Esophageal Chest Pain

Abstract

Esophageal chest pain has come under critical scrutiny recently [1]. Motility disorders in particular have fallen out of favor as a cause of chest pain [1–3], to the extent that chest pain of uncertain origin has now become a rare indication for esophageal manometry in the United States [4]. The reasons for this include changing perceptions about the relevance of the commonest manometric diagnosis, the so called “nutcracker esophagus” [2,3,5], the effect of stress on manometric parameters [2,6], the lack of response of chest pain to motility modifying drugs [7] and the finding in several studies employing prolonged ambulatory motility recording that chest pain events in patients with chest pain of uncertain origin are rarely accompanied by disturbances of esophageal motility [8-10]. Gastro-esophageal reflux (GOR) remains the single commonest disorder resulting in atypical chest pain [11,12], but it will continue to remain unrecognized and untreated without appropriate investigation: indeed, the importance of carrying out 24 hour esophageal pH monitoring in all such individuals, even those with manometric abnormalities, though proposed more than 12 years ago [11,12], has only gradually received acceptance [13,14]. Abnormal esophageal sensory perception is an emerging concept, with new conditions of hypersensitive, hyperreactive [15] or irritable esophagus [16] being proposed. The value of provocation with esophageal acid perfusion [17] and pharmacological agents such as edrophonium [18] has been called into question. There is however a danger of allowing the pendulum to swing too far: it is premature to dismiss provocation tests and motility disorders entirely. The aim of this review is to provide a balanced overview with particular emphasis on the value of gastroenterological investigations in patients with chest pain of uncertain origin.