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Changing Focus on Unexplained Esophageal Chest Pain
- Raj K. Goyal, MD
- Department of Veterans Affairs Medical Center, West Roxbury, MA 02132 Acknowledgments: The author thanks Donna Kantarges and Lisa Underhill for help with manuscript preparation. Grant Support: By grant DK 31092 from the National Institutes of Health. Requests for Reprints: Raj K. Goyal, MD, Research and Development Service (151), Department of Veterans Affairs Medical Center, 1400 VFW Parkway, West Roxbury, MA 02132.
In this issue, two articles [1, 2] address aspects of esophageal chest pain, including the importance of reflux esophagitis, esophageal motility disorders, and esophageal sensory disorder in noncardiac chest pain.
Coronary artery disease and reflux esophagitis are common clinical disorders [3]. In their classic presentations, coronary ischemia with exertional angina and reflux esophagitis with heartburn and acid regurgitation can be easily diagnosed. However, the pain in these two disorders is usually atypical. Because coronary artery disease is so serious, patients who have atypical chest pain are first evaluated for this disorder. Patients with strong indications of coronary artery disease (exertional angina-like pain, cardiac risk factors, and abnormal stress test results) have coronary angiography. However, one third to one half of these patients have no substantial coronary lesions and are categorized as having noncardiac chest pain. In this issue, Frobert and colleagues [1] report the results of their investigation into how frequently reflux esophagitis occurs in selected patients with noncardiac chest pain.
Using long-term pH monitoring, the authors found no difference in the esophageal reflux index between patients and controls. In this series, however, 16% of patients and no controls had a positive esophageal acid perfusion test result, suggesting that these patients may have reflux esophagitis or a so-called irritable esophagus [4]. Other studies [4, 5] have reported higher frequencies of reflux esophagitis in patients with noncardiac chest pain than in controls. These differences may reflect meaningful biological associations but may also indicate some bias in the selection of patients who had coronary angiography and the lack of a uniform definition of noncardiac or unexplained chest pain. Thus, although routine testing for reflux esophagitis in patients with noncardiac chest pain (as defined by Frobert and colleagues [1]) may not produce pain, it may be prudent to rule out reflux …
