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Query: UMLS:C0008031 (chest pain)
 17,248 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Gastroesophageal reflux disease (GERD) is a common condition that effects about 10% of the adult population comprising a broad spectrum of symptoms and varying degrees of severity and frequency. Extra-esophageal manifestations are increasingly being recognized. Up to 50% of patients with an endoscopically proven or negative esophagitis suffer from symptoms other than heartburn or acid regurgitation such as laryngitis, hoarseness, chronic cough, asthma, or non-cardiac chest pain. The therapy of choice is proton pump inhibitors.
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PMID:Extra-esophageal disorders in gastroesophageal reflux disease. 1538 51

The esophageal complications of gastroesophageal reflux disease (GERD) are well described and include erosive esophagitis, stricture, Barrett esophagus, and adenocarcinoma. Primary care physicians often encounter patients with "extraesophageal" manifestations of GERD in the absence of heartburn. Patients may present with symptoms involving the pulmonary system, noncardiac chest pain, and ear, nose, and throat disorders. The diagnosis of reflux disease in these individuals may be challenging because, in addition to the absence of heartburn, endoscopy is often negative. Laryngoscopy and 24-hour dual-channel intraesophageal pH-metry may have greater diagnostic yields, but they are costly, invasive, and time-consuming. A trial of proton pump inhibitor (PPI) therapy is increasingly being considered a first-line diagnostic test in those with suspected reflux-related extraesophageal symptoms. The duration as well as dose of PPI should be based on the presenting symptoms, with patients having pulmonary manifestations often requiring twice-daily therapy for 2 to 3 months. In contrast, symptoms of reflux-related noncardiac chest pain may be relieved with a 1-week, standard-dose treatment trial. Patients who fail to experience symptom resolution or improvement should undergo further diagnostic evaluations including 24-hour esophageal pH studies while continuing their PPI therapy to establish persistent versus absent acid reflux. The role of fundoplication or other surgical/laparoscopic procedures in these patients has yet to be determined.
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PMID:Extraesophageal symptoms: what role for the proton pump inhibitors? 1547 54

Elective esophageal variceal ligation (EVL) is performed to decrease the risk of variceal hemorrhage. Side effects of EVL include hemorrhage, chest pain, dysphagia, and odynophagia. Because gastric acid may exacerbate postbanding ulcers and delay healing, proton pump inhibition may decrease side effects associated with EVL. The aim of this study was to assess the efficacy of pantoprazole, a proton pump inhibitor, as an adjunct to elective EVL. We performed a double-blinded, randomized, placebo-controlled trial of pantoprazole after elective EVL. Subjects in the pantoprazole arm received 40 mg pantoprazole intravenously after EVL followed by 40 mg oral pantoprazole for 9 days. Control subjects received intravenous and oral placebo. Subjects underwent upper endoscopy 10 to 14 days after banding. Primary outcomes included the size and number of ulcers and the subjects' reports of dysphagia, chest pain, and heartburn. Forty-four subjects were randomized: 42 completed the protocol. At follow-up endoscopy, the mean number of ulcers was similar in the two groups. However, the ulcers in the pantoprazole group were on average half as large as in the placebo group (37 mm(2) vs. 82 mm(2), P < .01). Chest pain, dysphagia, and heartburn scores were not significantly different. Four subjects, all in the placebo group, had adverse outcomes, including 3 who bled from postbanding ulcers and 1 with sepsis. In conclusion, subjects receiving pantoprazole after elective EVL had significantly smaller postbanding ulcers on follow-up endoscopy than subjects receiving placebo. However, the total ulcer number and patient symptoms were not different between the groups.
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PMID:Pantoprazole reduces the size of postbanding ulcers after variceal band ligation: a randomized, controlled trial. 1572 58

Functional chest pain is a common, yet poorly understood entity. The focus of this review is to explore the evolving research and clinical approaches with a particular emphasis on the sensory or afferent neuronal dysfunction of the esophagus as a key player in the manifestation of this pain syndrome. Although once regarded as a psychologic or esophageal motility disorder, recent advances have shown that many of these patients have visceral hyperalgesia. Whether visceral hypersensitivity is a central or peripheral perturbation of the gut-brain axis remains debatable. Response to empirical therapy with high-dose proton pump inhibitors, upper endoscopy, or prolonged recording of esophageal pH may identify gastroesophageal reflux disease as a source of chest pain. Esophageal balloon distension study can serve as a useful test for identifying hypersensitivity. Newer techniques, including functional magnetic resonance imaging, magnetoencephalogram, and cortical evoked potentials, are being investigated. High doses of proton pump inhibitors and low doses of tricyclic antidepressants or trazadone remain the mainstay of therapy, although several new approaches including theophylline have been shown to be beneficial.
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PMID:Functional chest pain: nociception and visceral hyperalgesia. 1579 86

Noncardiac chest pain (NCCP) may affect up to 23% of the U.S. population. The clinical approach and referral patterns of primary care physicians (PCPs) when evaluating NCCP subjects are unknown. We aimed to determine the preferences of diagnostic tests, referral patterns, and treatment plans of NCCP patients by PCPs. PCPs were randomly selected from the American Medical Association national membership list. A 24-item questionnaire was mailed, which focused on demographic information, characteristics of practice, preferences of diagnostic tests, referral patterns, and treatment plans. Two hundred five (40%) PCPs returned the questionnaire (mean age, 49; 77% males; practice type--community-based, 40.5%; hospital-based, 10.7%; and combined, 47.3%; physician type--internists, 46.3%; family physicians, 44.4%; general practitioners, 4.9%; and others, 2.9%). The mean number of NCCP patients seen in the past 6 months was 108 (6.4% of total patients) and 79.5% were treated primarily by PCPs. The three most common diagnostic tests used were empirical proton pump inhibitor (PPI) trial (45.6%), chest radiograph (39.9%), and upper endoscopy (18.7%). Most PCPs reported that they are either comfortable (44.6%) or very comfortable (21.2%) in diagnosing NCCP. The three most commonly used therapeutic modalities for NCCP were PPIs (37.8%), lifestyle modification (33.7%), and H2 blockers (12.4%). Of those NCCP patients referred to a subspecialist, most ended up in gastroenterology (75.6%), followed by cardiology (7.8%) and pulmonary (1.6%) clinics. We conclude that most PCP's diagnose and treat NCCP patients without referring them to a gastroenterologist. However, diagnostic and treatment strategies may not follow the current understanding and knowledge of the disorder.
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PMID:Attitudes and referral patterns of primary care physicians when evaluating subjects with noncardiac chest pain--a national survey. 1584 97

The close anatomical relations of the heart and oesophagus, and the similarity of symptoms attributable to disorders of either organ, often lead to diagnostic difficulty in patients with chest pain. A definitive diagnosis of non-cardiac chest pain attributable to oesophageal reflux or spasm is hampered, both by the need for prolonged ambulatory monitoring of pH, manometry, and endoscopy, and by the common occurrence of asymptomatic reflux and spasm, and the corresponding difficulty in linking an episode of reflux or spasm with an episode of pain. Moreover, some patients with non-cardiac chest pain and normal tests of oesophageal structure and function have centrally mediated hypersensitivity, both within and without the oesophagus. Rather than proceed with investigations, in the absence of symptoms to suggest structural disease of the oesophagus, it would be reasonable to attempt symptomatic treatment with a proton pump inhibitor or an antidepressant.
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PMID:The heart and the oesophagus: intimate relations. 1608 43

Gastroesophageal reflux disease (GERD) is the most common disease of the gastrointestinal system. Heartburn, regurgitation, and dysphagia are the most common symptoms of GERD. However, chest pain, chronic cough, laryngitis, hoarseness, and other otolaryngologic manifestation can be the primary manifestations of the disease. Endoscopy, barium studies, and especially pH monitoring and therapeutic trials may help in establishing the diagnosis of GERD. The introduction of H2 antagonists and especially of proton pump inhibitors (PPI) has brought symptomatic relief in most patients. However, surgical procedures, especially laparoscopic fundoplication, are still required in some patients. Barrett's esophagitis is the most common complication of GERD and is associated with a high prevalence of esophageal adenocarcinoma. Whether or not treatment with either PPIs or H2 antagonists can prevent this complication is still under investigation.
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PMID:Gastroesophageal reflux. 1619 96

Chest pain is common: one in four of the population have an episode annually. Of those who present to hospital, nearly two-thirds have noncardiac chest pain. More than half of these cases might have gastroesophageal reflux disease. Opinion differs over what is the most appropriate application of current investigatory methods. Evidence suggests that, once cardiac disease is ruled unlikely, empiric use of a proton pump inhibitor is an option; if acid suppression fails, detailed investigations as clinically indicated can be considered. A range of esophageal investigations is available, including 24-hour or 48-hour esophageal pH testing and esophageal manometry, as well as provocative tests, but there is no consensus as to which methods are the most useful. Psychiatric evaluation is not routine, but psychiatric or psychological disorders are common. Musculoskeletal disorders are also common, but are frequently overlooked. It is possible to subject patients to a comprehensive set of investigations before empiric therapy, but recent studies have failed to demonstrate an improved outcome using this exhaustive approach. A new tactic is required, with less attention spent on absolute diagnostic accuracy and more emphasis on optimizing the long-term clinical outcome in patients with noncardiac chest pain. It is possible that the targeted use of multiple drug trials in a policy of 'therapy as investigation' might be a superior methodology.
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PMID:Diagnosis and treatment of noncardiac chest pain. 1622 78

The extra-oesophageal signs that are most commonly related to gastro-oesophageal reflux include chest pain, asthma, chronic cough, posterior laryngitis and dental erosions. It is characteristic to find in such patients a poor presence of symptoms and endoscopic and pH-metric findings that are common in typical reflux. The therapeutic response to antisecretory drugs has become the most cost-effective tool for the diagnosis and treatment of this condition. Both the evidence available and expert agreement in consensus conferences support the use of proton pump inhibitors with doubled standard doses for at least 12 weeks in most cases. While an acceptable response is achieved with this significant acid inhibition, there are still questions to be answered in these and other aspects, such as the true prevalence, path physiology and diagnosis of this condition. It is therefore necessary and increasingly useful to create multidisciplinary teams with the aim to improve and promote understanding and the care of patients suffering from these supra-oesophageal symptoms caused by gastro-oesophageal reflux.
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PMID:Supra-oesophageal manifestations of gastro-oesophageal reflux disease. 1633 60

A 54-year-old man presented to the ER with chest pain. He underwent an upper endoscopy revealing a large linear esophageal tear and a CT chest showed free air in the mediastinum. He was managed conservatively and was discharged 2 days later. An UGI series revealed a distal esophageal stricture. He was commenced on esomeprazole for gastroesophageal reflux symptoms and his dysphagia improved significantly. Upper endoscopy revealed multiple rings throughout the esophagus. Biopsies from the distal and mid-esophagus were normal. The underlying pathophysiology, in patients with dysphagia and a ringed esophagus has evoked debate in the literature. Opinions range from underlying gastroesophageal reflux disease (GERD) to eosinophilic esophagitis (EE). Our patient's symptoms of GERD and dysphagia resolved with proton pump inhibitor therapy. Normal histology excluded underlying EE. There have been a few case reports of esophageal perforation in patients with a ringed esophagus, and underlying EE, but none with spontaneous perforation occurring in a 'ringed esophagus'. Perforations in the upper and mid-esophagus can usually be managed conservatively, while those in the distal esophagus often need surgery due to the high risk of developing mediastinitis. However, our patient, despite sustaining a large tear in the distal esophagus, did well with conservative management. This case demonstrates that spontaneous perforation in the ringed esophagus, with normal underlying histology can occur in the distal esophagus and may not require surgery.
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PMID:Spontaneous perforation in the ringed esophagus. 1633 13


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