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[Diagnostic evaluation of the patient with esophageal chest pain: our experience]
E Bovero1, M Poletti, F De Iaco
1Divisione di Gastroenterologia ed Endoscopia Digestiva, Ospedale San Martino, Genova.
Insights
This study highlights how gastroesophageal reflux, including non-acid types, causes chest pain in many patients. Combining esophageal monitoring with provocative tests improves diagnosis of reflux-induced pain.
Area of Science:
- Gastroenterology and Cardiology
- Esophageal physiology
- Differential diagnosis of chest pain
Context:
- Chest pain often mimics cardiac issues, necessitating a "cardio-esophageal" differential diagnosis.
- Collaboration between gastroenterology and cardiology is crucial for accurate diagnosis.
- Standard diagnostic methods require enhancement for complex cases.
Purpose:
- To investigate the diagnostic utility of combined esophageal function tests and provocative maneuvers for angina-like chest pain.
- To correlate gastroesophageal reflux events with symptom presentation.
- To evaluate the role of non-acid reflux in symptom generation.
Summary:
- Prolonged gastroesophageal pH monitoring, coupled with electrocardiographic monitoring, identified reflux as the cause of pain in 63% of patients.
- Non-acid reflux (mixed and alkaline) showed a significant association with pain.
- Provocative tests, including stress tests, esophageal distension, and electrostimulation, increased diagnostic yield by 15.5% compared to pH monitoring alone.
Impact:
- Improved diagnostic accuracy for chest pain of unclear origin.
- Enhanced understanding of the role of various reflux types in symptom manifestation.
- Provides a framework for integrating esophageal testing with cardiac evaluations for better patient outcomes.
Abstract:
Our experience in the field of the "cardio-esophageal" differential diagnosis of angina-like pain derives from the close cooperation between the Divisions of Gastroenterology and Cardiology. Commonly applied tests of esophageal function, always performed during electrocardiographic monitoring, are prolonged gastro-esophageal pH monitoring plus the adoption, as provocative tests, of the stress test in the course pH monitoring, of endo-esophageal distension and of electrostimulation in the course of manometry. An evaluation of prolonged pH monitoring tracings is performed not solely to locate a quantitatively pathological reflux, but especially to identify temporal correlations between the symptoms and the reflux. This explains how we were able to relate pain to reflux in 63% of the patients who took the test. Furthermore, use of esophagogastric monitoring makes it possible to identify the critical share of the non-acid reflux, i.e. mixed (21%) or alkaline (6%). Episodes of non-acid reflux feature a significantly higher rate of association with pain than acid reflux (12.5% of symptomatic acid refluxes, versus 6% of symptomatic acid refluxes, versus 6% of mixed refluxes and 7.15% of alkaline refluxes). Execution of an ergometric test, performed according to routine cardiologic procedures during pH monitoring, constitutes a valid stimulation for reflux-dependent pain, enabling us to achieve a diagnostic gain of 15.5% compared to pH monitoring alone. As stated, elicitation of pain by motor causes is performed using endo-esophageal distension (positive in 30% of cases) and with electrostimulation, a new test studied at our center.(ABSTRACT TRUNCATED AT 250 WORDS)