous and diverse, and include adherence, persistent acid, functional disorders, nonacid reflux, and PPI bioavailability. The evaluation should start with a symptom assessment and may progress to imaging, endoscopy, and monitoring of esophageal pH, impedance, and bilirubin. There are a variety of pharmacologic and procedural interventions that should be selected based on the underlying mechanism of PPI failure. Pharmacologic treatments can include antacids, prokinetics, alginates, bile acid binders, reflux inhibitors, and antidepressants. Procedural options include laparoscopic fundoplication and LINX as well as endoscopic procedures, such as transoral incisionless fundoplication and Stretta. Several alternative and complementary treatments of possible benefit also exist.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Methodology for a trial of brain-centered versus anticholinergic therapy in women with urgency urinary incontinence

INTRODUCTION AND HYPOTHESIS

We describe the rationale and methodology for a study comparing mind-body treatment and pharmacotherapy in women with urgency urinary incontinence (UUI). To explore brain associations in UUI, a subset of patients will also undergo functional magnetic resonance imaging (fMRI). We hypothesize that hypnotherapy, a mind-body intervention, will be at least as effective as pharmacotherapy in treating UUI. We also hypothesize that fMRI findings will change following treatment, with changes potentially differing between groups.

METHODS

We describe the development and design challenges of a study comparing the efficacy of hypnotherapy and conventional pharmacotherapy in the treatment of UUI. The study randomizes women to either of these treatments, and outcome measures include bladder diaries and validated questionnaires. Sample size estimates, based on a noninferiority test (alpha = 0.025, beta = 0.20), after considering dropout subjects and subjects lost to follow-up, indicated that approximately 150 woman would be required to test the hypothesis that hypnotherapy is not inferior to pharmacotherapy within a 5 % noninferiority margin. The study will also evaluate fMRI changes in a subset of participants before and after therapy. Challenges included designing a study with a mind-body therapy and a comparison treatment equally acceptable to participants, standardizing the interventions, and confronting the reality that trials are time-consuming for participants who have to make appropriate accommodations in their schedule.

RESULTS

Study enrollment began in March 2013 and is ongoing.

CONCLUSIONS

We describe the design of a randomized controlled trial comparing mind-body therapy and pharmacotherapy in the treatment of UUI and the challenges encountered in its implementation.

Non-cardiac Chest Pain: A Review for the Consultation-Liaison Psychiatrist

BACKGROUND

Patients presenting with chest pain to general practice or emergency providers represent a unique challenge, as the differential is broad and varies widely in acuity. Importantly, most cases of chest pain in both acute and general practice settings are ultimately found to be non-cardiac in origin, and a substantial proportion of patients experiencing non-cardiac chest pain (NCCP) suffer significant disability. In light of emerging evidence that mental health providers can serve a key role in the care of patients with NCCP, knowledge of the differential diagnosis, psychiatric co-morbidities, and therapeutic techniques for NCCP would be of great use to both consultation-liaison (C-L) psychiatrists and other mental health providers.

METHODS

We reviewed prior published work on (1) the appropriate medical workup of the acute presentation of chest pain, (2) the relevant medical and psychiatric differential diagnosis for chest pain determined to be non-cardiac in origin, (3) the management of related conditions in psychosomatic medicine, and (4) management strategies for patients with NCCP.

RESULTS

We identified key differential diagnostic and therapeutic considerations for psychosomatic medicine providers in 3 different clinical contexts: acute care in the emergency department, inpatient C-L psychiatry, and outpatient C-L psychiatry. We also identified several gaps in the literature surrounding the short-term and long-term management of NCCP in patients with psychiatric etiologies or co-morbid psychiatric conditions.

CONCLUSIONS

Though some approaches to the care of patients with NCCP have been developed, more work is needed to determine the most effective management techniques for this unique and high-morbidity population.

Effect of psychological therapy on disease activity, psychological comorbidity, and quality of life in inflammatory bowel disease: a systematic review and meta-analysis

BACKGROUND

Inflammatory bowel disease is associated with psychological comorbidity and impaired quality of life. Psychological comorbidity could affect the natural history of inflammatory bowel disease. Psychological therapies might therefore have beneficial effects on disease activity, mood, and quality of life in patients with inflammatory bowel disease. We did a systematic review and meta-analysis examining these issues.

METHODS

In this systematic review and meta-analysis, we searched MEDLINE, Embase, Embase Classic, PsychINFO, and the Cochrane Central Register of Controlled Trials for articles published between 1947 and Sept 22, 2016. Randomised controlled trials (RCTs) recruiting patients with inflammatory bowel disease aged at least 16 years that compared psychological therapy with a control intervention or usual treatment were eligible. We pooled dichotomous data to obtain relative risks of induction of remission in active disease or prevention of relapse of quiescent disease, with 95% CIs. We pooled continuous data to estimate standardised mean differences in disease activity indices, anxiety, depression, perceived stress, and quality-of-life scores in patients dichotomised into those with clinically active or quiescent disease, with 95% CIs. We extracted data from published reports and contacted the original investigators of studies for which the required data were not available. We pooled all data using a random-effects model.

FINDINGS

The search identified 1824 studies, with 14 RCTs of 1196 patients eligible for inclusion. The relative risk of relapse of quiescent inflammatory bowel disease with psychological therapy versus control was 0·98 (95% CI 0·77-1·24; p=0·87; I²=50%; six trials; 518 patients). We observed a significant difference in depression scores (standardised mean difference -0·17 [-0·33 to -0·01]; p=0·04; I²=0%; seven trials; 605 patients) and quality of life (0·30 [0·07-0·52]; p=0·01; I²=42%; nine trials; 578 patients) with psychological therapy versus control at the end of therapy for patients with quiescent disease. However, these beneficial effects were lost at final point of follow-up (depression scores -0·11 [-0·27 to 0·05], p=0·17, I²=0%, eight trials, 593 patients; quality of life 0·15 [-0·05 to 0·34], p=0·14, I²=22%, ten trials, 577 patients). When we assessed the effect of individual physiological therapies on quality of life, only cognitive behavioural therapy had any significant beneficial effect (0·37 [0·02-0·72]). We noted no effect on disease activity indices or other psychological wellbeing scores when compared with control in patients with quiescent disease. Dichotomous data for induction of remission and continuous data for change in clinical disease activity indices, depression, anxiety, and perceived stress scores were only reported in one RCT of patients with active disease. Quality of life was assessed in two RCTs of patients with active disease, but was not significantly different between intervention and control groups (0·27 [-0·05 to 0·59]).

INTERPRETATION

Psychological therapies, and cognitive behavioural therapy in particular, might have small short-term beneficial effects on depression scores and quality of life in patients with inflammatory bowel disease. Further RCTs of these interventions in patients with coexistent psychological distress are required.

FUNDING

None.

[Gastroenterological diseases as triggers of chest pain]

BACKGROUND

Non-cardiac chest pain is very common and gastroenterological diseases are one of the most important causes. The frequency distribution of the underlying causes depends on the sector of the healthcare system in which it is ascertained. In individual cases it must always be taken into consideration that detection of coronary heart disease, for example, does not exclude another origin of chest pain.

OBJECTIVE

This article provides a systematic review of gastroenterological diseases that can cause chest pain. Furthermore, a management algorithm was developed.

MATERIAL AND METHODS

This article is based on a selective search of the literature.

RESULTS AND DISCUSSION

The most frequent cause is gastroesophageal reflux disease, which is also known as reflux-chest pain syndrome. If there are no clinical alarm signals, treatment is carried out with a proton pump inhibitor either as a diagnostic test or as a probatory therapy. If this initial management does not lead to satisfactory symptom control, extended diagnostics are indicated. In individual cases this concerns the detection or exclusion of a reflux disease, of motility disorders and structural damage to the esophagus as well as diseases of the upper abdominal organs, which can evoke chest pain. After exclusion of these morphologically and/or functionally defined diseases, a so-called functional chest pain is present. The essential mechanisms are altered pain processing, esophageal hypersensitivity and mental comorbidities. The treatment of functional chest pain often proves to be difficult.

Asia-Pacific consensus on the management of gastro-oesophageal reflux disease: an update focusing on refractory reflux disease and Barrett's oesophagus

OBJECTIVE

Since the publication of the Asia-Pacific consensus on gastro-oesophageal reflux disease in 2008, there has been further scientific advancement in this field. This updated consensus focuses on proton pump inhibitor-refractory reflux disease and Barrett's oesophagus.

METHODS

A steering committee identified three areas to address: (1) burden of disease and diagnosis of reflux disease; (2) proton pump inhibitor-refractory reflux disease; (3) Barrett's oesophagus. Three working groups formulated draft statements with supporting evidence. Discussions were done via email before a final face-to-face discussion. We used a Delphi consensus process, with a 70% agreement threshold, using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria to categorise the quality of evidence and strength of recommendations.

RESULTS

A total of 32 statements were proposed and 31 were accepted by consensus. A rise in the prevalence rates of gastro-oesophageal reflux disease in Asia was noted, with the majority being non-erosive reflux disease. Overweight and obesity contributed to the rise. Proton pump inhibitor-refractory reflux disease was recognised to be common. A distinction was made between refractory symptoms and refractory reflux disease, with clarification of the roles of endoscopy and functional testing summarised in two algorithms. The definition of Barrett's oesophagus was revised such that a minimum length of 1 cm was required and the presence of intestinal metaplasia no longer necessary. We recommended the use of standardised endoscopic reporting and advocated endoscopic therapy for confirmed dysplasia and early cancer.

CONCLUSIONS

These guidelines standardise the management of patients with refractory gastro-oesophageal reflux disease and Barrett's oesophagus in the Asia-Pacific region.

Feasibility and acceptability of esophageal-directed hypnotherapy for functional heartburn

Functional heartburn (FH) is a benign but burdensome condition characterized by painful, burning epigastric sensations in the absence of acid reflux or symptom-reflux correlation. Esophageal hypersensitivity and its psychological counterpart, esophageal hypervigilance (EHv) drive symptom experience. Hypnotherapy (HYP) is an established and preferred intervention for refractory symptoms in functional gastrointestinal disorders (FGIDs) and could be applied to FH. The objective of this study was to determine the feasibility, acceptability, and clinical utility of 7 weekly sessions of esophageal-directed HYP (EHYP) on heartburn symptoms, quality of life, and EHv. Similar to other work in FGIDs and regardless of hypnotizability, there were consistent and significant changes in heartburn symptoms, visceral anxiety, and quality of life and a trend for improvement in catastrophizing. We would recommend EHYP in FH patients who are either non-responsive to medications or who would prefer a lifestyle intervention.

[Current issues on gastroesophageal reflux disease]

Gastroesophageal reflux disease (GERD) is one of the most common problems in gastrointestinal disorders. With the increase in our understanding on the pathophysiology of GERD along with the development of proton pump inhibitors, the diagnostic and therapeutic approaches to GERD have changed dramatically over the past decade. However, GERD still poses a problem to many clinicians since the spectrum of the disease has evolved to encompass more challenging presentations such as refractory GERD and extraesophageal manifestations. This has led to significant confusion regarding the optimal approach to these patients. This article aims to discuss current issues on GERD.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

A Review of Esophageal Chest Pain

Noncardiac chest pain is a term that encompasses all causes of chest pain after a cardiac source has been excluded. This article focuses on esophageal sources for chest pain. Esophageal chest pain (ECP) is common, affects quality of life, and carries a substantial health care burden. The lack of a systematic approach toward the diagnosis and treatment of ECP has led to significant disability and increased health care costs for this condition. Identifying the underlying cause(s) or mechanism(s) for chest pain is key for its successful management. Common etiologies include gastroesophageal reflux disease, esophageal hypersensitivity, dysmotility, and psychological conditions, including panic disorder and anxiety. However, the pathophysiology of this condition is not yet fully understood. Randomized controlled trials have shown that proton pump inhibitor therapy (either omeprazole, lansoprazole, or rabeprazole) can be effective. Evidence for the use of antidepressants and the adenosine receptor antagonist theophylline is fair. Psychological treatments, notably cognitive behavioral therapy, may be useful in select patients. Surgery is not recommended. There remains a large unmet need for identifying the phenotype and prevalence of pathophysiologic mechanisms of ECP as well as for well-designed multicenter clinical trials of current and novel therapies.

Hypnosis Treatment of Gastrointestinal Disorders: A Comprehensive Review of the Empirical Evidence

Hypnotherapy has been investigated for 30 years as a treatment for gastrointestinal (GI) disorders. There are presently 35 studies in the published empirical literature, including 17 randomized controlled trials (RCTs) that have assessed clinical outcomes of such treatment. This body of research is reviewed comprehensively in this article. Twenty-four of the studies have tested hypnotherapy for adult irritable bowel syndrome (IBS) and 5 have focused on IBS or abdominal pain in children. All IBS hypnotherapy studies have reported significant improvement in gastrointestinal symptoms, and 7 out of 10 RCTs in adults and all 3 RCTs in pediatric patient samples found superior outcomes for hypnosis compared to control groups. Collectively this body of research shows unequivocally that for both adults and children with IBS, hypnosis treatment is highly efficacious in reducing bowel symptoms and can offer lasting and substantial symptom relief for a large proportion of patients who do not respond adequately to usual medical treatment approaches. For other GI disorders the evidence is more limited, but preliminary indications of therapeutic potential can be seen in the single randomized controlled trials published to date on hypnotherapy for functional dyspepsia, functional chest pain, and ulcerative colitis. Further controlled hypnotherapy trials in those three disorders should be a high priority. The mechanisms underlying the impact of hypnosis on GI problems are still unclear, but findings from a number of studies suggest that they involve both modulation of gut functioning and changes in the brain's handling of sensory signals from the GI tract.

Hypnotherapy for Esophageal Disorders

Hypnotherapy is an evidence based intervention for the treatment of functional bowel disorders, particularly irritable bowel syndrome. While similar in pathophysiology, less is known about the utility of hypnotherapy in the upper gastrointestinal tract. Esophageal disorders, most of which are functional in nature, cause painful and uncomfortable symptoms that impact patient quality of life and are difficult to treat from a medical perspective. After a thorough medical workup and a failed trial of proton pump inhibitor therapy, options for treatment are significantly limited. While the pathophysiology is likely multifactorial, two critical factors are believed to drive esophageal symptoms--visceral hypersensitivity and symptom hypervigilance. The goal of esophageal directed hypnotherapy is to promote a deep state of relaxation with focused attention allowing the patient to learn to modulate physiological sensations and symptoms that are not easily addressed with conventional medical intervention. Currently, the use of hypnosis is suitable for dysphagia, globus, functional chest pain/non-cardiac chest pain, dyspepsia, and functional heartburn. In this article the authors will provide a rationale for the use of hypnosis in these disorders, presenting the science whenever available, describing their approach with these patients, and sharing a case study representing a successful outcome.

Role of a health psychologist in the management of functional esophageal complaints

Upper gastrointestinal complaints are common among patients in a gastrointestinal clinic. Outside of typical gastroesophageal reflux disease symptoms that are treated with medication, the symptom presentations of esophageal patients, particularly those with functional conditions, are often difficult to treat and account for high health-care utilization. This manuscript describes the role of a health psychologist in the treatment of esophageal disorders using behavioral medicine interventions. Observations over the course of a 1-year period indicate that the sample presents with a relatively low level of psychological distress but reports negative effects of their symptoms on health-related quality of life. Five case examples of commonly treated disorders (globus, non-cardiac chest pain, functional dysphagia, rumination syndrome, supragastric belching) are described to highlight how behavioral treatment can improve patients' symptoms, decrease health-care utilization, and improve overall quality of life in a timely and relatively simple manner. Successful treatment outcomes are associated with a collaborative working alliance between patient, health psychologist, and gastroenterologist. Results indicate the benefit of referring appropriate esophageal patients to a health psychologist with specialization in gastroenterology.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Hypnotherapy for irritable bowel syndrome: an audit of one thousand adult patients

BACKGROUND

Gut-focused hypnotherapy improves the symptoms of irritable bowel syndrome (IBS) with benefits being sustained for many years. Despite this, the technique has not been widely adopted by healthcare systems, possibly due to relatively small numbers in published studies and uncertainty about how it should be provided.

AIM

To review the effect of hypnotherapy in a large cohort of refractory IBS patients.

METHODS

One thousand IBS patients fulfilling Rome II criteria, mean age 51.6 years (range 17-91 years), 80% female, receiving 12 sessions of hypnotherapy over 3 months, were studied. The primary outcome was a 50 point reduction in the IBS Symptom Severity Score. The fall in scores for Noncolonic Symptoms, Quality of Life and Anxiety or Depression, were secondary outcomes. The Federal Drug Administration's recommended outcome of a 30% or more reduction in abdominal pain was also recorded.

RESULTS

Overall, 76% met the primary outcome which was higher in females (females: 80%, males: 62%, P < 0.001) and those with anxiety (anxious: 79%, non-anxious: 71%, P = 0.010). The mean reduction in other scores was: IBS Symptom Severity Score, 129 points (P < 0.001), Noncolonic Symptom Score, 65 (P < 0.001) and Quality of Life Score, 66 (P < 0.001). Sixty-seven per cent reported a 30% or more reduction in abdominal pain scores. Pain days fell from 18 to 9 per month. Patients with anxiety and depression fell from 63% to 34% and 25% to 12% respectively (P < 0.001). Outcome was unaffected by bowel habit subtype.

CONCLUSION

These results provide further evidence that gut-focused hypnotherapy is an effective intervention for refractory IBS.

Current Diagnosis and Management of Suspected Reflux Symptoms Refractory to Proton Pump Inhibitor Therapy

Suspected reflux symptoms that are refractory to proton pump inhibitors (PPIs) are rapidly becoming the most common presentation of gastroesophageal reflux disease (GERD) in patients seen in gastroenterology clinics. These patients are a heterogeneous group, differing in symptom frequency and severity, PPI dosing regimens, and responses to therapy (from partial to absent). Before testing, the physician needs to question the patient carefully about PPI compliance and the timing of drug intake in relation to meals. Switching PPIs or doubling the dose is the next step, but only 20% to 25% of the group refractory to PPIs will respond. The first diagnostic test should be upper gastrointestinal endoscopy. In more than 90% of cases, the results will be normal, but persistent esophagitis may suggest pill esophagitis, eosinophilic esophagitis, or rarer diseases, such as lichen planus, Zollinger-Ellison syndrome, or genotype variants of PPI metabolism. If the endoscopy results are normal, esophageal manometry and especially reflux testing should follow. Whether patients should be tested on or off PPI therapy is controversial. Most physicians prefer to test patients off PPIs to identify whether abnormal acid reflux is even present; if it is not, PPIs can be stopped and other diagnoses sought. Testing patients on PPI therapy allows nonacid reflux to be identified, but more than 50% of patients have a normal test result, leaving the clinician with a conundrum-whether to stop PPIs or continue them because the GERD is being treated adequately. Alternative diagnoses in patients with refractory GERD and normal reflux testing include achalasia, eosinophilic esophagitis, gastroparesis, rumination, and aerophagia. However, more than 50% will be given the diagnosis of functional heartburn, a visceral hypersensitivity syndrome. Treating patients with PPI-refractory GERD-like symptoms can be difficult and frustrating. Any of the following may help: a histamine-2 receptor antagonist at night, baclofen to decrease transient lower esophageal sphincter relaxations, pain modulators, acupuncture, or hypnotherapy. At this time, antireflux surgery should be limited to patients with abnormal acid reflux defined by pH testing and a good correlation of symptoms with acid reflux.

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

BACKGROUND

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

OBJECTIVES

To summarize treatment efficacy for patients presenting with NCCP.

METHODS

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

RESULTS

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

LIMITATIONS

Only a small number of studies were available.

CONCLUSIONS

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

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

BACKGROUND & AIMS

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

METHODS

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

RESULTS

Thirty-five studies comprising various treatments were included and grouped under 5 broad categories. Patient inclusion criteria were extremely variable, and studies were generally small with methodological concerns. There was good evidence to support the use of omeprazole and fair evidence for lansoprazole, rabeprazole, theophylline, sertraline, trazodone, venlafaxine, imipramine, and cognitive behavioral therapy. There was poor evidence for nifedipine, diltiazem, paroxetine, biofeedback therapy, ranitidine, nitrates, botulinum toxin, esophageal myotomy, and hypnotherapy.

CONCLUSIONS

Ideally, treatment of ECP should be aimed at correcting the underlying mechanism(s) and relieving symptoms. Proton pump inhibitors, antidepressants, theophylline, and cognitive behavioral therapy appear to be useful for the treatment of ECP. However, there is urgent and unmet need for effective treatments and for rigorous, randomized controlled trials.

Medical treatments of GERD: the old and new

The mainstay of pharmacological therapy for GERD is gastric acid suppression with proton pump inhibitors (PPIs), which are superior to histamine-2 receptor antagonists for healing erosive esophagitis and achieving symptomatic relief. However, up to one-third of patients may not respond to PPI therapy, creating the need for alternative treatments. Potential approaches include transient lower esophageal sphincter relaxation inhibitors, augmentation esophageal defense mechanisms by improving esophageal clearance or enhancing epithelial repair, and modulation of sensory pathways responsible for GERD symptoms. This review discusses the effectiveness of acid suppression and the data on alternative pharmacological approaches for the treatment of GERD.

Hypnosis in paediatric respiratory medicine

Hypnotherapy is an often misunderstood yet effective therapy. It has been reported to be useful within the field of paediatric respiratory medicine as both a primary and an adjunctive therapy. This article gives a brief overview of how hypnotherapy is performed followed by a review of its applications in paediatric patients with asthma, cystic fibrosis, dyspnea, habit cough, vocal cord dysfunction, and those requiring non-invasive positive pressure ventilation. As the available literature is comprised mostly of case series, retrospective studies, and only a single small randomized study, the field would be strengthened by additional randomized, controlled trials in order to better establish the effectiveness of hypnosis as a treatment, and to identify the processes leading to hypnosis-induced physiologic changes. As examples of the utility of hypnosis and how it can be taught to children with respiratory disease, the article includes videos that demonstrate its use for patients with cystic fibrosis.

Nonspecific motility disorders, irritable esophagus, and chest pain

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

Neurophysiology of pain and hypnosis for chronic pain

In the past decade there has been a dramatic increase in (1) understanding the neurophysiological components of the pain experiences, (2) randomized clinical trials testing the efficacy of hypnotic treatments on chronic pain, and (3) laboratory research examining the effects of hypnosis on the neurophysiological processes implicated in pain. Work done in these areas has not only demonstrated the efficacy of hypnosis for treating chronic pain but is beginning to shed light on neurophysiological processes that may play a role in its effectiveness. This paper reviews a selection of published studies from these areas of research, focusing on recent findings that have the most potential to inform both clinical work and research in this area. The paper concludes with research and clinical recommendations for maximizing treatment efficacy based on the research findings that are available.

A brief cognitive-behavioral intervention for treating depression and panic disorder in patients with noncardiac chest pain: a 24-week randomized controlled trial

BACKGROUND

Most patients with noncardiac chest pain experience anxiety and depressive symptoms. Commonly they are reassured and referred back to primary care, leaving them undiagnosed and untreated. Some small studies have suggested efficacy of 12 cognitive behavioral therapy (CBT) sessions. Our aim was to examine efficacy of brief CBT in reducing anxiety and depressive symptoms in patients with noncardiac chest pain and comorbid panic and/or depressive disorders.

METHODS

In this 24-week randomized controlled trial comparing CBT (n = 60) versus treatment as usual (TAU, n = 53), we included all adults who presented at the cardiac emergency unit of a university hospital with noncardiac chest pain, scored ≥8 on the hospital anxiety and depression scale (HADS) and were diagnosed with a comorbid panic and/or depressive disorder with the Mini International Neuropsychiatric Interview. CBT consisted of six individual sessions. Main outcome was disease severity assessed with the clinical global inventory (CGI) by a blinded independent rater.

RESULTS

ANCOVA in the intention-to-treat and completer sample showed that CBT was superior to TAU after 24 weeks in reducing disease severity assessed with CGI (P < .001). Secondary outcomes on anxiety (HADS-anxiety, state trait anxiety inventory (STAI)-trait) and depressive symptoms (Hamilton depression rating scale) were in line with these results except for HADS-depression (P = .10), fear questionnaire (P = .13), and STAI-state (P = .11).

CONCLUSIONS

Brief CBT significantly reduces anxiety and depressive symptoms in patients with noncardiac chest pain who are diagnosed with panic and/or depressive disorders. Patients presenting with noncardiac chest pain should be screened for psychopathology and if positive, CBT should be considered.