Noncardiac chest pain (NCCP) is very common, affecting up to 25% of the adult population in the United States. Treatment for NCCP has markedly evolved in the past decade and is presently focused on gastroesophageal reflux disease (GERD) and visceral hypersensitivity.
Pain modulators (e.g. low dose tricyclic antidepressants) are often the mainstay of therapy in refractory situations. Smooth muscle relaxants (sublingual nitroglycerine, phosphodiesterase-5 inhibitors, and calcium channel blockers) can be used in hypermotility states, although their efficacy has not been demonstrated in controlled trials. Hypnotherapy, biofeedback, transcutaneous nerve stimulation, and behavioral and cognitive therapy complement pharmacologic therapy, although additional -studies are needed; acupuncture may be of benefit.
Y oung women) was to test both the short-term and long-term effects of a series of three suberythemal UV radiation (UVR) exposures on the VitD status and well-being of young healthy women during winter in a repeat measure design. These medications are effective to reduce painful symptoms associated with GERD, acid reflux, dyspepsia, acid peptic disease and certain ulcers.
GERD is the most common underlying mechanism for NCCP and thus should be excluded first when evaluating a patient with NCCP. Noncardiac chest pain (NCCP) is very prevalent in the community. Although mortality remains low, morbidity and the financial implications are high. Women, those of middle age especially, should be thoroughly investigated as per current guidelines for coronary artery disease before labeling their chest pain as NCCP. Gastroesophageal reflux disease is the most common cause of NCCP; other esophageal pathology including esophageal hypersensitivity however, neuromuscular disease and eosinophilic esophagitis may also cause NCCP.
Treatment of NCCP has dramatically improved since the introduction of the PPI class of drugs.However, better therapeutic modalities should be sought out to improve our current treatment of GERD-related NCCP further. The lansoprazole empirical trial is highly specific and sensitive for diagnosing gastro-oesophageal reflux disease-related non-cardiac chest pain patients. The trial enables diagnosing most of the responders within the first 2 days and thus a shorter duration of therapy may be considered in a subset of non-cardiac chest pain patients.
A New Strategy for the Treatment of Inflammatory Pain: Prevention or Elimination of Central Sensitiz…
Backgroundnon-cardiac chest pain (NCCP) is recurrent retrosternal chest pain in the absence of significant coronary artery disease. It can affect up to 25% of the population.Pathophysiologygood history and examination help to differentiate between causes of chest pain, such as coronary heart disease, musculoskeletal pain, abdominal disease, pulmonary causes and oesophageal pathology. Targeted investigations should be performed according to clinical suspicion.Patients with a high risk of ischaemic heart disease should have cardiac investigations.
Ambulatory pH or pH/impedance monitoring off PPI therapy assesses for abnormal esophageal acid exposure and reflux association with NCCP events using simple and statistical symptom association probability tests. Esophageal manometry is typically performed concurrent with ambulatory pH monitoring and can identify esophageal dysmotility, some patterns of which may be associated with esophageal hypersensitivity. Acid suppression with a PPI is the first therapeutic measure initiated even prior to investigation in NCCP.
Non-cardiac chest pain (NCCP) consists of recurrent angina-type pain unrelated to ischemic heart disease or other cardiac source after a reasonable workup. The most common esophageal cause of NCCP is gastro-esophageal reflux disease (GERD), followed by esophageal motor esophageal and disorders visceral hypersensitivity. Noxious triggers for NCCP include non-acidic and acidic reflux events, mechanical distension and muscle spasm, particularly longitudinal smooth muscle contraction.
Our pilot study showed good feasibility in terms of most of the assessments and procedures used. In subsequent larger research projects the schedule may be practicable for investigating the influence of skin type on the acute and long-term effects of UVB on VitD status, including 1,25(OH) 2 D assessments as well as questionnaires for affective state/well-being in the research program. For possible future application of UVR, for example, in patients suffering from rheumatoid arthritis, week appears more practical than several weeks of exposure a limited number of UVR exposures within one, and might ensure greater compliance. The six-week study of Bogh et al. (2012) with three UVR exposures per week reported a high rate of drop-outs [ 40 ].
The pilot study on healthy young women with predominantly Fitzpatrick skin types II and III showed the feasibility of our schedule with three escalating suberythemal UVR exposures to improve the VitD status not only acutely but also for a longer time, as all twenty participants received every predefined UVR without significant adverse skin reactions. To our knowledge there are no systematic studies investigating the effects of UVR exposures on the VitD status, and different aspects of well-being in patients with clear psychiatric diagnosis of major/minor depression or seasonal affective disorder but without medical comorbidity in parallel. On the other hand, differences in reported findings in studies with VitD supplementation in patients with depression are likely not only to be affected by study population and dosage schemes, but by choice of diagnostic criteria also, screening tools and self-report questionnaires used. In our opinion, the choice of a suitable self-rating test to detect possible mood changes seems to present a problem.
Behavioural hypnotherapy and therapy have been found to be useful in selected cases. Summarychest pain should be taken seriously, with any underlying pathology early identified and treated. Patients with NCCP should receive repeated and consistent reassurance, in the hope of averting chronic disability. A multidisciplinary approach to NCCP may be required in those with chronic symptoms. The proton pump inhibitor (PPI) test is a short course of high-dose PPI, used to diagnose gastroesophageal reflux disease (GERD).
In this subgroup of NCCP patients, pain modulators have been demonstrated to be the most efficacious therapeutic strategy. The role of provocative testing has diminished in the last decade due to poor sensitivity and the introduction of the PPIs.
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The patient was treated with morphine sulfate, metoclopramide, midazolam, diazepam, acetaminophen, ketamine, hyoscine butylbromide, propofol, dexamethasone and amoxycillin, and received parenteral nutrition. As the source of pain remained unclear, a second esophagoduodenoscopy was performed to determine a diagnosis, resulting in pain relief. Thus, in the present case, esophagoduodenoscopy was therapeutic and diagnostic. Furthermore, although the treatment of acute chest pain may be a challenge in palliative care, the present study indicates that pain treatment should be adjusted to anatomical, pathophysiological and pharmacological factors, and may pose risks due to the unavoidable parenteral co-administration of multiple agents with strong therapeutic effects.
After a cardiac source has been excluded, the most likely cause of NCCP is GERD. Clinical history cannot make the diagnosis of GERD-related NCCP often. The PPI test is a simple, highly sensitive, and cost-effective tool that should be the first diagnostic test used in evaluating these patients. Patients with GERD-related NCCP require long-term therapy with a PPI,double the standard dose commonly. The introduction of the wireless pH system and the multi-channel intraluminal impedance will help us to further understand the role of GERD in NCCP.
Referral to a gastroenterologist should be considered if there is no response. 24-hour oesophageal pH monitoring can identify patients with reflux unresponsive to PPI; oesophageal dysmotility can be identified by manometry in selected patients. Tricyclic antidepressants at relatively low dose may have a role.