1/14. chest pain. Differentiating GIT from cardiac causes.BACKGROUND: chest pain is a common presenting symptom in general practice. Although a cardiac cause is not the commonest origin, a high index of suspicion is needed. When the diagnosis is not clear, a cardiac cause should be considered until proven otherwise. A gastrointestinal origin of chest pain is not infrequent and may be due to oesophageal, gastric or biliary disease. Oesophageal causes are most common and include reflux, hypersensitivity or dysmotility. OBJECTIVE: This paper reviews the main gastrointestinal causes that may present with acute chest pain. DISCUSSION: Clinical history taking is the key to decision making and guides the choice of prompt or routine investigation or a therapeutic trial. When reflux is suspected as the cause, a therapeutic trial of high dose antisecretory therapy is appropriate. Investigations may be helpful when typical reflux symptoms are not present or there is a poor response to this approach. Investigations may include endoscopy, ambulatory pH monitoring, barium swallow or oesophageal manometry.- - - - - - - - - - ranking = 1keywords = chest pain, chest (Clic here for more details about this article) |
2/14. Nonspecific esophageal motor disorder associated with thickened muscularis propria of the esophagus.A case of a nonspecific esophageal motor disorder associated with muscular hypertrophy, revealed by endoscopic ultrasonography, is reported. A 41-year-old man was admitted to the hospital with chest pain and dysphagia. Manometric studies of the esophagus disclosed prolonged duration of propulsive waves with normal amplitude. Endoscopic ultrasonography showed downward thickening of the esophageal muscular layer; the maximum thickness was found at the lower esophageal sphincter. Thickening of the esophageal wall of unknown etiology has been reported as a diffuse esophageal muscular hypertrophy. Previous cases of diffuse esophageal muscular hypertrophy were diagnosed by autopsy. Some cases involved dysphagia and/or chest pain. Therefore, some of the reported cases of nonspecific esophageal motor disorders may have been associated with diffuse esophageal muscular hypertrophy. association of the two categories was shown by endoscopic ultrasonography for the first time in the present case. Endoscopic ultrasonography is a useful tool for the diagnosis of the thickening of the muscular layer of the esophagus.- - - - - - - - - - ranking = 1.963931717757keywords = chest pain, chest (Clic here for more details about this article) |
3/14. vocal cord dysfunction concurrent with a nutcracker esophagus and the role of gastroesophageal reflux disease.BACKGROUND: Psychological disorders were originally thought to be the sole cause of vocal cord dysfunction (VCD). Subsequently, other organic diseases, including structural laryngeal abnormalities, have also been reported to be associated with VCD. OBJECTIVES: To describe the first patient with VCD concurrent with a nutcracker esophagus and to establish the association between VCD and gastroesophageal reflux disease (GERD) by using the Bernstein test. methods: Symptom assessments, neuropsychiatric evaluations, fiberoptic laryngoscopy, pulmonary function tests, allergic skin prick tests, radiographs of the chest and sinuses, esophageal manometry (including 24-hour ambulatory esophageal ph monitoring), and the Bernstein test were performed. RESULTS: A 36-year-old woman had dyspnea, hoarseness, chest pain, and wheezes without relief for a decade. Neuropsychiatric evaluations disclosed mild depression. Fiberoptic laryngoscopy showed posterior laryngitis and paradoxical vocal cord adduction with audible inspiratory stridor. Pulmonary function tests showed attenuation of the inspiratory limb with notching in both flow-volume loops and a mid-vital capacity expiratory to inspiratory flow ratio of 4. All the symptoms except chest pain were improved dramatically by speech therapy and empirical treatment for GERD. Esophageal manometry revealed a nutcracker esophagus; 24-hour ambulatory esophageal ph monitoring demonstrated multiple short reflux episodes. The Bernstein test was conducted, and all the manifestations were reproduced with 0.1 N hydrochloric acid but not with isotonic sodium chloride infusion. CONCLUSIONS: This is the first human case report confirming that GERD can trigger an acute attack of VCD and may induce chest pain as a nutcracker esophagus in patients with VCD. It strengthens this association and expands our knowledge of diverse manifestations of this clinical entity.- - - - - - - - - - ranking = 2.963931717757keywords = chest pain, chest (Clic here for more details about this article) |
4/14. Transition from nutcracker esophagus to achalasia.Nutcracker esophagus is essentially a manometric diagnosis characterized by high-amplitude, often prolonged duration of peristaltic contractions in the distal two thirds of the esophagus. Its association with noncardiac chest pain and/or dysphagia has been recognized and reported by numerous esophageal motility laboratories. There are very few long-term studies of the natural history of this abnormality. We report a patient who presented with dysphagia and, on initial investigation, was found to have classical nutcracker esophagus. On reinvestigation three years later, however, he had developed achalasia of the cardia. The transition from nutcracker esophagus to achalasia has not previously been reported.- - - - - - - - - - ranking = 0.9819658588785keywords = chest pain, chest (Clic here for more details about this article) |
5/14. Hypertensive lower esophageal sphincter: what does it mean?The hypertensive lower esophageal sphincter (LES) (mean LES pressure greater than 45 mm Hg; LES relaxation greater than 75%; normal peristalsis) is a poorly characterized motility disorder associated with chest pain and dysphagia. Therefore, we carried out a multidisciplinary study to assess esophageal pressures and function in 15 symptomatic hypertensive LES patients (3 men, 12 women; mean age, 53 years). On-line computer analysis showed a significant (p less than 0.05) increase in LES pressure (55.5 versus 14.9 mm Hg) and residual pressure (6.8 versus 1.1 mm Hg) as well as a decrease in percentage of LES relaxation (87 versus 93%) in patients compared with age-matched controls. All patients had normal peristalsis but 7 of 15 had nutcracker esophagus (mean distal amplitude, 216 mm Hg). No patient had evidence of impaired liquid transport on barium esophagram. The emptying of solids as assessed by radionuclide scans was normal in 14 of 15 patients. Of the 12 patients who completed both psychological inventories, nine had elevated scores on scales assessing anxiety and somatization. The heterogenous nature of this disorder is illustrated by a patient with a changeable narrowing in the distal esophagus associated with the transient impaction of a marshmallow. Dysphagia but not chest pain improved after pneumatic dilatation. We conclude that the hypertensive LES is a heterogenous disorder. Despite abnormal LES parameters, most patients have normal esophageal function, and frequent psychological abnormalities may contribute to their report of symptoms. A minority have abnormal esophageal transit.- - - - - - - - - - ranking = 1.963931717757keywords = chest pain, chest (Clic here for more details about this article) |
6/14. Esophageal chest pain.Recurrent chest pain frequently results in significant disability and anxiety, even after cardiac disease has been excluded. A stepwise approach is recommended for the diagnosis of pulmonary conditions, musculoskeletal disorders and structural problems of the upper gastrointestinal tract that can produce chest pain. If a search for these disorders proves negative, an esophageal source of chest pain should be strongly suspected. Although gastroesophageal reflux disease is the most common and easily treated cause of esophageal chest pain, esophageal motility disorders should also be considered. Motility disorders include achalasia, diffuse esophageal spasm, nutcracker esophagus, hypertensive lower esophageal sphincter and nonspecific motility disorders.- - - - - - - - - - ranking = 7.855726871028keywords = chest pain, chest (Clic here for more details about this article) |
7/14. "Segmental aperistalsis" of the esophagus: a cause of chest pain and dysphagia.Although some patients with chest pain and dysphagia have manometric evidence of classic esophageal motor disorders, other patients with these symptoms may have only nonspecific findings of unknown importance. We describe five patients with chest pain and dysphagia in whom esophageal manometry showed a segment of esophagus with an increased frequency of simultaneous contractions associated with normal motility in the more proximal and distal esophagus. All patients had corresponding segmental abnormalities on video-esophagograms augmented with a solid bolus; in four patients, the solid bolus caused reproduction of symptoms during the esophagography. We conclude that "segmental aperistalsis" may cause chest pain and dysphagia, and that the diagnosis may be made by careful manometric analysis of the entire esophagus, complemented by esophagography with a solid bolus.- - - - - - - - - - ranking = 6.8737610121495keywords = chest pain, chest (Clic here for more details about this article) |
8/14. Pathophysiology and management of noncardiac chest pain.Noncardiac chest pain is a common but important clinical challenge with respect to diagnostic strategy as well as therapeutic intervention. The most common esophageal disorder associated with chest pain syndrome is gastroesophageal reflux; 24-hour ambulatory monitoring of esophageal pH and the determination of the symptom index are useful in patient evaluation. A high frequency of abnormal esophageal motility has been reported in noncardiac chest pain, but its clinical significance remains controversial. patients with chest pain and normal coronary angiogram may have microvascular angina. Musculoskeletal conditions account for at least 10% of the cases of noncardiac chest pain. The potential effects of stress and altered psychological states in this phenomenon must be considered. The role of panic attacks in the production of pain needs to be clarified. Investigations to elucidate the exact cause of chest pain as well as its treatment should be individualized to the patient.- - - - - - - - - - ranking = 9.819658588785keywords = chest pain, chest (Clic here for more details about this article) |
9/14. Segmental motor abnormalities of the distal oesophagus.patients with chest pain and/or dysphagia may present non-specific motor abnormalities that do not fit into classical categories of primary motor disorders. Two such patients are described, both with segmental aperistalsis of the distal oesophagus and with fairly normal proximal motility and LES function. Delayed radionuclide oesophageal transit was noted in both cases. Medical treatment was only partially effective and one patient required pneumatic dilatation. The aperistaltic segments have remained unchanged over 3-4 year follow-ups. These patients account for less than 1% of all those diagnosed with oesophageal motor abnormalities in our hospital in the last ten years.- - - - - - - - - - ranking = 0.9819658588785keywords = chest pain, chest (Clic here for more details about this article) |
10/14. Laparoscopic Heller cardiomyotomy and thoracoscopic esophageal long myotomy for the treatment of primary esophageal motor disorders.The technique of laparoscopic and thoracoscopic esophageal myotomy is described. The laparoscopic Heller procedure was performed in a patient with manometrically diagnosed achalasia and the thoracoscopic long esophageal myotomy in another with diffuse esophageal spasm. Both operations were performed in the same fashion as during open surgery, using standard laparoscopic surgical instruments. Antireflux procedures using the Dor and modified Belsey fundoplications protected patients from iatrogenic reflux. Complete relief of dysphagia in the first case and chest pain in the second has been confirmed after 2- and 4-month follow-up, respectively. Laparoscopic Heller myotomy and thoracoscopic long esophageal myotomy are technically feasible and reduce surgical trauma, hospitalization, and postoperative recovery. They offer a viable alternative for the definitive management of primary esophageal motor disorders comparable with that of open surgery.- - - - - - - - - - ranking = 0.018034141121495keywords = chest (Clic here for more details about this article) |
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