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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

The study was carried out on 18 patients with angina pectoris in whom the usual treatment with nitroderivatives and/or Ca-antagonists did not improve or prevent the angina-like chest pain in the absence of unstable angina. The patients underwent the following oesophageal examinations: X-ray, endoscopy-biopsy, manometry, acid perfusion test and 24-hour oesophageal pH ambulatory monitoring, the latter two being made in association with dynamic ECG. The presence of coronary insufficiency had been previously determined by means of ECG and scintigraphic stress tests and, when necessary, coronary arteriography was performed. In 10/18 patients severe oesophageal motor disorders were observed, the most frequent being diffuse oesophageal spasm. In the entire group the lower oesophageal sphincter basal tone was significantly lower than normal. In 14/18 patients a pathologic gastroesophageal reflux was detected: in 2 of these patients a temporal correlation between pain attacks and episodes of gastroesophageal reflux were observed in the absence of ECG modifications. Acid perfusion test induced the angina-like chest pain in another 2 patients without ECG modifications. In conclusion, the angina-like chest pain of these patients is not due to a failure of the antianginal therapy in relieving the coronary insufficiency, but is most probably related to gastroesophageal reflux. This oesophageal disorder may be considered a side effect caused by prolonged therapy with nitroderivatives and Ca-antagonists. In fact, these drugs decrease the lower oesophageal sphincter tone which is the main barrier against the reflux of gastric contents into the oesophagus so favoring gastroesophageal reflux and related disorders, including oesophageal pain.
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PMID:"Oesophageal angina" in patients with angina pectoris: a possible side effect of chronic therapy with nitroderivates and Ca-antagonists. 139 24

Gastroesophageal reflux disease (GERD) refers to symptoms or tissue damage that result from gastroesophageal reflux. Reflux esophagitis is a subset of GERD and implies the presence of esophageal inflammation, ie, esophageal erosions that are visible endoscopically, or nonerosive inflammation that can be documented by biopsies. Heartburn is the most common and specific symptom of GERD. In some patients, chest pain or respiratory symptoms may be the only presenting signs. In patients aged < 50 years with uncomplicated GERD, empiric therapy (typically with antacids or an H2-receptor antagonist) is appropriate. For older patients, those with complications, and those whose symptoms do not respond to empiric therapy, endoscopic evaluation is indicated. Many patients will improve with standard twice-daily dosing of an H2-receptor antagonist. However, GERD is generally more resistant to antisecretory pharmacologic therapy than is peptic ulcer disease. Those patients who fail to respond to standard dosing of an H2-receptor antagonist may get relief from high-dose H2-receptor antagonists or omeprazole therapy.
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PMID:Gastroesophageal reflux disease in adults: pathophysiology, diagnosis, and management. 145 52

This study investigates 113 consecutive patients with gastro-oesophageal reflux disease before and after fundoplication and crural repair with respect to symptomatic improvement of chest pain, angina pectoris, exercise-linked chest pain, meal-linked chest pain, dyspnea, and air hunger, and any correlation between these items and smoking habits. The patients were followed by identical questionnaires completed at the time of oesophageal manometric examination prior to operation and from 6 months up to more than 5 years after operation. There was a highly significant reduction in all kinds of chest pain including angina pectoris, and of dyspnea at follow-up independent of smoking habits. However, air hunger was not significantly reduced. The present results suggest that gastro-oesophageal reflux disease should be taken into consideration in the symptomatic diagnosis of angina pectoris.
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PMID:Remission of angina pectoris and dyspnea by fundoplication in gastro-oesophageal reflux disease. 148 38

During the last five years, 672 patients were referred to our esophageal investigation unit; 110 patients (16.3%) of these presented with chest pain of undetermined etiology (CPUE) alone. Since the nature of this pain is intermittent and rarely present during the diagnostic study, acid perfusion and intravenous edrophonium tests were added as provocative tests after baseline esophageal manometry. Following completion of the motility studies, 24-hr pH study was performed to detect gastroesophageal reflux (GER). Twenty-nine patients (26.4%) had positive acid perfusion (APT) test whereas 26 patients (23.6%) had positive edrophonium test (ET). In the group of patients with positive acid perfusion test, 12/29 (41.3%) had GER, 8/29 (27.5%) had both motility disorder and GER, 2/29 (6.8%) had motility disorder, and 7/29 (24.1%) had normal esophageal motility and 24-hr pH studies. In the other group, 13/26 (50%) had motility disorder and 13/26 (50%) had both motility disorder and GER. There were no significant differences between the two tests as far as reproducibility of symptoms was concerned. We conclude that ATP and ET showed the esophageal origin of CPUE in half of our patients and therefore in a substantial percentage of patients the esophageal origin of chest pain will remain very difficult to prove.
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PMID:Acid perfusion and edrophonium provocation tests in patients with chest pain of undetermined etiology. 149 45

The diagnosis of gastroesophageal reflux disease (GERD) entails the identification of patients with esophagitis and its complications as well as patients who have symptoms but no mucosal disease. Endoscopy is mandatory to establish a diagnosis of reflux esophagitis, to exclude other esophageal disease and to permit directed biopsy if columnar metaplasia, dysplasia or carcinoma is suspected. The lesions of reflux esophagitis--erosions, ulceration, stricturing and metaplasia--should be identified and graded independently, using a classification system such as the recently described "MUSE" (Metaplasia, Ulcer, Stricture, Erosions) system. Fluoroscopy can identify associated structural changes such as stricturing or esophageal shortening. Measures of esophageal acid exposure time may be used to quantify reflux before and after treatment; however, if the patient has typical symptoms but no esophagitis, a temporal association between symptoms and episodes of esophageal acidification should be sought. Ambulatory 24-hour esophageal pH-monitoring with accurate event-marking provides recordings suitable for an objective statistical analysis, which was evaluated prospectively in 14 patients. Computerized analysis of 24-hour esophageal pH recordings diagnosed 5 patients as having acid-related symptoms although only 3 of 5 patients fulfilling the criteria for pathological reflux had pH-related chest pain. This finding was confirmed by 5 experts who analyzed all recordings visually, unaware of the result of the computer analysis. The Bernstein test should be reserved for patients whose symptoms are too infrequent to permit an objective assessment of symptom occurrence during pH monitoring. In conclusion, i) endoscopy is the test of choice for the diagnosis of esophagitis but it should be supplemented by a standardized and reliable scoring system for disease severity; ii) ambulatory esophageal pH recording with accurate event-marking is the test of choice for the diagnosis of GER-related symptoms, but it should be supplemented by an objective assessment of the temporal relationship between symptoms and esophageal pH; and iii) esophageal manometry is the test of choice for evaluating esophageal peristalsis and LES (lower esophageal sphincter) function but, in the context of GERD, its main indication is the assessment of GERD patients who are being considered for surgery. The widespread use of other tests for clinical purposes must await a better understanding of the pathophysiological mechanisms which can lead to the development of GERD.
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PMID:Diagnostic assessment of gastroesophageal reflux disease: what is possible vs. what is practical? 157 93

Recurrent chest pain in patients with normal coronary arteries is a difficult clinical problem. Although long-term studies have shown that these patients have an excellent prognosis in terms of cardiac morbidity and mortality, many patients remain physically debilitated and continue to visit emergency departments. Recent information suggests that microvascular angina, esophageal disorders (including reflux disease and dysmotility), and panic disorder may be important causes of pain in such patients. It is particularly important to consider the diagnosis of gastroesophageal reflux disease, which is easier to diagnose and treat than most other causes of recurrent chest pain.
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PMID:Chest pain in patients with normal coronary arteries. A new look at potential causes. 157 28

Patients with unexplained chest pain represent a major clinical dilemma for primary-care physicians, gastroenterologists, and cardiologists. References to this prevalent clinical problem date to more than 150 years ago; confusion about its pathophysiology has resulted in the use of a variety of descriptive terms such as "noncardiac," "atypical," and "angiographically negative" chest pain. Since none of these terms applies to all cases, the description "chest pain of undetermined origin" may be preferable. Because the esophagus has a similar location and innervation as the heart, an esophageal source for unexplained chest pain syndromes has been frequently suggested. Recent studies have emphasized the importance of gastroesophageal reflux as a likely component of esophageal pain. Moreover, "irritable esophagus" is an emerging concept that implies a generalized alteration in esophageal pain threshold, that is, abnormal nociception. The potential effects of stress or altered psychological states in this phenomenon must be considered, and the role of "panic attacks" in the production of pain in these patients needs to be clarified. In addition, stress may produce altered esophageal motility and lead to manometric abnormalities such as the "nutcracker esophagus" or a hypertensive lower esophageal sphincter. Finally, the precise contribution of the heart in producing pain in patients with normal coronary angiograms remains unclear because the precise role of microvascular angina has yet to be clarified.
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PMID:Chest pain of undetermined origin: overview of pathophysiology. 159 59

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


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