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Unexplained Chest Pain: The Hypersensitive, Hyperreactive, and Poorly Compliant Esophagus

Satish S.C. Rao, MD, PhD; Hans Gregersen, MD, DrMsci; Bernard Hayek, MSc; Robert W. Summers, MD; and James Christensen, MD
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From the University of Iowa College of Medicine and Department of Veterans Affairs Medical Center, Iowa City, Iowa, and the University of Aarhus, Aarhus, Denmark. Acknowledgments: The authors thank L. Burmeister, PhD, for his assistance with the statistical analysis and D. Fujiwara, MD, for his help with the pilot studies. Grant Support: In part by the 1994 American College of Gastroenterology Research Award and by the Merit Review funds from the Department of Veterans Affairs Medical Center. Requests for Reprints: Satish S.C. Rao, MD, MRCP(UK), PhD, 4612 JCP, Internal Medicine Division, University of Iowa Hospitals and Clinics, Iowa City, IA 52242. Current Author Addresses: Dr. Rao: Internal Medicine/GI Division, University of Iowa Hospitals and Clinics, 4612 JCP, Iowa City, IA 52242.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1996;124(11):950-958. doi:10.7326/0003-4819-124-11-199606010-00002
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Objective: To determine whether neuromuscular dysfunction of the esophagus causes chest pain in patients in whom no disease is found on cardiac work-up, upper gastrointestinal endoscopy, esophageal manometry, and 24-hour pH studies.

Design: Prospective study.

Setting: Tertiary referral center.

Patients: 24 consecutive patients and 12 healthy controls.

Measurements: A new technique, impedance planimetry, was used to measure the sensory, motor, and biomechanical properties of the human esophagus. The impedance planimeter, which consists of a probe with four ring electrodes, three pressure sensors, and a balloon, simultaneously measures intraluminal pressure and cross-sectional areas. This allows calculation of the biomechanical variables of the esophageal wall.

Results: Stepwise balloon distentions from 5 to 50 cm H2O induced a first sensation at a mean pressure (±SD) of 15 ± 9 cm H2O in patients and 30 ± 11 cm H2O in controls (P < 0.001). Moderate discomfort and pain were reported by 20 of 24 patients (83%) at 26 ± 9 cm H2O and at 36 ± 9 cm H2O, respectively, but by none of the controls (P < 0.001). Typical chest pain was reproduced in 20 of 24 patients (83%). In patients, the reactivity of the esophagus to balloon distention was greater (P = 0.01), the pressure elastic modulus was higher (P = 0.02), and the tension-strain association showed that the esophageal wall was less distensible (P = 0.02). Distention excited tertiary contractions and secondary peristalsis at a lower threshold of pressure (P = 0.05) and with a higher motility index in patients than in controls (P = 0.04).

Conclusion: In patients with chest pain and normal cardiac and esophageal evaluations, impedance planimetry of the esophagus reproduces pain and is associated with a 50% lower sensory threshold for pain, a 50% lower threshold for reactive contractions, and reduced esophageal compliance.


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Figure 1.
Schematic representation of the probe and the signal-processing system used for impedance planimetry of the esophagus.

D equals detection electrode; E equals excitation electrode; I equals infusion channel used for balloon distention; P equals perfusion channel used for measuring intraluminal pressure.

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Figure 2.
Individual values for the inflation pressures that induced a first sensation, moderate discomfort, and pain in controls (white circles) and patients (black circles).22

Bars represent the mean and 95% CI. The maximum inflation pressure was 50 cm H O in controls and 65 cm H O in patients. NCCP equals noncardiac chest pain.

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Figure 3.
Association between wall tension and strain in response to stepwise increases in balloon pressure in controls (white circles) and patients (black circles).

The curve in the patient group is shifted to the left. This suggests that for the same level of tension (force), the degree of strain or the deformability of the esophageal wall was less in patients than in controls (that is, the esophagus was stiffer). Bars represent the mean and 95% CI.

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Figure 4.

Effect of serial increments in balloon pressure on the pressure elastic modulus (wall stiffness) of the esophagus. Effect of graded balloon distention on the reactivity of the esophagus. Bars represent the mean and 95% CI. White circles = controls; black circles = patients.

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