Abstract & Commentary

Synopsis: Contrary to expectations, the most common esophageal motility abnormality in patients with noncardiac chest pain is hypotensive lower esophageal sphincter (LES), and the most common motor abnormality in dysphagia is ineffective peristalsis. If chest pain and dysphagia are both present, the most common motility finding is achalasia.

Source: Dekel R, et al. Aliment Pharmacol Ther. 2003;18:1083-1089.

Few prospective data exist on specific esophageal motor abnormalities in patients who present with noncardiac chest pain or dysphagia. However, at least in the past, many gastroenterologists would have predicted a high prevalence of esophagospastic disorders (eg, esophageal spasm or nutcracker esophagus) in patients with these complaints. This report from multiple cooperating centers describes findings in 403 patients who presented with dysphagia and 140 patients with noncardiac chest pain and 44 patients with both symptoms on presentation.

Sixty one percent (61%) of patients with noncardiac chest pain were found to have hypotensive LES pressure. Only 10% each were found to have nutcracker esophagus (high pressure peristalsis > 180 mm Hg) or nonspecific esophageal motor abnormalities. If patients presented with dysphagia, 27% had ineffective peristalsis followed by 18% with achalasia and 14% with nonspecific motor abnormalities. Also, 35% and 25% of patients with both dysphagia and noncardiac chest pain had achalasia and nonspecific motor abnormalities, respectively. Previous studies have suggested that reflux plays an important role noncardiac chest pain (60%); and motility disturbances have been historically implicated in 30% of such patients. Only 2% of patients with noncardiac chest pain had diffuse esophageal spasm in this prospective study, 7% in dysphagia, and 10% of patients with both of these symptoms; 10% or less had nutcracker esophagus in any of these groups.

Comment by Malcolm Robinson, MD, FACP, FACG

On balance, manometric testing was not really helpful in patients with either noncardiac chest pain or dysphagia alone. Many of these patients would have responded to a therapeutic trial of acid suppression. Dysphagia was the most common reason for referral for manometry (70%), but a relatively small minority had any clinically relevant motor abnormality found. Indeed, normal motility testing was found in 53-70% of these patients regardless of the indication for testing. Dysphagia patients had more abnormal manometric findings than noncardiac chest pain (47% vs 30%; P < .0001). Overall, manometry could have led to a beneficial therapeutic intervention in only 16.4% of patients with dysphagia. The patients most likely to benefit from motility studies are those with both dysphagia and chest pain (eg, 35% achalasia). On balance, relatively few patients need esophageal motility studies for their management in most situations. However, availability of motility testing remains critical for the diagnosis of achalasia and, in more general terms, for the preoperative assessment of patients considered for anti-reflux procedures.

Dr. Robinson, Medical Director, Oklahoma Foundation for Digestive Research; Clinical Professor of Medicine, University of Oklahoma College of Medicine Oklahoma City, OK, is Associate Editor of Internal Medicine Alert.