Читать книгу The Esophagus - Группа авторов - Страница 63

Noncardiac chest pain is a frequently encountered clinical scenario, with GI causes implicated for 10–20% of cases, the majority of which are esophageal in origin [3]. Among causes of esophageal chest pain, nearly half the cases are due to GERD [23–25]. Evidence has shown that an empiric trial of a PPI for GERD in patients presenting with ECP can be both therapeutic and diagnostic [31–37]. The prevalence of GERD as the etiologic factor in ECP is so high that, even when patients are not responding to PPI, we advocate for pH‐impedance monitoring as the next step to exclude subclinical reflux as a source of symptoms. For those patients without an anticipated response to PPI without evidence of symptom corresponding reflux on pH‐impedance monitoring, high‐resolution manometry is the most appropriate next step for diagnosis and best‐directed therapy. Among motility disorders, achalasia, jackhammer esophagus, and distal esophageal spasm are most closely associated with ECP. More in‐depth discussion of these treatment options is discussed in separate chapters (Chapters 15, 16, 25, 27, 28, 34, and 35); however, they include medications (calcium channel blockers, nitrates, and phosphodiesterase inhibitors), pneumatic balloon dilation, botulinum toxin injection, and either surgical or endoscopic myotomy. The use of POEM, in particular, for superior treatment of ECP patients with Type III achalasia has a best practice recommendation [177, 178]. Finally, a subset of patients without GERD and with no evidence of motility disorders are characterized by the presence of esophageal hypersensitivity. While the treatment options of esophageal hypersensitivity are varied, they remain largely focused on the overlap with functional gastrointestinal and mental health disorders, relying on antidepressants and non‐pharmacologic behavioral interventions as a mainstay of initial therapy. Certainly, the evaluation of and treatment of ECP can pose a clinical challenge owing to the ambiguity of patient presentation and symptomatic complaints. For this reason, we advocate for the algorithmic approach (Figure 2.1), which tailors the evaluation and treatment in a cost‐effective and evidence‐based rational.