Balloon Distension Test to Evaluate Esophageal Chest Pain
Balloon Distension Test to Evaluate Esophageal Chest Pain
Over a 6-year period, 612 subjects with unexplained, NCCP were referred to our clinic for evaluation. Among this group, 348 (105 male/243 female; mean age 46 years) subjects fulfilled the inclusion and exclusion criteria and were enrolled in this study. The majority of these patients were on PPI before enrolment. The remaining subjects were excluded because their chest pain was explained by another source such as cardiac, pulmonary or psychiatric illnesses or they had evidence for gallbladder disease, peptic ulcer disease, GERD, previous abdominal surgeries (Nissen, gastric, etc.), had significant comorbid illnesses (stroke, COPD, etc.), or were unable or unwilling to complete the study protocol.
Characteristics of Chest Pain. Our subjects reported frequent episodes of chest pain with a mean (±s.d.) frequency score of 2.5 ± 0.3, approximately one episode of chest pain per week. The intensity and duration of pain were rated as 2.2 ± 0.2 and 2.2 ± 0.2 respectively. These data indicate that the chest pain was moderately severe in intensity and typically lasted between 10 and 30 min.
After initial clinical evaluation, 16 (5%) subjects were excluded because 3 had musculoskeletal chest pain and 13 had new features suggestive of cardiac disease and were referred back to cardiology. Thus, 332 patients underwent EGD (Figure 2). This test revealed either macroscopic and/or microscopic oesophagitis in 48 (14%) subjects including patients with eosinophilic oesophagitis who were therefore assigned a diagnosis of GERD and/or oesophagitis, and were excluded from further workup. The remaining 284 patient underwent an oesophageal manometry. Seven (2%) subjects were found to have manometric features of achalasia and were excluded from further work up. Another 61 subjects received a diagnosis of nonspecific oesophageal dysmotility. These 63 subjects together with the 214 subjects with normal oesophageal manometry [total 277 (80%)] underwent a 24 h ambulatory pH study. Abnormal acid reflux, defined as total percent time pH < 4 was ≥4.5%, was found in 96 (28%) subjects. Acid reflux was most likely responsible for chest pain in this group. The remaining 181 (52%) subjects were felt to have nonreflux, noncardiac chest pain. These subjects underwent EBDT. Among them, oesophageal hypersensitivity was identified in 128 (37%) subjects and oesophageal normosensitivity in 48 (14%) subjects (Figure 3). Typical chest pain was reproduced in 97/128 (76%) subjects.
(Enlarge Image)
Figure 2.
Consort diagram of the diagnostic evaluation in patients with unexplained non-cardiac chest pain.
(Enlarge Image)
Figure 3.
This figure shows the proportion of subjects with non-cardiac chest pain in whom sequential testing of oesophageal mucosa and sensori-motor function revealed an oesophageal source for their chest pain. pH = 24 h ambulatory oesophageal pH test. EBDT, oesophageal balloon distension test; EGD, oesophagogastroduodenoscopy; EM, oesophageal manometry.
Of the 61 subjects who were identified as having oesophageal dysmotility on manometry testing, 21 had an abnormal pH study and 20 subjects had a hypersensitive oesophagus. The remaining 20 subjects had dysmotility as the only oesophageal disorder that could explain their chest pain. In this group, nutcracker oesophagus was identified in 14 (4%) patients, diffuse oesophageal spasm (DES) in 1 (0.3%) and nonspecific oesophageal dysmotility in 6 (1.7%) subjects.
Tolerability. All subjects included in this study tolerated balloon distension without any adverse events. Overall, six subjects (1.7%) could not tolerate either oesophageal intubation or first balloon distension. These subjects were not included in the analysis.
Results
Demographics
Over a 6-year period, 612 subjects with unexplained, NCCP were referred to our clinic for evaluation. Among this group, 348 (105 male/243 female; mean age 46 years) subjects fulfilled the inclusion and exclusion criteria and were enrolled in this study. The majority of these patients were on PPI before enrolment. The remaining subjects were excluded because their chest pain was explained by another source such as cardiac, pulmonary or psychiatric illnesses or they had evidence for gallbladder disease, peptic ulcer disease, GERD, previous abdominal surgeries (Nissen, gastric, etc.), had significant comorbid illnesses (stroke, COPD, etc.), or were unable or unwilling to complete the study protocol.
Characteristics of Chest Pain. Our subjects reported frequent episodes of chest pain with a mean (±s.d.) frequency score of 2.5 ± 0.3, approximately one episode of chest pain per week. The intensity and duration of pain were rated as 2.2 ± 0.2 and 2.2 ± 0.2 respectively. These data indicate that the chest pain was moderately severe in intensity and typically lasted between 10 and 30 min.
Diagnostic Yield of Oesophageal Diagnostic Tests
After initial clinical evaluation, 16 (5%) subjects were excluded because 3 had musculoskeletal chest pain and 13 had new features suggestive of cardiac disease and were referred back to cardiology. Thus, 332 patients underwent EGD (Figure 2). This test revealed either macroscopic and/or microscopic oesophagitis in 48 (14%) subjects including patients with eosinophilic oesophagitis who were therefore assigned a diagnosis of GERD and/or oesophagitis, and were excluded from further workup. The remaining 284 patient underwent an oesophageal manometry. Seven (2%) subjects were found to have manometric features of achalasia and were excluded from further work up. Another 61 subjects received a diagnosis of nonspecific oesophageal dysmotility. These 63 subjects together with the 214 subjects with normal oesophageal manometry [total 277 (80%)] underwent a 24 h ambulatory pH study. Abnormal acid reflux, defined as total percent time pH < 4 was ≥4.5%, was found in 96 (28%) subjects. Acid reflux was most likely responsible for chest pain in this group. The remaining 181 (52%) subjects were felt to have nonreflux, noncardiac chest pain. These subjects underwent EBDT. Among them, oesophageal hypersensitivity was identified in 128 (37%) subjects and oesophageal normosensitivity in 48 (14%) subjects (Figure 3). Typical chest pain was reproduced in 97/128 (76%) subjects.
(Enlarge Image)
Figure 2.
Consort diagram of the diagnostic evaluation in patients with unexplained non-cardiac chest pain.
(Enlarge Image)
Figure 3.
This figure shows the proportion of subjects with non-cardiac chest pain in whom sequential testing of oesophageal mucosa and sensori-motor function revealed an oesophageal source for their chest pain. pH = 24 h ambulatory oesophageal pH test. EBDT, oesophageal balloon distension test; EGD, oesophagogastroduodenoscopy; EM, oesophageal manometry.
Dysmotility, Pain and Acid Reflux
Of the 61 subjects who were identified as having oesophageal dysmotility on manometry testing, 21 had an abnormal pH study and 20 subjects had a hypersensitive oesophagus. The remaining 20 subjects had dysmotility as the only oesophageal disorder that could explain their chest pain. In this group, nutcracker oesophagus was identified in 14 (4%) patients, diffuse oesophageal spasm (DES) in 1 (0.3%) and nonspecific oesophageal dysmotility in 6 (1.7%) subjects.
Tolerability. All subjects included in this study tolerated balloon distension without any adverse events. Overall, six subjects (1.7%) could not tolerate either oesophageal intubation or first balloon distension. These subjects were not included in the analysis.
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