Noncardiac chest pain

Abstract

GERD is the most common esophageal cause of NCCP, followed by functional chest pain and esophageal dysmotility. The proton pump inhibitor test, upper endoscopy, wireless pH capsule and pH-impedance are used to identify GERD-induced NCCP. High-resolution esophageal manometry is the main tool to identify esophageal motor disorder in non-GERD-related NCCP. Negative diagnostic assessment suggests functional chest pain. Potent antireflux treatment is offered to patients with GERD-related NCCP; medical, endoscopic or surgical interventions are considered in esophageal dysmotility; and neuromodulators are prescribed for functional chest pain. Assessment and treatment of psychological comorbidity should be considered in all NCCP patients.

Extra-Esophageal Presentation of Gastroesophageal Reflux Disease: 2020 Update

“…Chest pain is a common presentation to emergency departments [69], although only 25% of individuals who experience this symptom present to a hospital [70]. Beyond GERD (30-60% of cases), other esophageal causes of NCCP are esophageal dysmotility (15-30%) and esophageal hypersensitivity [68,69,71], alone or in combination.…”

“…The 24-h pH monitoring permits revealing reflux events by identifying pH reductions, with abnormal findings in 40-50% of the cases [71]. The AGA suggest using together with esophageal pH recording a symptom reflux association scheme to accurately diagnose when the chest pain symptom is due to gastroesophageal reflux [71]. The impact of pH-impedance measurement is relevant in patients who do not have esophagitis and do not respond to anti-secretory therapy.…”

“…The impact of pH-impedance measurement is relevant in patients who do not have esophagitis and do not respond to anti-secretory therapy. In fact, some patients experience chest pain triggered by non-acid reflux, which is identifiable by impedance measurement but not pH monitoring [71].…”

“…In these patients, a non-pathological reflux (based on characteristics or duration) triggers painful symptoms, such as heartburn or chest pain. Visceral hypersensitivity increases the perception of stimuli due to neuronal hyperexcitability as peripheral sensitization of esophageal sensory afferents and modulation of afferent neural function at the spinal dorsal root or the central nervous system [71]. Esophageal sensitivity has been studied by instilling hydrochloric acid into the distal esophagus in subjects affected by NCCP and healthy volunteers: all patients with NCCP had a reproduction of their pain during instillation.…”

“…NCCP is associated with psychological diseases, such as panic disorder, anxiety, and depression, which can cause chest pain independently from GERD or enhance reflux perception [71,92]. Of all the GERD-related EE manifestations, chest pain is the most associated to psychometric abnormalities.…”