Esophageal Mast Cell Infiltration in a 32-Year-Old Woman with Noncardiac Chest Pain

Noncardiac chest pain (NCCP) is one of the most common esophageal symptoms and lacks a clearly defined mechanism. The most common cause of NCCP is gastroesophageal reflux disease (GERD). One of the accepted mechanisms of NCCP in a patient without GERD has been altered visceral sensitivity. Mast cells may play a role in visceral hypersensitivity in irritable bowel syndrome. In this case, a patient with NCCP and dysphagia who was unresponsive to proton pump inhibitor treatment had an increased esophageal mast cell infiltration and responded to 14 days of antihistamine and antileukotriene treatment. We suggest that there may be a relationship between esophageal symptoms such as NCCP and esophageal mast cell infiltration.

Noncardiac Chest Pain: Update on the Diagnosis and Management / 대한소화기학회지

Noncardiac chest pain (NCCP) is defined as recurring, angina-like, retrosternal chest pain of noncardiac origin. Although patients with NCCP have excellent long-term prognosis, most suffer persistently from their symptoms. Several pathophysiological mechanisms have been suggested, including gastroesophageal reflux disease (GERD), esophageal motility disorder, esophageal hypersensitivity, and psychological comorbidity. Among them, GERD is the most common cause of NCCP. Therefore, GERD should first be considered as the underlying cause of symptoms in patients with NCCP. Empirical proton pump inhibitor (PPI) treatment with a preferably double dose for more than 2 months could be cost-effective. PPI test can also be used for diagnosis of GERD-related NCCP, but it should be considered for patients with NCCP occurring at least weekly and its duration should be at least 2 weeks. However, upper endoscopy and esophageal pH monitoring are necessary when the diagnosis of GERD is uncertain. Esophageal impedance-pH monitoring could further improve the diagnostic yield. Patients with GERD-related NCCP should preferably be treated with a double dose PPI until symptoms remit (may require more than 2 months of therapy for optimal symptom control), followed by dose tapering to determine the lowest PPI dose that can control symptoms. However, treatment of patients with non-GERD-related NCCP is challenging. An empirical treatment of antidepressants could be considered. If there are specific esophageal motility disorders, smooth muscle relaxants or endoscopic treatment may be considered in selected cases. If none of these traditional treatments is effective, a psychology consultation for cognitive behavioral therapy should be considered.

Clinical Approach on the Management for Patients with Noncardiac Chest Pain in Korea / 대한내과학회지

Gastroesophageal reflux disease (GERD) is the most common cause of noncardiac chest pain (NCCP). An empirical trial with a proton pump inhibitor (the PPI test) was introduced as a non-invasive, readily available alternative diagnostic tool for NCCP. So, PPI test is known to be the first diagnostic step for NCCP. In Korea, in contrast to Western countries, patients with NCCP but who are without alarming features have been recommended to undergo esophagogastroduodenoscopy (EGD) to exclude gastric cancer or peptic ulcers because of the higher prevalence of peptic ulcer disease and gastric cancers in the region. However, there are only a few small sized studies in Korea. The report of Pyo et al. showed that out of 349 NCCP patients, reflux esophagitis was diagnosed in 35 patients (10.0%), peptic ulcer in 48 patients (13.8%) and gastric cancer in 1 patient. This result suggests that in Korea, unlike the West, stomach/duodenal lesions other than GERD are common causes of NCCP. Therefore, in Korea, prior to PPI test or empirical therapy, performing EGD is necessary for evaluating NCCP to rule out gastroduodenal lesions. Furthermore, a large scaled prospective study is needed to assess the accurate relation of endoscopic findings and chest pain.

Necessity of Upper Gastrointestinal Endoscopy in Patients with Noncardiac Chest Pain / 대한내과학회지

BACKGROUND/AIMS: Gastroesophageal reflux disease (GERD) is the most frequent cause of noncardiac chest pain (NCCP) in Western countries. Gastroduodenal disease has a high prevalence in Korea; thus, it is important to evaluate the stomach/duodenum. We retrospectively reviewed the findings in patients with chest pain who were diagnosed by coronary angiography (CAG) to be normal or who had minimal coronary lesions to evaluate the necessity of performing esophagogastroduodenoscopy (EGD) in patients with NCCP. METHODS: A total of 565 patients with chest pain underwent CAG followed by EGD from February 2000 to March 2011 at Konyang University Hospital. We excluded patients who underwent EGD more than 3 days after CAG or had significant coronary lesions. We retrospectively reviewed the EGD findings of the remaining 349 patients. RESULTS: Of the 349 patients, 151 were male, and the average age of the patients was 57.7+/-11.44 years. After performing EGD, GERD was diagnosed in 35 patients (10.0%; LA [Los Angeles classification]-A, 30; LA-B, three; LA-C, two) and peptic ulcer was diagnosed in 48 patients (13.8%; gastric ulcer, 34; duodenal ulcer, 10; gastric and duodenal ulcer, four). Gastritis was diagnosed in 253 patients (72.5%; erosive, 89; erythematous, 90; hemorrhagic, 10; mixed, 64). Duodenitis, esophagitis, Barrett's esophagus, hiatus hernia, and gastric cancer was diagnosed in 36 (10.3%), three (0.9%), two (0.6%), three (0.9%), and one patient, respectively. CONCLUSIONS: Unlike the situation in the west, stomach/duodenal lesions other than GERD are common causes of NCCP in Korea, Therefore, prior to proton pump inhibitor testing or empirical therapy, EGD is necessary to evaluate NCCP and to rule out gastroduodenal lesions.

Recent Advances in Noncardiac Chest Pain in Korea

Gastroesophageal reflux disease (GERD) is the most common cause of noncardiac chest pain (NCCP) and is present in up to 60% of patients with NCCP in Western countries. In Korea, after a reasonable cardiac evaluation, GERD is reported to underlie 41% of NCCP cases. Typical reflux symptoms are frequent in Korean patients suffering from NCCP. Therefore, a careful history of the predominant symptoms, including heartburn and acid regurgitation, is relatively indicative of the GERD diagnosis in Korea. In Korea, in contrast to Western countries, patients aged 40 years and over who have been diagnosed with NCCP but who are without alarming features should undergo endoscopy to exclude gastric cancer or peptic ulcers because of the higher prevalence of peptic ulcer disease and gastric cancers in the region. In a primary care setting, in the absence of any alarming symptoms, a symptomatic response to a trial of a proton pump inhibitor (PPI) is sufficient for the presumptive diagnosis of GERD. In addition, the optimal duration of a PPI test may be at least 2 weeks, as GERD symptoms tend to be less frequent or atypical in Korean patients than in patients from Western countries. In patients diagnosed with GERD-related NCCP, long-term therapy (more than 2 months) with double the standard dose of a PPI is required to alleviate symptoms. Esophageal dysmotility is relatively uncommon, and pain modulators seem to offer significant improvement of chest pain control in non-GERD-related NCCP. Most traditionally available tricyclics or heterocyclics have many undesirable effects. Therefore, newer drugs with fewer side effects (for example, the serotonin - norepinephrine reuptake inhibitors) may be needed.

Distinct Characteristics of Noncardiac Chest Pain in Korea / 대한내과학회지

Gastroesophageal reflux disease (GERD) is the most common cause of noncardiac chest pain (NCCP) and was reported to cause 41% of cases of NCCP in a recent study of Korea. Typical reflux symptoms were reported to be frequent in Korean patients suffering from NCCP. Therefore, a careful history of the symptoms is relatively indicative of GERD diagnosis in Korea. In Korea, contrasting Western countries, patients with NCCP but present no alarm features should undergo endoscopy to exclude gastric cancer or peptic ulcer. In a primary care setting, PPI test is sufficient for the presumptive diagnosis of GERD. Specifically in Korea, the optimal duration of PPI test may be at least 2 weeks because of less frequent or atypical GERD symptoms. In patients diagnosed with GERD-related NCCP, the initial long term therapy (more than 2 months) followed to the maintenance therapy is required to alleviate symptoms. Esophageal dysmotility is relatively uncommon, and pain modulators seem to offer significant improvement in chest pain control in non GERD-related NCCP. Unfortunately, the majority of traditionally available tricyclics or heterocyclics have many undesirable effects. Therefore, newer drugs with fewer side effects may be needed, such as the serotonin-norepinephrine reuptake inhibitors.

Gastroesophageal reflux disease in noncardiac chest pain: Clinical characteristics and PPI test / 대한내과학회지

Gastroesophageal reflux disease (GERD) is the most common cause of noncardiac chest pain (NCCP) and is present in up to 60% of patients with NCCP in the West. In Korea, GERD is reported to cause 41% of cases of NCCP, after a reasonable cardiac evaluation. In a recent prospective study in Korea, an empirical trial of a proton pump inhibitor (PPI) was diagnostic for patients with GERD-related NCCP, as elsewhere in the world, and its optimal duration was reported to be at least two weeks in Korea, which is unlike the situation in the West. The report of Choi et al. showed that about 40% of NCCP in non-erosive reflux disease patients had esophageal disorders, including GERD and esophageal motility disorders, and that the standard dose or a low dose of PPI was effective for managing GERD-related NCCP. However, the retrospective nature of the study has limitations, such as an insufficient systemized symptom analysis and the standardization of the dose and interval of the PPI. A large-scale prospective study is needed to assess the accurate diagnosis and effective treatment of NCCP.

The clinical characteristics of noncardiac chest pain and treatment response in non-erosive reflux disease (NERD) / 대한내과학회지

BACKGROUND/AIMS: Noncardiac chest pain (NCCP) is defined as recurring angina-like retrosternal chest pain of noncardiac origin. Gastroesophageal reflux disease (GERD) is by far the most common cause of NCCP. We evaluated the incidence of some esophageal abnormalities as a cause of NCCP and the treatment response to a proton pump inhibitor (PPI). METHODS: Forty seven NCCP cases were selected from 184 cases who underwent 24-hour ambulatory pH monitoring or esophageal manometry. Patients were excluded if they had a history of gastrointestinal surgery, pancreatobiliary disorder, coronary artery disease, valvular heart disease, depression or tuberculosis. In this study, all GERD patients had non-erosive reflux disease (NERD). RESULTS: Of the 47 NCCP cases, 30 (63.8%) were female and 17 (36.2%) were male. Only 7 (14.9%) cases had typical GERD symptoms such as acid regurgitation and heartburn. Of the 47 NCCP cases, 12 (25.5%) had GERD-related NCCP, and six (12.8%) had esophageal motility disorder. Of the 12 cases diagnosed as GERD-related NCCP, nine (75.0%) showed a satisfactory PPI response. The PPI was effective for GERD-related NCCP compared with non-GERD related NCCP (p=0.015). CONCLUSIONS: About 40% of NERD patients with NCCP had an esophageal disorder including GERD and esophageal motility disorder. A PPI was effective for GERD-related NCCP.

Clinical Distinct Features of Noncardiac Chest Pain in Young Patients

BACKGROUND/AIMS: Noncardiac chest pain (NCCP) is a very common disorder world-wide and gastroesophageal reflux disease (GERD) is known to be the most common cause. The prevalence of NCCP may tend to decrease with increasing age. However, there is little report about young aged NCCP. The aim of this study was to examine the prevalence of GERD and to evaluate the efficacy of proton pump inhibitor (PPI) test in the young NCCP patients. METHODS: Thirty patients with at least weekly NCCP less than 40 years were enrolled. The baseline symptoms were assessed using a daily symptom diary for 14 days. Esophago-gastro-duodenoscopy (EGD) and 24 hr esophageal pH monitoring were performed for the diagnosis of GERD and esophageal manometry was done. Then, patients were tried with lansoprazole 30 mg twice daily for 14 days, considering positive if a symptom score improved > or = 50% compared to the baseline. RESULTS: Nine (30%) of the patients were diagnosed with GERD at EGD and/or 24 hr esophageal pH monitoring, also, 3 (10%) were diagnosed with GERD-associated esophageal motility disorder and 3 (10%) were non GERD-associated. Concerning PPI test, GERD-related NCCP had a higher positive PPI test (n = 8, 89%) than non GERD-related NCCP (n = 5, 24%) (p = 0.002). CONCLUSIONS: In young patients with NCCP, a prevalence of GERD diagnosed using EGD and/or 24 hr esophageal pH monitoring was 30%. PPI test was very predictable on diagnosis of GERD-related NCCP, thus, PPI test in young NCCP patients may assist to the physician's clinical judgment of NCCP.

Upper gastrointestinal tract findings in patients with noncardiac chest pain / 대한내과학회지

Noncardiac chest pain (NCCP) is defined as recurring angina-like retrosternal chest pain of noncardiac origin. Although gastroesophageal reflux disease (GERD) is recognized as the most frequent cause of this disorder, the pathophysiology remains to be elucidated fully. In Western countries, upper endoscopy has limited value in the differential diagnosis of NCCP because most of the mucosal findings detected are consistent with GERD. By contrast, in Korea the prevalence of gastric or duodenal ulcers in NCCP patients ranges from 17.9 to 20.7%. Considering this high prevalence and the different treatment strategies for GERD and peptic ulcer disease, upper endoscopy should be included in the initial work-up for NCCP in Korean patients.

The endoscopic findings in patients with noncardiac chest pain who have a normal coronary angiogram / 대한내과학회지

BACKGROUND/AIMS: Noncardiac chest pain (NCCP) mainly results from esophageal lesions in the developed world. By contrast, gastroesophageal reflux disease (GERD) is a less frequent cause of NCCP than peptic ulcer disease in China and Japan. Therefore, both esophageal lesions and stomach and duodenal lesions are likely to be important causes of NCCP in Korea. We used upper gastrointestinal endoscopy to evaluate lesions of the esophagus, stomach, and duodenum in NCCP patients after cardiac chest pain was ruled out by coronary angiography (CAG). METHODS: From the patients who underwent CAG between 2004 and 2008, we identified 89 patients who had normal CAG or minimal disease. We retrospectively analyzed the endoscopic findings of these 89 patients who were diagnosed with NCCP. RESULTS: At endoscopy for the 89 patients, the percentages of GERD, gastric ulcer, and duodenal ulcer were 20.2% (n=18), 14.6% (n=13), and 3.3% (n=3) respectively. Of the 16 cases diagnosed as peptic ulcer, 11 were evaluated by biopsy or the Campylobacter-like organism (CLO) test for suspected Helicobacter pylori infection. Six (54%) cases were positive for H. pylori and five (46%) were negative. CONCLUSIONS: In Korea, the incidence of peptic ulcer disease (17.9%) as a cause of NCCP is similar to that of GERD (20.2%). Consequently, we should perform endoscopy to determine the cause of NCCP.

Esophageal Motility and Reflux Diseases in Patients with Noncardiac Chest Pain / 대한소화관운동학회지

BACKGROUND/AIMS: Some patients complaining chest pain have normal coronary angiograms. In these cases of noncardiac chest pain, esophageal disease might be a reasonable explanation. However, causal relationship between esophageal motility or reflux disease and chest pain may be difficult to be proven. Therefore, we performed this study to evaluate the esophageal abnormality as a potential cause of noncardiac chest pain. METHODS: We underwent esophagogastroduodenoscopy, esophageal mancenetry and 24 hour esophageal pH monitoring in 58 patients with chest pain and normal coronary arteriogram or negative thallium study. RESULTS: Of 58 patients, 17 patients (29.3%) had abnormal esophageal manometry test. There were 6 cases of nonspecific esophageal motility disorder, 5 cases of hypertensive lower esophageal sphincter, 5 cases of diffuse esophageal spasm and 1 case of nutcracker esophagus. In 56 patients with 24 hour pH monitoring, 13 patients had positive DeMeester score and 29 patients experienced chest pain during the test period. 11 patients (18.9%) had both positive DeMeester score and chest pain. Mean symptom index of these patients was 70.0% (range 40-100%). CONCLUSIONS: Esophageal motility disorders and gastroesophegeal reflux diseases were frequantly found in patients with noncardiac chest pain. Much efforts should be made to find esophageal cause in patients with noncardiac chest pain.