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Current Treatment Options in Gastroenterology

, Volume 14, Issue 4, pp 429–443 | Cite as

How to Diagnose and Treat Functional Chest Pain

  • Jose M. Remes-TrocheEmail author
Motility (H Parkman and R Schey, Section Editors)
Part of the following topical collections:
  1. Topical Collection on Motility

Opinion statement

Chest pain that is not explained by reflux disease or cardiac, musculoskeletal, mucosal, or motor esophageal abnormalities is classified as functional chest pain (FCP). Although several mechanisms are involved, esophageal hypersensitivity plays a major role and it could be considered a biomarker for FCP. Psychologic comorbidity such as anxiety, neuroticism, depression, and somatization is common. When the diagnosis of FCP is suspected, patients should undergo evaluation with esophageal motility testing, endoscopy, 24-h esophageal pH monitoring, and in some cases, sensory tests. Once the diagnosis of FCP has been established, treatment options rely on controlling patients’ symptoms. Medical treatment has focused predominantly on medications that target pain, such as antidepressants and other pain neuromodulators. Non-pharmacologic interventions with complementary behavioral treatments, such as cognitive behavioral therapy, biofeedback, and hypnosis, have recently been recognized as useful in FCP patients. The latest findings on the evaluation and treatment of FCP are outlined herein.

Keywords

Functional chest pain Antidepressants Pain modulators Esophagus Hypersensitivity 

Notes

Compliance with Ethical Standards

Conflict of Interest

José Maria Remes-Troche has served as a member of the advisory board for Commonwealth, Allergan and Carnot; has received grant support for research from Sanfer and Asofarma; and also has served as speaker for Takeda, Allergan, Carnot, Menarini and Sanfer.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References and Recommended Reading

Recently published papers of particular interest have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Eslick GD, Coulshed DS, Talley NJ. Review article: the burden of illness of non-cardiac chest pain. Aliment Pharmacol Ther. 2002;16:1217–23.CrossRefPubMedGoogle Scholar
  2. 2.
    Webster R, Norman P, Goodacre S, Thompson A. The prevalence and correlates of psychological outcomes in patients with acute non-cardiac chest pain: a systematic review. Emerg Med J. 2012;29(4):267–73.CrossRefPubMedGoogle Scholar
  3. 3.
    Hsia RY, Hale Z, Tabas JA. A national study of the prevalence of life-threatening diagnoses in patients with chest pain. JAMA Intern Med. 2016;176(7):1029–32.CrossRefPubMedGoogle Scholar
  4. 4.
    Ford AC, Suares NC, Talley NJ. Meta-analysis: the epidemiology of noncardiac chest pain in the community. Aliment Pharmacol Ther. 2011;34(2):172–80.CrossRefPubMedGoogle Scholar
  5. 5.
    Thompson WG, Irvine EJ, Pare P, Ferrazzi S, Rance L. Functional gastrointestinal disorders in Canada: first population-based survey using Rome II criteria with suggestions for improving the questionnaire. Dig Dis Sci. 2002;47:225–35.CrossRefPubMedGoogle Scholar
  6. 6.•
    Fass R, Navarro-Rodriguez T. Non cardiac chest pain. J Clin Gastroenterol. 2008;42:636–46. This article provides an excellent review of the mechanisms involved in FCP, its diagnosis and treatment.CrossRefPubMedGoogle Scholar
  7. 7.
    Fass R, Dickman R. Non-cardiac chest pain: an update. Neurogastroenterol Motil. 2006;18:408–17.CrossRefPubMedGoogle Scholar
  8. 8.
    Cheung TK, Hou X, Lam KF, Chen J, Wong WM, Cha H, et al. Quality of life and psychological impact in patients with noncardiac chest pain. J Clin Gastroenterol. 2009;43:13–8.CrossRefPubMedGoogle Scholar
  9. 9.
    Ortiz-Garrido O, Ortiz-Olvera NX, González-Martínez M, Morán-Villota S, Vargas-López G, Dehesa-Violante M, et al. Clinical assessment and health-related quality of life in patients with non-cardiac chest pain. Rev Gastroenterol Mex. 2015;80(2):121–9.PubMedGoogle Scholar
  10. 10.
    Eslick GD, Talley NJ. Non-cardiac chest pain: predictors of health care seeking, the types of health care professional consulted, work absenteeism and interruption of daily activities. Aliment Pharmacol Ther. 2004;20:909–15.CrossRefPubMedGoogle Scholar
  11. 11.••
    Aziz Q, Fass R, Gyawali CP, Miwa H, Pandolfino JE, Zerbib F. Esophageal disorders. Gastroenterology. 2016;150:1368–79. This article provides the most recent Rome IV diagnosis criteria for functional esophageal disorders, including FCP.CrossRefGoogle Scholar
  12. 12.
    Remes-Troche JM. The hypersensitive esophagus: pathophysiology, evaluation, and treatment Options. Curr Gastroenterol Rep. 2010;12:4.CrossRefGoogle Scholar
  13. 13.
    Lembo AJ. Visceral hypersensitivity in noncardiac chest pain. Gastroenterol Clin North Am. 2004;33:55–60.CrossRefPubMedGoogle Scholar
  14. 14.
    Richter JF, Barish CF, Castell DO. Abnormal sensory perception in patients with esophageal chest pain. Gastroenterology. 1986;91:845–52.CrossRefPubMedGoogle Scholar
  15. 15.
    Nasr I, Attaluri A, Hashmi S, Gregersen H, Rao SS. Investigation of esophageal sensation and biomechanical properties in functional chest pain. Neurogastroenterol Motil. 2010;22(5):520–6.PubMedPubMedCentralGoogle Scholar
  16. 16.
    Drewes AM, Schipper KP, Dimcevksi C, Petersen P, Andersen OK, Gregersen H, et al. Multimodal assessment of pain in the esophagus: a new experimental model. Am J Physiol Gastrointest Liver Physiol. 2002;283:G95–103.CrossRefPubMedGoogle Scholar
  17. 17.
    Fass R, Naliboff B, Higa L, Johnson C, Kodner A, Munakata J, et al. Differential effect of long-term esophageal acid exposure on mechanosensitivity and chemosensitivity in humans. Gastroenterology. 1998;115:1363–73.CrossRefPubMedGoogle Scholar
  18. 18.
    Trimble KC, Pryde A, Heading RC. Lowered oesophageal sensory thresholds in patients with symptomatic but not excess gastro-oesophageal reflux: evidence for a spectrum of visceral sensitivity in GORD. Gut. 1995;37:7–12.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Tack J. Is there a unifying role for visceral hypersensitivity and irritable bowel syndrome in non-erosive reflux disease? Digestion. 2008;78 Suppl 1:42–5.CrossRefPubMedGoogle Scholar
  20. 20.
    Remes-Troche JM, Chahal P, Mudipalli R, Rao SS. Adenosine modulates oesophageal sensorimotor function in humans. Gut. 2009;58:1049–55.CrossRefPubMedGoogle Scholar
  21. 21.
    Remes-Troche JM, Attaluri A, Hashmi S, Paulson J, Rao SSC. The role of adenosine in esophageal nociception in patients with functional chest pain. Gastroenterol. 2009;136(5):A-93.Google Scholar
  22. 22.
    Aziz Q, Andersson J, Valind S, Thompson D. Identification of human brain loci processing esophageal sensation using positron emission tomography. Gastroenterology. 1997;113:50–97.CrossRefPubMedGoogle Scholar
  23. 23.
    Willert RP, Woolf CJ, Hobson AR, Delaney C, Thompson DG, Aziz Q. The development and maintenance of human visceral pain hypersensitivity is dependent on the N-methyl-D-aspartate receptor. Gastroenterology. 2004;126:683–92.CrossRefPubMedGoogle Scholar
  24. 24.
    Rao SS, Hayek B, Summers RW. Functional chest pain of esophageal origin: hyperalgesia or motor dysfunction. Am J Gastroenterol. 2001;96:2584–9.CrossRefPubMedGoogle Scholar
  25. 25.
    Balaban DH, Yamamoto Y, Liu J, Pehlivanov N, Wisniewski R, DeSilvey D, et al. Sustained esophageal contraction: a marker of esophageal chest pain identified by intraluminal ultrasonography. Gastroenterology. 1999;116:29–37.CrossRefPubMedGoogle Scholar
  26. 26.
    Pehlivanov N, Liu J, Mittal R. Sustained esophageal contraction: a motor correlate of heartburn symptom. Am J Physio Gastrointest Liver Physiol. 2001;281:G743–51.Google Scholar
  27. 27.
    Clouse RE, Lustman PJ. Psychiatric illness and contraction abnormalities of the esophagus. N Engl J Med. 1983;309:1337–42.CrossRefPubMedGoogle Scholar
  28. 28.
    Olden KW. The psychological aspects of noncardiac chest pain. Gastroenterol Clin North Am. 2004;33:61–7.CrossRefPubMedGoogle Scholar
  29. 29.
    Farmer AD, Coen SJ, Kano M, Naqvi H, Paine PA, Scott SM, et al. Psychophysiological responses to visceral and somatic pain in functional chest pain identify clinically relevant pain clusters. Neurogastroenterol Motil. 2014;26(1):139–48.CrossRefPubMedGoogle Scholar
  30. 30.•
    Hershcovici T, Achem SR, Jha LK, Fass R. Systematic review: the treatment of noncardiac chest pain. Aliment Pharmacol Ther. 2012;35(1):5–14. A comprehensive systematic review regarding all therapeutic options for FCP.CrossRefPubMedGoogle Scholar
  31. 31.
    Cremonini F, Wise J, Moayyedi P, Talley NJ. Diagnosticandtherapeuticuseofproton pump inhibitors in noncardiac chestpain: a meta -analysis. Am J Gastroenterol. 2005;100:1226–32.CrossRefPubMedGoogle Scholar
  32. 32.
    Wang W, Huang J, Zheng G, Wong WM, Lam SK, Karlberg J, et al. Isproton pump inhibitortesting an effectiveapproachtodiagnose gastroesophageal refluxdisease in patientswith noncardiac chestpain? Arch Intern Med. 2005;165:1222–8.CrossRefPubMedGoogle Scholar
  33. 33.
    Pace F, Pace M. The proton pump inhibitor test and the diagnosis of gastroesophageal reflux disease. Expert Rev Gastroenterol Hepatol. 2010;4(4):423–7.CrossRefPubMedGoogle Scholar
  34. 34.
    Hsia PC, Maher KA, Lewis JH, Cattau Jr EL, Fleischer DE, Benjamin SB. Utility of upper endoscopy in the evaluation of noncardiac chest pain. Gastrointest Endosc. 1991;37(1):22–6.CrossRefPubMedGoogle Scholar
  35. 35.
    Frøbert O, Funch-Jensen P, Jacobsen NO, Kruse A, Bagger JP. Upper endoscopy in patients with angina and normal coronary angiograms. Endoscopy. 1995;27(5):365–70.CrossRefPubMedGoogle Scholar
  36. 36.
    Dickman R, Mattek N, Holub J, Peters D, Fass R. Prevalence of upper gastrointestinal tract findings in patients with noncardiac chest pain versus those with gastroesophageal reflux disease (GERD)-related symptoms: results from a national endoscopic database. Am J Gastroenterol. 2007;10(6):1173–9.CrossRefGoogle Scholar
  37. 37.
    Achem SR, Almansa C, Krishna M, Heckman MG, Wolfsen HC, Talley NJ, et al. Oesophageal eosinophilic infiltration in patients with noncardiac chest pain. Aliment Pharmacol Ther. 2011;33:1194–201.CrossRefPubMedGoogle Scholar
  38. 38.
    Katz PO, Dalton CB, Richter JE, Wu WC, Castell DO. Esophageal testing of patients with noncardiac chest pain or dysphagia. Results of three years' experience with 1161 patients. Ann Intern Med. 1987;106(4):593–7.CrossRefPubMedGoogle Scholar
  39. 39.
    Nasr I, Attaluri A, Coss-Adame E, Rao SS. Diagnostic utility of the oesophageal balloon distension test in the evaluation of oesophageal chest pain. Aliment Pharmacol Ther. 2012;35(12):1474–81.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.••
    Kahrilas PJ, Bredenoord AJ, Fox M, Gyawali CP, Roman S, Smout AJ, et al. The Chicago classification of esophageal motility disorders, v3.0. Neurogastroenterol Motil. 2015;27(2):160–74. This document provides the diagnosis criteria for major esophageal motility disorders according high resolution esophageal manometry, the technique considered as the gold-standard.CrossRefPubMedGoogle Scholar
  41. 41.
    Barret M, Herregods TV, Oors JM, Smout AJ, Bredenoord AJ. Diagnostic yield of 24-hour esophageal manometry in non-cardiac chest pain. Neurogastroenterol Motil. 2016. doi: 10.1111/nmo.12818.PubMedGoogle Scholar
  42. 42.
    Richter JE, Hewson EG, Sinclair JW, Dalton CB. Acid perfusion test and 24 -hour esophageal pH monitoring with symptom index. Comparison of tests for esophageal acid sensitivity. Dig Dis Sci. 1991;36:565–71.CrossRefPubMedGoogle Scholar
  43. 43.
    Dekel R, Martinez-Hawthorne SD, Guillen RJ, Fass R. Evaluation of symptom index in identifying gastroesophageal reflux disease -related noncardiac chest pain. J Clin Gastroenterol. 2004;38:24–9.CrossRefPubMedGoogle Scholar
  44. 44.
    Kim BJ, Choi SC, Kim JJ, Rhee JC, Rhee PL. Pathological bolus exposure plays a significant role in eliciting non-cardiac chest pain. J Gastroenterol Hepatol. 2010;25(12):1855–60.CrossRefPubMedGoogle Scholar
  45. 45.
    Prakash C, Clouse RE. Wireless pH monitoring in patients with non-cardiac chest pain. Am J Gastroenterol. 2006;101:446–52.CrossRefPubMedGoogle Scholar
  46. 46.
    Karamanolis G, Triantafillou K, Pasha P, Vlachogiannakos I, Gaglia A, Polymeros D, et al. Bravo 48-hour wireless pH monitoring in patients with non-cardiac chest pain. Objective gastro esophageal reflux disease parameters predict the responses to proton pump inhibitors. Neurogastroenterol Motil. 2012;18(2):169–73.CrossRefGoogle Scholar
  47. 47.
    Fass R. Sensory testing of the esophagus. J Clin Gastroenterol. 2004;38:628–41.CrossRefPubMedGoogle Scholar
  48. 48.
    Rao SS, Gregersen H, Hayek B, Summers RW, Christensen J, et al. Unexplained chest pain: The hypersensitive, hyperreactive, and poorly compliant esophagus. Ann Intern Med. 1996;124:950–8.CrossRefPubMedGoogle Scholar
  49. 49.
    Drewes AM, Schipper KP, Dimcevski G, Petersen P, Andersen OK, Gregersen H, et al. Multi-modal induction and assessment of allodynia and hyperalgesia in the human oesophagus. Eur J Pain. 2003;7(6):539–49.CrossRefPubMedGoogle Scholar
  50. 50.
    Kwiatek MA, Kahrilas K, Soper NJ, Bulsiewicz WJ, McMahon BP, Gregersen H, et al. Esophagogastric junction distensibility after fundoplication assessed with a novel functional luminal imaging probe. J Gastrointest Surg. 2010;14(2):268–76.CrossRefPubMedPubMedCentralGoogle Scholar
  51. 51.
    Lin Z, Kahrilas PJ, Xiao Y, Nicodème F, Gonsalves N, Hirano I, et al. Functional luminal imaging probe topography: an improved method for characterizing esophageal distensibility in eosinophilic esophagitis. Therap Adv Gastroenterol. 2013;6(2):97–10.CrossRefPubMedPubMedCentralGoogle Scholar
  52. 52.
    Pandolfino JE, de Ruigh A, Nicodème F, Xiao Y, Boris L, Kahrilas PJ. Distensibility of the esophagogastric junction assessed with the functional lumen imaging probe (FLIP™) in achalasia patients. Neurogastroenterol Motil. 2013;25(6):496–501.CrossRefPubMedPubMedCentralGoogle Scholar
  53. 53.
    McMahon B, Rao SS, Gregersen H, Kwiatek MA, Pandolfino JE, Drewes AM, et al. Distensibility testing of the esophagus. Ann N Y Acad Sci. 2011;1232:331–40.CrossRefPubMedGoogle Scholar
  54. 54.
    Nguyen TM, Eslick GD. Systematic review: the treatment of noncardiac chest pain with antidepressants. Aliment Pharmacol Ther. 2012;35(5):493–500.CrossRefPubMedGoogle Scholar
  55. 55.•
    Weijenborg PW, de Schepper HS, Smout AJ, Bredenoord AJ. Effects of antidepressants in patients with functional esophageal disorders or gastroesophageal reflux disease: a systematic review. Clin Gastroenterol Hepatol. 2015;13(2):251–9. This paper is the most recent systematic review regarding antidepressants as a pain modular for functional esophageal disorders. This study concludes that imipramine, sertraline and venlafaxine are useful for symptomatic control in FCP.CrossRefPubMedGoogle Scholar
  56. 56.
    Cannon 3rd RO, Quyyumi AA, Mincemoyer R, Stine AM, Gracely RH, Smith WB, et al. Imipramine in patients with chest pain despite normal coronary angiograms. N Engl J Med. 1994;330:1411–7.CrossRefPubMedGoogle Scholar
  57. 57.
    Cox ID, Hann CM, Kaski JC. Low dose imipramine improves chest pain but not quality of life in patients with angina and normal coronary angiograms. Eur Heart J. 1998;19:250–4.CrossRefPubMedGoogle Scholar
  58. 58.
    Varia I, Logue E, O’connor C, Newby K, Wagner HR, Davenport C, et al. Randomized trial of sertraline in patients with unexplained chest pain of noncardiac origin. Am Heart J. 2000;140:367–72.CrossRefPubMedGoogle Scholar
  59. 59.
    Lee H, Kim JH, Min BH, Lee JH, Son HJ, Kim JJ, et al. Efficacy of venlafaxine for symptomatic relief in young adult patients with functional chest pain: a randomized, double-blind, placebo-controlled, crossover trial. Am J Gastroenterol. 2010;105:1504–12.CrossRefPubMedGoogle Scholar
  60. 60.
    Doraiswamy PM, Varia I, Hellegers C, Wagner HR, Clary GL, Beyer J, et al. A randomized controlled trial of paroxetine for noncardiac chest pain. Psychopharmacol Bull. 2006;39:15–24.PubMedGoogle Scholar
  61. 61.
    Spinhoven P, Van der Does AJ, Van Dijk E, Van Rood YR. Heart-focused anxiety as a mediating variable in the treatment of noncardiac chest pain by cognitive-behavioral therapy and paroxetine. J Psychosom Res. 2010;69:227–35.CrossRefPubMedGoogle Scholar
  62. 62.
    Clouse RE, Lustman PJ, Eckert TC, Ferney DM, Griffith LS. Low-dose trazodone for symptomatic patients with esophageal contraction abnormalities. A double-blind, placebo-controlled trial. Gastroenterology. 1987;92:1027–36.CrossRefPubMedGoogle Scholar
  63. 63.
    Stahl SM. Mechanism of action of trazodone: a multifunctional drug. CNS Spectr. 2009;14(10):536–46.CrossRefPubMedGoogle Scholar
  64. 64.
    Fagiolini A, Comandini A, Dell’Osso MC, Kasper S. Rediscovering trazodone for the treatment of major depressive disorder. CNS Drugs. 2012;26(12):1033–49.CrossRefPubMedPubMedCentralGoogle Scholar
  65. 65.
    Handa M, Mine K, Yamamoto H, Hayashi H, Tsuchida O, Kanazawa F, et al. Antidepressant treatment of patients with diffuse esophageal spasm: a psychosomatic approach. J Clin Gastroenterol. 1999;28:228–32.CrossRefPubMedGoogle Scholar
  66. 66.
    Atluri DK, Chandar AK, Fass R, Falck-Ytter Y. Systematic review with meta-analysis: selective serotonin reuptake inhibitors for noncardiac chest pain. Aliment Pharmacol Ther. 2015;41(2):167–76.CrossRefPubMedGoogle Scholar
  67. 67.
    Viazis N, Keyoglou A, Kanellopoulos AK, Karamanolis G, Vlachogiannakos J, Triantafyllou K, et al. Selective serotonin reuptake inhibitors for the treatment of hypersensitive esophagus: a randomized, double-blind, placebo-controlled study. Am J Gastroenterol. 2012;107(11):1662–7.CrossRefPubMedGoogle Scholar
  68. 68.
    Malik Z, Bayman L, Valestin J, Rizvi-Toner A, Hashmi S, Schey R. Dronabinol increases pain threshold in patients with functional chest pain: a pilot double-blind placebo-controlled trial. Dis Esophagus. 2016. doi: 10.1111/dote.12455.Google Scholar
  69. 69.
    Rodriguez-Stanley S, Zubaidi S, Proskin HM, Kralstein JR, Shetzline MA, Miner Jr PB. Effect of tegaserod on esophageal pain threshold, regurgitation and symptom relief in patients with functional heartburn and mechanical sensitivity. Clin Gastroenterol Hepatol. 2006;4:442–50.CrossRefPubMedGoogle Scholar
  70. 70.
    Rao SS, Mudipalli RS, Remes-Troche JM, Utech CL, Zimmerman B. Theophylline improves esophageal chest pain--a randomized, placebo-controlled study. Am J Gastroenterol. 2007;102:930–8.CrossRefPubMedGoogle Scholar
  71. 71.
    Rao SS, Mudipalli RS, Mujica V, Utech CL, Zhao X, Conklin JL. An open-label trial of theophylline for functional chest pain. Dig Dis Sci. 2002;12:2763–8.CrossRefGoogle Scholar
  72. 72.
    Kirch S, Gegg R, Johns MM, Rubin AD. Globus pharyngeus: effectiveness of treatment with proton pump inhibitors and gabapentin. Ann Otol Rhinol Laryngol. 2013;122:492–5.CrossRefPubMedGoogle Scholar
  73. 73.
    van Peski-Oosterbaan AS, Spinhoven P, van Rood Y, van der Does JW, Bruschke AV, Rooijmans HG. Cognitive-behavioral therapy for noncardiac chest pain: a randomized trial. Am J Med. 1999;106:424–9.CrossRefPubMedGoogle Scholar
  74. 74.
    Klimes I, Mayou RA, Pearce MJ, Coles L, Fagg JR. Psychological treatment for atypical non-cardiac chest pain: a controlled evaluation. Psychol Med. 1990;203:605–11.CrossRefGoogle Scholar
  75. 75.
    Mayou RA, Bryant BM, Sanders D, Bass C, Klimes I, Forfar C. A controlled trial of cognitive behavioural therapy for non-cardiac chest pain. Psychol Med. 1997;27:1021–31.CrossRefPubMedGoogle Scholar
  76. 76.
    Jonsbu E, Dammen T, Morken G, Moum T, Martinsen EW. Short-term cognitive behavioral therapy for non-cardiac chest pain and benign palpitations: a randomized controlled trial. J Psychosom Res. 2011;70:117–23.CrossRefPubMedGoogle Scholar
  77. 77.
    Coss-Adame E, Rao SS. A review of esophageal chest pain. Gastroenterol Hepatol (NY). 2015;11(11):759–66.Google Scholar
  78. 78.
    Kuijpers PM, Denollet J, Wellens HJ, Crijns HM, Honig A. Noncardiac chest pain in the emergency department: the role of cardiac history, anxiety or depression and Type D personality. Eur J Cardiovasc Prev Rehabil. 2007;14(2):273–9.CrossRefPubMedGoogle Scholar
  79. 79.
    Webster R, Thompson Norman P, Goodacre SA. The acceptability and feasibility of an anxiety reduction intervention for emergency department patients with non-cardiac chest pain. Psychol Health Med. 2016;29:1–11.Google Scholar
  80. 80.
    Riehl ME, Kefer L. Hypnotherapy for esophageal disorders. Am J Clin Hypn. 2015;58(1):22–33.CrossRefPubMedPubMedCentralGoogle Scholar
  81. 81.
    Jones H, Cooper P, Miller V, Brooks N, Whorwell PJ. Treatment of non-cardiac chest pain: a controlled trial of hypnotherapy. Gut. 2006;55:403–1408.CrossRefGoogle Scholar
  82. 82.
    Shapiro M, Shanani R, Taback H, Abramowich D, Scapa E, Broide E. Functional chest pain responds to biofeedback treatment but functional heartburn does not: what is the difference? Eur J Gastroenterol Hepatol. 2012;24(6):708–14.CrossRefPubMedGoogle Scholar
  83. 83.
    Gasiorowska A, Navarro-Rodriguez T, Dickman R, Wendel C, Moty B, Powers J, et al. Clinical trial: the effect of Johrei on symptoms of patients with functional chest pain. Aliment Pharmacol Ther. 2009;29(1):126–34.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2016

Authors and Affiliations

  1. 1.Digestive Physiology and Gastrointestinal Motility Laboratory, Medical-Biological Research Institute (IIMB)Universidad VeracruzanaVeracruzMexico
  2. 2.College of Medicine Miguel Aleman ValdesVeracruzMexico
  3. 3.Digestive Physiology and Motility LaboratoryUniversity of Veracruz, Veracruz, MéxicoVeracruzMexico

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