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Query: UMLS:C0017168 (gastroesophageal reflux disease)
 11,783 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Recently, 24-h recording of intraesophageal pH and pressure signals in ambulatory subjects has become possible. Several research applications of the technique have emerged, but until now only a few clinical applications have been established, the most important of which is noncardiac chest pain. In the computer analysis of the signals, the patient with noncardiac chest pain is used as his or her own control; motility and pH profiles during pain are compared with asymptomatic base-line values obtained from the same patient. Automated analysis by means of a computer avoids observer bias and saves time. By means of 24-h monitoring, motor abnormalities have been identified as the cause of the chest pain in 4.5% to 18% and reflux in 4.5% to 25% of the patients studied. In addition, patients were identified who have both dysmotility- and reflux-related pain episodes. The yield of 24-h monitoring is highest in patients who have frequent pain episodes. A high yield of 24-h monitoring was found in patients with noncardiac chest pain admitted to a coronary care unit. Seventy-six per cent of these patients were found to have either reflux- of dysmotility-related chest pain. Patients with proven coronary artery disease who do not respond well to adequate treatment frequently have gastroesophageal reflux (39%) or esophageal motor abnormalities (50%) as the cause of their ongoing pain attacks. In these patients, identification of the esophageal cause of the symptoms not only helps the physician to select the optimal treatment but also reduces the patient's need for medical care.
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PMID:Clinical application of 24-hour ambulatory esophageal pH and pressure monitoring. 129 44

Identifying the cause of recurrent chest pain may be difficult. Significant coronary artery disease must be excluded before patients can be assured that their symptoms are truly "noncardiac." A normal coronary angiogram is the most definitive test but this may not preclude the presence of a new "fly in the ointment," i.e., microvascular angina. Musculoskeletal pain syndromes, psychological problems, and esophageal disorders, including both esophageal motility disorders and gastroesophageal reflux disease, are the most common causes of noncardiac chest pain. Nearly 30% of these patients will have an esophageal motility disorder, although its clinical relevance in the asymptomatic patient is controversial. Simple, inexpensive, provocation tests (most commonly edrophonium, bethanechol, and/or balloon distention) have been developed to recreate motility-related chest pain in the laboratory. These tests can identify the esophagus as the source of pain, but in most cases they do not direct therapy. Other disadvantages of provocation tests include the lack of a gold standard reference point, side effects, and the need for placebo because of a subjective end point. Recently, ambulatory esophageal pH and pressure monitoring have been used to define precisely the cause of esophageal chest pain. These systems can record multiple episodes of pain for up to 24 hours in an outpatient setting and have shown that gastroesophageal reflux (rather than motility disorders) is the most common esophageal cause of pain. However, these studies also suggest that many episodes of chest pain do not have an identifiable esophageal cause. Furthermore, this equipment is expensive, uncomfortable, may alter normal activity, and is not useful in patients having infrequent pain episodes. Psychological disturbances should be carefully sought in any patient with noncardiac chest pain: Many patients have anxiety, depression, or panic attacks that may complicate or contribute to their reported symptoms. It is questionable if these patients need additional testing. Rather, the challenge of the future is to prove that the multitude of tests aid in the overall treatment and outcome of patients with noncardiac chest pain.
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PMID:Overview of diagnostic testing for chest pain of unknown origin. 159 63

It is imperative to assess the psychosocial factors that may influence the subjective experiences and pain behavior of persons with chronic unexplained chest pain. Both psychologists and physicians tend to rely on self-report measures of psychological distress, which provide little unique information about patients with chronic chest pain to differentiate them from patients with other painful disorders such as irritable bowel syndrome, gastroesophageal reflux disease, or coronary artery disease. However, assessment of pain-coping strategies, spouse responses to the patient's pain behaviors, and pain thresholds for esophageal balloon distention do differentiate patients with chronic chest pain from healthy controls and patients with various other chronic pain disorders. Specifically, chronic chest pain patients tend to use relatively passive pain-coping strategies such as praying and hoping, and to report relatively high levels of spouse reinforcement of pain behaviors. Finally, in response to esophageal balloon distention, chronic chest pain patients display low pain thresholds that do not generalize to stimulation by mechanical finger pressure. Preliminary evidence suggests these low thresholds are due primarily to a tendency to set low standards for making pain judgments regarding esophageal stimuli of moderate-to-high intensity levels.
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PMID:Psychosocial and psychophysical assessments of patients with unexplained chest pain. 159 68

During the session on diagnostic testing, various diagnostic tests used to identify the cause of chest pain were discussed. This critique of diagnostic assessments of the complex etiology of chest pain is presented as a contribution toward further investigation and clarification of this difficult clinical syndrome. The first step in the evaluation process is to exclude coronary artery disease. Patients with angina and normal coronary artery flow may have atypical disease, such as microvascular angina or syndrome X. The precise relationship between these disorders and esophageal disease or gastroesophageal reflux, as well as their possible involvement in chest pain of undetermined origin, requires further definition. A limitation of esophageal provocation tests is that they may identify the esophagus as the source of pain without determining the specific esophageal disorder that causes the pain. Problems associated with 24-hour pH and pressure monitoring include (a) poor correlation between reflux episodes and heartburn symptoms, (b) the lack of a good functioning swallowing signal, and (c) the huge amount of data that must be analyzed, along with shortcomings in computer-aided analysis. Nevertheless, the various available diagnostic tests can provide important information to the clinician.
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PMID:Critique of the session on diagnostic testing. 159 70

35 patients with angina-like chest pain underwent esophageal manometry after a coronary artery disease had been ruled out by angiography. Furthermore, patients after gastric or esophageal surgery, with pathologic upper gastrointestinal endoscopy or with pathologic gastroesophageal reflux as seen on 24-hour-pH-metry were excluded from this study. 29 out of 35 patients (83%) had a normal manometric study, six patients (17%) had a motility disorder; five of these showed an unspecific dismotility pattern and were asymptomatic while the study was done; only one patient presented with esophageal spasm. Since only this latter patient was symptomatic while the study was done, a correlation between symptoms and this motility disorder seems likely. --If pathologic gastroesophageal reflux has been ruled out, esophageal manometry can establish a diagnosis in only 3% of patients with angina-like chest pain without esophageal symptoms (dysphagia, odynophagia, heartburn or regurgitation). We conclude that this complicated examination should not be done in these patients.
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PMID:[Esophageal motility disorders with thoracic pain of unknown origin]. 188 9

Patients with recurrent chest pain free of significant coronary artery disease account for 10% to 30% of patients undergoing coronary angiography. Recent studies suggest that gastroesophageal reflux disease may be very common in these patients. The cause of this chest pain seems to be related primarily to an acid-sensitive mucosa regardless of the presence of esophagitis. Unfortunately, a careful history will not distinguish chest pain arising from a cardiac versus an esophageal source. Therefore, all patients must undergo a thorough cardiac evaluation before assuming that acid reflux is the cause of their complaints. Initial gastroenterology evaluation will usually include upper GI endoscopy or barium studies, possibly with acid perfusion (Bernstein) testing, or both. However, the more sensitive and specific test for acid-related disease is prolonged esophageal pH monitoring. This study quantifies the amount of acid reflux but, more importantly, identifies the relationship between chest pain and acid reflux episodes. Patients should be studied in the outpatient setting with emphasis placed on performing activities that replicate their chest pain. Although we presume that acid-induced chest pain responds as well as heartburn to vigorous antireflux regimens, there are few studies to address this issue. Nevertheless, I have had great success in treating these patients with either high-dose H2 blockers or omeprazole therapy.
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PMID:Gastroesophageal reflux disease as a cause of chest pain. 189 6

Recurring substernal chest pain is an important clinical problem, causing anxiety for patients and their physicians because of the fear of possible cardiac disease. The differential diagnosis includes coronary artery disease, oesophageal disorders such as acid reflux disease and motility disturbances, musculoskeletal problems, psychological disorders including panic attacks, and a new 'fly in the ointment'--microvascular angina. History alone usually cannot distinguish cardiac from non-cardiac chest pain. After exclusion of significant coronary artery disease, attention must be turned to oesophageal disorders, which may be seen in as many as 50% of these patients. Oesophageal motility disorders, particularly the nutcracker oesophagus, are common, but the relationship between pain and abnormal contraction pressures is not well established. Provocative tests such as edrophonium (Tensilon) and balloon distension help to identify the oesophagus as the source of chest pain but do not direct therapy. Recent studies with ambulatory oesophageal monitoring suggest that gastro-oesophageal reflux may be a more common cause of chest pain than motility disorders. This is an important finding as acid reflux is a treatable problem, while therapies for motility disorders may only worsen reflux disease. The recent observation that oesophageal disorders are frequently associated and interact with psychological disorders such as anxiety, depression, somatization and panic attacks complicates the evaluation and understanding of chest pain. How these various abnormalities may be linked is an unresolved issue. Increased central nervous system stimulation and altered visceral and/or central pain sensitivity could be the common factors. It is hoped that further research into these areas will lead to new understandings of and possible solutions to the complex problem of non-cardiac chest pain.
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PMID:Investigation and management of non-cardiac chest pain. 191 53

We conducted a prospective study to determine the role of the esophagus in causing chest pain in patients with established CAD on optimum therapy. Thirty-two men with documented CAD who complained of frequent and usually daily retrosternal chest pain were evaluated. Following a standard esophageal manometry and acid perfusion test, simultaneous two-channel ambulatory Holter monitor and esophageal pH record tests were performed for 24 hours. Fifty-three episodes of chest pain were documented in 20 patients; 11 patients were free of pain. Of the 20 patients who complained of chest pains, 17 (85 percent) demonstrated at least one episode of PPR, defined as a drop in distal esophageal pH to less than 4 within ten minutes before or after the onset chest pain. Episodes of asymptomatic GER were common. The correlation of PPR with chest pain was 70 percent (37/53 episodes) and of ischemic ECG changes with chest pain 13 percent (7/53); in the remaining, there was no correlation with either. Two patients demonstrated simultaneous PPR and ischemic ECG changes. Seventeen esophageal motility abnormalities were observed in 14 patients (45 percent). It is our conclusion that esophageal disorders contribute to chest pain in patients with documented CAD. In this group, GER plays a greater role than in those with normal coronary arteries. In addition, esophageal motility disorders are common in these patients. Esophageal testing can be undertaken safely in these patients.
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PMID:Esophageal contribution to chest pain in patients with coronary artery disease. 220 34

Diagnostic interventions in nuclear medicine may be defined as the coadministration of a nonradioactive drug or application of a physical stimulus or physiologic maneuver to enhance the diagnostic utility of a nuclear medicine test. The rationale for each interventional maneuver follows from the physiology or metabolism of the particular organ or organ system under evaluation. Diagnostic inference is drawn from the pattern of change in the biodistribution of the tracer in response to the intervention-induced change in metabolism or function. In current practice, the most commonly performed interventional maneuvers are aimed at studies of the heart, genitourinary system, hepatobiliary system, and gastrointestinal tract. The single most commonly performed interventional study in the United States is the stress Thallium-201 myocardial perfusion scan aimed at the diagnosis of coronary artery disease. The stress portion of the study is accomplished with dynamic leg exercise on a treadmill and is aimed at increasing myocardial oxygen demands. Areas of myocardium distal to hemodynamically significant lesions in the coronary arteries become ischemic at peak stress due to the inability of the stenotic vessel to respond to the oxygen demand/blood flow needs of the myocardium. Ischemic areas are readily recognized as photopenic defects on scans obtained immediately after exercise, with "normalization" upon delayed imaging. Diuresis renography is aimed at the differential diagnosis of hydroureteronephrosis. By challenging the urinary tract collecting structures with an augmented urine flow, dilated, unobstructed systems can be differentiated from systems with significant mechanical obstruction. Obstructed systems have a low ability to respond even after effective diuresis, resulting in a characteristic prolonged retention of the radiotracer. Hepatobiliary interventions are most commonly employed in the clinical setting of suspected acute cholecystitis. Administering a cholecystogogue before a hepatobiliary tracer promotes visualization of the gallbladder by causing it to go through a contraction/filling cycle in which the filling phase occurs during maximum exposure to the radionuclide. This maneuver can convert a false positive study that suggests the presence of acute cholecystitis to a true negative study. Other gastrointestinal interventions are aimed at enhancing the detection of gastroesophageal reflux and gastrointestinal bleeding. Many new interventions have been developed that are currently aimed at research problems rather than clinical problems.(ABSTRACT TRUNCATED AT 400 WORDS)
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PMID:Diagnostic interventions in nuclear medicine. 264 73

Noncardiac chest pain remains an enigma that often defies precise diagnosis. Overlap of symptoms between esophageal and cardiac disorders may make differentiation extremely difficult. Exclusion of coronary artery disease is a key element of the management of noncardiac chest pain. Once this is accomplished, the physician can address the fears and concerns of the patient with confidence and often avoid any diagnostic studies of the esophagus. When diagnostic studies are performed, the physician should be mindful of their limitations. Since gastroesophageal reflux disease is probably the most common cause of esophageal chest pain, prompt recognition and treatment of this disorder may provide relief for many patients. Future studies should address the relationship between physiologic events in the esophagus and chest pain.
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PMID:Noncardiac chest pain. There's often an esophageal cause. 267 66


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