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Spectrum of esophageal disorders in children with chest pain
Abstract
The charts of 83 children with chest pain who underwent esophageal manometry followed by esophagogastroscopy were reviewed. Forty-seven (57%) had normal esophageal histology and normal motility (group I). Esophagitis and normal motility were demonstrated in 15 children (group II), normal esophageal histology and esophageal dysmotility in 13 (group III), and both esophagitis and abnormal motility in 8 (group IV). Diffuse esophageal spasm and achalasia were the most common motility disorders identified (in seven and four patients, respectively). The presence and duration of symptoms, the age, and the gender were not different among the four patient groups. After six months of H2-receptor blockade, 12 of 15 group II patients were asymptomatic, whereas a significantly smaller percentage (five of 18) of patients with abnormal esophageal motility responded to esophageal dilation or treatment with calcium channel blockade, H2-receptor antagonist, and/or prokinetic agents (P less than 0.01). These data suggest that the evaluation of children with chest pain should include esophageal motility testing and esophagoscopy, even in the absence of other gastrointestinal-associated symptoms, and that while treatment of esophagitis results in resolution of symptoms, motility disorders were relatively refractory to therapy.
... OESOPHAGEAL MANOMETRY [1][2][3][4][5] Indications 1 To diagnose achalasia and other primary motility disorders, such as diffuse oesophageal spasm and nutcracker oesophagus (Figs 1,2). 2 To assess oesophageal motor function in children and adolescents with dysphagia, odynophagia, and chest pain of noncardiac origin. 3 To assess the appropriate location at which a pH electrode for the recording of gastroesophageal reflux activity should be positioned, in particular when there is an anatomical malformation (i.e. ...
... Indications1 To assess antroduodenal motility in children with chronic intestinal pseudo-obstruction (Figs 3-5). 2 To assess antroduodenal motility when colectomy is considered for intractable constipation. 3 To distinguish between rumination and vomiting. ...
... Components of the report 1 General information Same as oesophageal manometry 2 Anal measurements: ...
... Chest pain in children may represent a variety of etiologies. Common among these etiologies are various problems with gastrointestinal origin, identified in many instances [3]. These etiologies have been reported to be responsible for 4-6% of children with chest pain [6,7]. ...
... Even when there is an identified cardiac finding such as MVP, there is still a good chance that the chest pain actually originates from a gastrointestinal problem [9]. Considering these facts, some authors suggest that children with chest pain must be evaluated for upper gastrointestinal problems even in the absence of other gastrointestinal-associated symptoms [3]. ...
Our objective was to evaluate and highlight the significance of epigastric tenderness in children and adolescents with chest pain. In a 26-months period, patients who were referred for pediatri cardiology evaluation at Shiraz University of Medical Sciences with chief complaint of chest pain were studied. Patients with epigastric tenderness were evaluated endoscopically by gastroenterologist. Patients who had positive findings on endoscopy were appropriately treated. Since there were no serious findings on cardiac evaluation, no other treatment was necessary. The patients were re-evaluated 4 weeks later. Response to therapy was defined as relief of the initial symptoms as well as epigastric tenderness. One hundred thirty-two patients were referred for evaluation of chest pain during this period. Epigastric tenderness was found in 44 (33.3%) of these patients and endoscopy was performed. Endoscopy showed positive findings in 41 (93.2%). Thirty (75%) of these patients had varying degrees of gastritis. Duodenitis was found in six (13.6%) and gasteroduodenitis in five (11.4%). Esophagitis, which was always associated with gastritis, was seen in five (11.4%). Only three (6.8%) had normal endoscopy. Urease test was positive in three (7.3%) of the specimens. Two of the patients did not return for follow up. From the remaining 39 patients who received gastroenterology treatment, resolution of symptoms was seen in 38 (97.4%). Careful history and physical examination must guide the assessment of children and adolescents referred for evaluation of chest pain. Epigastric tenderness must be used as a reliable sign to initiate a gastrointestinal evaluation.
... Oesophageal dysmotility and related conditions are a recognised cause of chest pain of non-cardiac origin. Katz et all found oesophageal manometric abnormalities in 33% of adults and Glassman et al found oesophageal dysmotility in 21 out of 83 (25.3%) of children under investigations for non-cardiac chest pain [1,2] . Conventional classification and treatment based on standard manometry improved the understanding and guided selection of treatments [3] . ...
Introduction: Oesophageal motility disorders (OMDs) are a recognized cause of pain in 25-33% of patients with non-cardiac chest pain. The understanding of these disorders based on standard multichannel oesophageal manometry has improved with high resolution oesophageal manometry (HROM). This could facilitate selection of treatment modality including identifying those suitable for surgical myotomy while preserving oesophageal function.
Material and methods: This discussion is based on a 65 year old lady with a 17 year history of oesophageal pain due to Nutcracker oesophagus. Persistence of symptoms despite medical management using proton pump inhibitors, calcium channel blockers, nitrates, endoscopic pneumatic dilatation & Botulinum toxin injection prompted re-referral to our specialist unit and analysis of residual oesophageal function using HROM. This revealed a segment of nutcracker oesophagus in the mid oesophagus with significant supine reflux.
Result: Surgical treatment with trans-hiatal open focused oesophageal myotomy with preservation of lower oesophageal sphincter and floppy Nissen fundoplication led to satisfactory and complete resolution of symptoms.
Discussion: HROM provides a clearer classification of the functional abnormalities and their co-relation to symptoms. This allows application of the best available treatment modality including surgery to achieve symptomatic relief with preservation of residual oesophageal function.
Conclusion: Limited evidence is currently available on the comparative benefits of available treatment modalities for OMDs. HROM provides greater insight into OMDs and the benefits of available treatment modalities allowing selection of optimal treatment modality and preserving oesophageal function while achieving relief of the patients distressing symptoms.
... 6 However, some studies found that even in the absence of the characteristic symptoms of GER such as heartburn, regurgitation, pain on swallowing, dysphagia, hemorrhage, or 'water brash', chil- dren with chest pain could be diagnosed as GERD. 4,9 Dekel et al. also indicated that the symptom index provided very little improvement in diagnosing GERD-related noncardiac chest pain in adults. 10 Similarly in our study, except for the respiratory associated symptoms for proximal sensor (Table 4), GERD symptom positivity (frequency of characteristic symptoms of GERD) was not significantly different between GERD-positive and GERD-negative groups for both sensors. ...
Objective: Causes of chest pain in children, rarely due to cardiac disease and usually described as idiopathic, account for 20% to 45% of all cases. In this study, we investigated the frequency of gastroesophageal reflux in children with noncardiac chest pain and the characteristics of the pain. Material and Methods: Children with at least two episodes per month of chest pain for a maximum of six months were enrolled in the study. After diagnostic evaluation excluded a cardiac source of chest pain, all patients underwent 24-hour pH monitoring. Characteristics of chest pain and other symptoms were recorded daily by the patients or their parents using the symptom diary. Lansoprazole treatment was administered to patients diagnosed as having gastroesophageal reflux disease. Then, the results of the lansoprazole treatment were evaluated on the basis of the presence of chest pain and other symptoms at the second month after the completion of therapy. Results: Thirty-one children (17 boys and 14 girls) aged between eight and 18 years (11.6±2.4 years) with the primary complaint of chest pain were studied. Based on the 24-hour pH monitoring test results, eight patients (25.8%) for distal sensor and six patients (19.4%) for proximal sensor were defined as Gastroesophageal Reflux Disease (GERD)-positive. No significant difference was noted for characteristics of chest pain and other symptoms between the GERD-positive and GERD-negative groups. All GERD-positive children became symptom-free after the two-month lansoprazole therapy. Conclusion: The symptoms of GERD-induced chest pain are often non-specific, and can be determined with certainty only by 24-hour pH monitoring, so 24-hour pH monitoring may proposed to all children with idiopathic chest pain.
... Potwierdza to zalecenia GLASSMANA i wsp. [7],którzy uważają, że ocena kliniczna dzieci z bólem klatki piersiowej powinna obejmować wykonanie ezofagoskopii i gastroskopii. W diagnostyce różnicowej choroby podstawowej należy też uwzględnić astmę indukowaną wysiłkiem [8], choroby serca i naczyń [9] oraz zaburzenia mięśniowo-szkieletowe [10]. ...
Wojewódzki Specjalistyczny Szpital Chorób Dziecięcych im. J. Korczaka we Wrocławiu Ordynator: prof. dr hab. n. med. Józef Prandota Opisono dwie dziewcrynki (\v wieku 15 i 13 lat) chorujące na zespół Tietzego manifestujący się silnymi bo-1{/IlIiklatki piersiowej oraz zgrubieniem polqcreti chrzęstno-kostnych żeber i mostka. Wabu przypadkach objawy cliorobowe poprzedziło zakażenie górnych dróg oddechowych, a 13-letnia dziewczynko przed 110-spitalizacjq trzykrotnie (w odstępach I miesiąca) mocno potknęła się, broniqc przed upadkiem gwaltownv-/IIi ruchami koTlc::.yngontych i skręceniem klatki piersiowej. U tej chorej stwierdzono ponadto odpływ io-lqdkowo-przelykowy i STallzapalny blony śluzowej żołądka oraz hipoimmunoglobulinemię A. S I a w a k I u c za we: zespoi Tietzego, ból klatki piersiowej, młodzież, odpływ źolqdkowo-prreiykowy Tietze syndrome. Difficulties in diagnosis of chest pain in adolescents Two girls, aged 15 and 13 years, witli Tietze syndrome manifesting with intensive ehest pain and swelling ofthe costochoudraljunctions are presented. In botli patients the clinical symptoms were preceded by au upper respiratory tract infectiou, and the l i-year-old girl stumbled 0/1 the left foot three limes before hospi-tali.otiou (in one tuonth intervals) and protected herselffromfalling down with violent movetnents of tlie upper extretnities and torsion ofthe chest. This girl also suffered jrom gastroesophageal rejlux and gustri-lis, and hypoimmunoglobulinaemia A.
... This was demonstrated in a study of 83 children with chest pain who underwent these procedures. 9 A total of 57% had normal oesophageal histology and normal motility. Among the others, 18% had oesophagitis on histology but normal motility, 15.6% had normal histology but gut dysmotility and 9.6% had both oesophagitis and dysmotility. ...
Swallowing is an important developmental process for human life. It requires the cooperation of the mouth, pharynx, and esophagus for successful completion. Esophageal dysphagia, or difficult swallowing, can be the result of behavioral, developmental, neurological, and respiratory disorders; gastroesophageal reflux (GER); and inflammatory diseases. It is observed in 25–45% of developing children and even more in those with developmental disorders.KeywordsDysphagiaEsophageal dysmotilityAchalasiaEsophagramMegaesophagusNutcracker esophagusDiffuse esophageal spasmEosinophilic esophagitisEsophageal pressure topography
Propulsion of gastrointestinal (GI) luminal contents requires coordinated contractions of intestinal smooth muscle in response to input from enteric neurons. The enteric nervous system is capable of independent function, modulated by motor input from the brain through the sympathetic and parasympathetic branches of the autonomic nervous system. Disorders of gastrointestinal motility can result from abnormalities of the GI neuromuscular lining due to developmental, inflammatory, autoimmune disorders, or due to autonomic dysregulation. Drugs that are commonly used to manage GI motility disorders can be categorized into three groups: (1) agents that enhance GI motility (prokinetic agents); (2) agents that inhibit GI motility and reduce normal peristalsis referred to as antimotility agents (opiates and opiate receptor agonists), or agents that reduce abnormally elevated gastrointestinal smooth muscle tone, referred to as antispasmodics (anticholinergics, direct smooth muscle relaxers, and calcium channel blockers); and (3) agents that act to promote evacuation of stool, referred to as laxatives. Some of these drugs can act on the receptors located on the enteric neurons and also work centrally on the brain and autonomic nervous system.
Metilfenidat tedavisi için çocuk kardiyoloji polikliniğine
başvuran hastaların yakın dönem EKG parametrelerinin izlemi
Amaç: Literatürde kronik boyun ağrısını ekranlı araç kullanımı açısından
değerlendiren spesifik bir çalışmaya rastlanmamıştır. Bu çalışmada
amacımız Bournemouth Boyun Ağrı Ölçeği’ni kullanarak iş yaşamında kronik
boyun ağrısı şikayeti ve ağrıya bağlı kısıtlılığı etkileyebilecek
sosyodemografik etkenlerin (yaş, cinsiyet, VKİ, medeni durum, eğitim, gelir düzeyi,
meslek) ve başta bilgisayar, cep telefonu kullanımı, oturarak çalışma şekli olmak üzere
çevresel faktörlerin değerlendirilmesidir.
Gereç ve Yöntemler: Gözlemsel (kesitsel) tipte planlanan çalışmamız 10 Mart- 10
Temmuz 2020 tarihleri arasında Gaziosmanpaşa Eğitim ve Araştırma Hastanesi Aile
Hekimliği ve Fizik Tedavi Polikliniklerine başvuran kronik boyun ağrısı mevcut 306
gönüllünün katılımı ile gerçekleştirildi. Katılımcılara sosyodemografik verileri,
Bournemouth boyun ağrı ölçeği, Birinci Basamakta Fiziksel Aktivite Anketi ve PHQ-9
sağlık değerlendirme sorularını içeren yüz yüze anket formu uygulandı. Verilerin
analizinde SPSS 22 programı kullanıldı.
Bulgular: %66’sı (n=202) kadın ve %34’ü (n=104) erkek olan 306 hastanın yaş ortalaması
40.6±13.1 yıl ve ağrı süreleri ortalama 26.04±29.9 aydı. Katılımcıların %57’si evli, %57.5
‘u üniversite mezunu, %64.7’si asgari ücret üzeri gelire sahipti. Kronik boyun ağrısı,
hastaların %73.5’unda mekanik boyun ağrısı nedenli idi. Bournemouth skoru; obez
olanlarda olmayanlara göre (p=0.003), düşük eğitim düzeyi olanlarda lise ve üniversite
mezunlarına göre (p= 0.039), sigara içenlerde içmeyen veya bırakanlara göre (p=0.001),
olası depresif olanlarda olmayanlara göre (p=0.000), fiziksel aktivite durumu hareketli
olanlarda olmayanlara göre (p=0.002) anlamlı düzeyde daha yüksek bulunurken, ayakta
ya da oturarak çalışma şekli açısından farklılık görülmedi. Bournemouth skoru ile günlük
telefon kullanma süresi (p=0.000 ;r=0.207), günlük bilgisayar başında geçirilen süre
(p=0.002 ;r=0.180), PHQ-9 depresyon düzeyi (p=0.000 ;r=0.558), boyun ağrı süresi (ay)
(p=0.031 ;r=0.123), ve VKİ (p= 0.025;r=0.128) arasında aynı yönlü, günlük uyku süresi
(p= 0.033;r= -0.122) ve yaş (p=0.000 ;r= -0.216) ile ters yönlü ilişki olduğu görüldü.
Günlük cep telefonu kullanım süresi arttıkça sırası ile istirahatte, aktivite sırasında ve
gece olan boyun ağrısı şiddetinde artış gözlenirken ( sırası ile r=0.114 p=0.045; r=0,247
p=0,000; r=0.206 p=0.000) günlük bilgisayar kullanımı arttıkça sadece aktivite sırasında
boyun ağrısı şiddetinde artış anlamlı bulunmuştur (r=0,183 p=0.001). PHQ depresyon
skorunun artışı ile bilgisayar (r=0.128 p=0.025) ve cep telefonu kullanımı (r=0,152
p=0,008) süresi arasında da ilişki saptanmıştır. Bournemouth boyun ağrı ölçeği
sorularının çalışmamızdaki Cronbach’s alpha değeri 0.914 bulunarak iç güvenirliliğinin
yüksek (>0.70) olduğu görülmüştür.
Sonuç: Çalışmamızda kronik boyun ağrısı nedenli şikayet ve özür artışını ölçen
Bournemouth boyun ağrı ölçek skoruna göre oturarak çalışma şekli ve oturma süresi
anlamlı bulunmazken, özellikle cep telefonu ve bilgisayar başında geçen süre anlamlı
bulunmuştur. İşyerlerinde ekranlı araç kullanımı kronik boyun ağrısı gibi meslek
hastalıkları gelişimi ve ergonomi açısından dikkate değer görülmüştür.
Anahtar Kelimeler: Bournemouth, boyun ağrısı, fiziksel aktivite, kronik ağrı
Özet
Amaç:
Lateks, Havea Brasiliensis bitki öz suyunun içerisine birtakım katkı
maddelerinin eklenmesi sonucu elde edilen bir ürün olup sağlık alanında
birçok tıbbi araç ve gereç içerisinde günlük yaşamda yaygın olarak
kullanılmaktadır. Günümüzde lateks alerjisi sıklığı; spina bifida, mesane
ekstrofisi gibi sık cerrahi girişimlere maruz kalan duyarlı popülasyonda,
sağlık çalışanlarında, lateksle ilgili üretim yapan işçilerde ve genel popülasyonda gittikçe
artmaktadır.
Lateks alerjisi sıklığı sağlık çalışanlarında %9.7, duyarlı hasta grubunda %7.2 ve genel
popülasyonda %4.3 olarak bildirilmektedir 1 . Lateks alerjisi iritan veya alerjik kontakt
dermatitten ürtiker, angioödem, rinit, astım, konjonktivit hatta anafilaksiye kadar
gidebilen klinik tablolara yol açabilir 2,3 . Anafilaksiye neden olan ajanlar arasında
nöromuskuler bloke edici ilaçlardan sonra ikinci sırada yer alır 4,5 . Lateks alerjisinin
tanısında deri prick test, K82 lateks spesifik IgE ve bunlarla sonuç alınamadığı
durumlarda nasal provokasyon testleri kullanılır. Ayrıca lateks malzemelerde kullanılan
yardımcı katkı maddeleri ve buna bağlı gelişen dermatit ile ilgili deri patch testleri demevcuttur. Biz burada polikliniğimizde takip ettiğimiz hastaları derledik ve lateks
alerjisinin yaygınlığına ve sağlık çalışanlarında sık görülen bir meslek hastalığı olduğuna
dikkat çekmeyi amaçladık.
Gereç ve Yöntem:
2014-2020 yılları arasında hastanemiz Alerji ve İmmunoloji Polikliniği’ne başvuran ve
polikliniğimiz takibinde olan lateks alerjisi tanılı hastalar rektrospektif olarak tarandı.
Hastalar yaş, cinsiyet, meslek, deri prick testi sonucu, K82 lateks spesifik IgE ve
semptomlar açısından değerlendirildi.
Bulgular:
Hastaların 18 (%69,2)’i kadın, 8 (30,8)’i erkek ve yaş ortalaması 41,6 idi. Hastaların
çoğunluğunu
%77(20/26) (1 cerrah, 1 sağlık memuru, 1 diş teknisyeni, 17 hemşire
olmak üzere) sağlık çalışanları oluşturdu. Dört hasta lateks eldiven kullanan işçi, 1 hasta
memur, 1 hasta da ev hanımı idi. Lateks prick testleri 2+ ila 5+ arasındaydı. K82 lateks
spesifik IgE bakılabilen hastalarda 1+ ila 4+ arasında değişmekte idi, sadece 1 hastada
ise K82 lateks spesifik Ige negatif bulundu. Semtomların sıklığı; %92 (24) dermatit, %38
(10) angioödem, %35 (9) rinit, %19 (5) konjonktivit, %11(3) ürtiker, %3 (1) dispne, %3 (1)
astım, %8 (2) anafilaksi ve bu semptomların kombinasyonları mevcut idi.
Sonuç:
Lateks alerjisi, lateks eldiven kullananlarda, kauçuk ve lastik üretimi yapan işçilerde,
lateks büro malzemeleri kullanan memur ve ofis çalışanlarında ve daha büyük
çoğunlukta da sağlık çalışanlarında görülebilen bir hastalıktır. Lateks eldivenlerin ve
lateksten yapılmış tıbbi malzemelerin yaygın kullanımı da lateks alerjisinin duyarlıkişilerde ortaya çıkmasının altında yatan sebeptir. Sağlık çalışanlarında sık görüldüğü için
de bir meslek hastalığı olarak değerlendirilmesinin uygun olacağını düşünüyoruz.
Anafilaksi gibi ölümcül klinik tablolara yol açabilmesi de bu konunun önemine işaret
etmektedir.
Anahtar Kelimeler: Lateks Alerjisi, Semptom, Tanı, Sağlık Çalışanları
Özet
Giriş ve Amaç: Psödoeksfoliasyon (PEX) sendromu, ekstraselüler matrikste fibriler bir materyalin üretimi, intraoküler ve ekstraoküler dokularda progresif birikimi ile karakterize bir hastalıktır. PEX sendromunda göz açısından başlıca glokom olmak üzere, katarakt, fakodonesis, lens subluksasyonu, yetersiz dilatasyon, kornea endoteli dekompazyonu gibi komplikasyonlar da görülebilir. PEX’in ekstraoküler manifestasyonları ile ilgili yapılmış çalışmalar, koroner arter hastalığı (KAH), koroner arter ektazisi, sistemik endotel disfonksiyonu, geçici iskemik ataklar, plazmada artmış homosistein seviyeleri nedeniyle kardiyovasküler sonlanımlarla ilişkili bir hastalık olabileceğini göstermektedir. Epikardiyal yağ dokusu (EAT), miyokardiyumun çevresinde bulunan yağ dokusu olup metabolik sendrom, koroner ateroskleroz, atriyal fibrilasyon gibi patolojilerin insidansı ile ilişkili olduğu gösterilmiştir. Biz bu çalışmada PEX sendromunun EAT kalınlığı ile ilişkisini değerlendirmeyi amaçladık.
Metod: Çalışmaya Sivas Cumhuriyet Üniversitesi Göz Hastalıkları polikliniği tarafından PEX sendromu tanısı konan 36 hasta ile yaş ve cinsiyet açısından benzer 50 sağlıklı gönüllüden oluşan toplam 86 katılımcı alındı. PEX sendromu olan hastalar ayrıca glokomu olan ve olmayanlar olarak değerlendirildi. Kardiyoloji bölümü tarafından yapılan transtorasik ekokardiyografide iki grubun ekokardiyografik parametreleri ve epikardiyal yağ dokusu kalınlığı kıyaslandı. EAT kalınlığının (mm) ölçümleri yapılırken parasternal uzun eksen görüntü kullanıldı ve sağ ventrikülün serbest duvarı önündeki epikardiyal yağ dokusunun maksimum diastolik kalınlığı en az üç kardiyak döngüde ölçülerek ortalaması alındı. Bulgular: Çalışmaya alınan 36 PEX’li hastanın ortalama yaşları 71,75±8,48 olup 19’u kadındı. Kontrol grubunun ise ortalama yaşları 69,08±8,47 olup 25’ i kadındı (p=0,09). Gruplar arasında diyastolik parametreler açısından anlamlı fark izlenmedi (p>0,05). Sol ventrikül end sistolik çapı PEX grubunda kontrol grubuna göre anlamlı olarak azalmıştı (3,25±0,37, 3,57±0,44, sırasıyla, p=0,001). Sağ ventrikül çapı PEX grubunda kontrol grubuna göre daha düşüktü (2,76±0,5, 3,06±0,42, sırasıyla, p=0,006). EAT değeri ise PEX grubunda kontrol grubuna göre anlamlı olarak daha yüksek izlendi (0,51±0,24, 0,36±0,21, sırasıyla p<0,005). PEX sendromu olan hastaların 16’sında glokom mevcuttu. Ekokardiyografik parametreler açısından değerlendirildiğinde glokomu olan ve olmayan gruplar arasında istatistiksel fark izlenmedi (p>0,05). PEX sendromunun bağımsız prediktörlerini belirlemek için yapılan çok değişkenli lojistik regresyon modelinde EAT'nin bağımsız bir prediktör olduğu gözlendi. (OR=2,43 [1,138-113,434], p=0,038) Sonuç: Epikardiyal yağ dokusu kalınlığı, kardiyovasküler sonlanımlar üzerinde progognostik bilgiler sağlayan ve KAH ciddiyeti ile ilşkilendirilen kolay uygulanabilir ve ucuz bir belirteçtir. PEX sendromu olan hastalarda epikardiyal yağ dokusu kalınlığı artışı, PEX sendromunda izlenen artmış kardiyovasküler sonlanımlar ile ilişkilendirilebilir.
Anahtar Kelimeler Epikardiyal Yağ Dokusu, Psödoeksfoliasyon Sendromu, Glokom
Chest pain is a common symptom in pediatrics. Anamnesis and clinical examination reveal the cause and subsequent approach. Paraclinical examinations are required in establishing the diagnosis, especially for the exclusion of a cardiac or pulmonary cause. The etiology is, in most cases, benign. The presence of cardiac or respiratory signs of gravity suggests an organic pathology which requires therapeutic intervention. The authors present the most common causes of non-traumatic chest pain and the approach of this symptom in the pediatric patients.
Disorders of gastrointestinal motility result from abnormal contractions of the smooth muscles of the gastrointestinal tract. This may result in diarrhea and bloating or constipation with or without accompanying abdominal pain. Drugs that act on the gastrointestinal tract may be categorized into three groups: (1) agents that enhance smooth muscle contractions, referred to as prokinetic agents; (2) agents that inhibit contractions, which may be agents that retard normal peristalsis referred to as antimotility agents (opiates and opiate receptor agonists), or agents that reduce abnormally elevated gastrointestinal smooth muscle tone, referred to as antispasmodics (anticholinergics, direct smooth muscle relaxers, and calcium channel blockers); and (3) agents that act to promote evacuation of stool, referred to as laxatives. This chapter will discuss prokinetics, antimotility agents, and antispasmodics, as well as laxatives commonly used in clinical practice.
Swallowing is an important developmental process for human life. It requires the cooperation of the mouth, pharynx, and esophagus for successful completion. Esophageal dysphagia, or difficult swallowing, can be the result of behavioral, developmental, and neurological respiratory disorders, GER, and inflammatory diseases. It is observed in 25–45 % of developing children and even more with developmental disorders
Disorders of gastrointestinal motility result from abnormal contractions of the smooth muscles of the gastrointestinal tract. This may result in diarrhea and bloating or constipation with or without accompanying abdominal pain. Drugs that act on the gastrointestinal tract may be categorized into three groups: (1) agents that enhance smooth muscle contractions, referred to as prokinetic agents; (2) agents that inhibit contractions, which may be agents that retard normal peristalsis referred to as antimotility agents (opiates and opiate receptor agonists) or agents that reduce abnormally elevated gastrointestinal smooth muscle tone, referred to as antispasmodics (anticholinergics, direct smooth muscle relaxers, and calcium channel blockers); (3) agents that act to promote evacuation of stool, referred to as laxatives. This chapter discusses prokinetics, antimotility agents, and antispasmodics, as well as laxatives commonly used in clinical practice.
The esophagus, which plays a primary role in food transport, is a collapsible organ with three main sections: upper esophageal sphincter (UES), esophageal body, and lower esophageal sphincter (LES). This chapter details basic pathophysiologic aspects of four disorders of esophageal motility, esophageal achalasia, esophageal spasm, nutcracker esophagus, and eosinophilic esophagitis and briefly describes nonspecific esophageal motility disorders. Each disorder causes different eating and digestive symptoms (dysphagia, abdominal and chest pain, heart burn, regurgitation of digested food) and may appear to mimic GERD or esophageal reflux. In some disorders, such as achalasia, much of the literature is based on the adult population, while pediatric information is noted only in case and retrospective studies. On the other hand, eosinophilic esophagitis is more prevalent in the pediatric population and may be related to food and environmental allergens. Diffuse esophageal spasm and nutcracker esophagus are benign and very rare in the pediatric population.
Although the underlying cause is most likely not cardiac-related, pediatric chest pain still needs to be taken seriously. Here's how to tell when this problem requires referral.
During the past decade there have been advances in the understanding of gastrointestinal (GI) motility and sensory disorders in children. Newly validated diagnostic techniques can accurately diagnose previously misunderstood patients, and progress is being made in the treatment of enteric neuromuscular disorders. In this chapter pediatric GI motility disorders are discussed according to the anatomy of the GI tract. The esophagus includes three functional regions: The upper esophageal sphincter (UES), the esophageal body, and the lower esophageal sphincter (LES). The UES consists of striated muscle, which relaxes in response to swallowing. The esophageal body is lined by striated muscle in the proximal third, mixed striated and smooth muscle in the middle third, and smooth muscle in the lower third. Esophageal peristalsis is initiated by swallowing and is independent of intrinsic myoelectrical activity. The coordinated motor pattern of the esophagus is called primary peristalsis. Secondary peristalsis is usually induced by luminal distention or incomplete clearance of luminal contents by primary peristalsis. This is an important mechanism for the clearance of gastric contents during gastroesophageal reflux. The lower esophageal sphincter (LES), a band of smooth muscle located at the junction of the distal esophagus and gastric cardia, is tonically contracted except during swallowing when it relaxes momentarily to allow the food bolus to pass into the stomach. Inappropriate LES relaxation independent of swallowing is the mechanism responsible for the majority of gastroesophageal reflux episodes both in adults and children.
Background: Disordered oesophageal and gastric motility may pose serious problems in affected children.
Methods: Review of literature.
Results: In premature infants, suction, swallowing and respiration may not be fully coordinated, which permits a penetration of food into the nasopharynx and aspiration. Oropharyngeal dysphagia occurs with central nervous disorders, tongue and pharyngeal muscle weakness, malformations and incomplete pharyngo-oesophageal sphincter relaxation upon swallowing. Oesophageal obstruction may result from impaired inhibitory innervation. In children with atresy, the motility of the remaining oesophagus is most often compromised. Achalasia of the gastro-oesophageal sphincter results from a lack of nitric-oxide synthase in the myenteric plexus. Diffuse oesophageal spasms may occur “spontaneously” or upon gastro-oesophageal refluxes. Reflux is fostered by transient, non-swallow-induced relaxations and a low gastro-oesophageal sphincter resting pressure; oesophageal clearance of refluate often is impaired. Pathological reflux diminishes during the first year of life but is frequent in children with respiratory diseases, apnoeas, mental retardation and cerebral palsy. Gastric emptying may be slow in preterm infants, gastro-oesophageal reflux disease and a variety of other conditions. Hypertrophic pyloric stenosis results from a lack of nitric-oxide synthesis in the myenteric plexus.
Conclusions: Oesophageal and gastric motility disorders should receive due attention. Their adequate treatment relies on appropriate diagnostic measures.
Diffuse esophageal spasm (DES) causes chest pain and/or dysphagia in adults. We reviewed charts of 278 subjects 0-18 years of age after esophageal manometry to describe the frequency and characteristics of DES in children. Patient diagnoses included normal motility (61%), nonspecific esophageal motility disorder (20%), DES (13%, n = 36), and achalasia (4%). Of patients with DES, the most common chief complaint was food refusal in subjects <5 years (14/24, 58%) and chest pain in subjects > 5 years (4/12, 33%). Comorbid medical conditions, often multiple, existed in 33 subjects. DES should be considered when young children present with food refusal.
Even though chest pain in children is a common complaint, an underlying gastrointestinal cause is rare. The four common gastrointestinal conditions that present with chest pain include eosinophilic esophagitis, gastroesophageal reflux disease, esophageal dysmotility, and foreign body ingestion. Other than ingestion of certain foreign bodies, most of these conditions are not life-threatening. Associated symptoms and history may be helpful in distinguishing these disorders, but further evaluation is often indicated to identify the precise cause.
The epidemiology and associated risk factors of pediatric chest pain are not well described. Several studies report the prevalence of chest pain types among children and adolescents; however, detailed prospective studies that aim to determine continued morbidity, mortality, health-care seeking behaviors, continued medication use, and quality of life are lacking. A greater understanding of pediatric chest pain epidemiology and risk factors is required.
A physician or athletic trainer will often be faced with an athlete complaining of chest pain during or after an event. Chest pain in children and adolescents is usually of a noncardiac origin; only 5% of cases are due to cardiac problems. With a properly documented history and physical evaluation, one can usually identify the etiology of the chest discomfort or at least rule out any serious difficulties. The various diagnostic possibilities include cardiac, musculoskeletal, pulmonary, gastrointestinal, and psychiatric causes of pain. We discuss several specific conditions, as well as the signs, symptoms, and basic management.
A child affected by exertional chest pain secondary to gastroesophageal reflux (GER) disease is reported. Family history revealed the presence of rumination in two members. In our patient, heart diseases as well as other causes of chest pain were excluded. An ultrasound examination of the gastro-esophageal junction, performed in the first 15 minute of the post-prandial period, showed a pathological number of GER episodes. The patient was treated with cisapride (0.2 mg/kg t.i.d. per os). At follow-up, after three months, he was symptom-free. We repeated an ultrasound examination, which resulted normal. Ours is the first paediatric case characterized by exertional chest pain secondary to GER disease.
Motility disorders are common in children and may affect any area of the GI tract. The past decade has brought significant advances in the understanding of motility disorders in pediatrics. More sophisticated testing techniques have helped to differentiate normal from abnormal motility in children of different ages. Manometry now may be used to clarify the pathophysiologic defect underlying chest pain, dysphagia, rumination, gastroparesis, chronic intestinal pseudo-obstruction, and colonic neuromuscular disorders. Motility testing also may be used to identify the motor defect responsible for persistence of symptoms after surgery for GER or HD. New investigational techniques and prokinetic agents likely to be available in the future also were discussed.
Symptoms of chest pain and dysphagia are common in the adult population. Most patients initially undergo an evaluation to exclude anatomic causes (ie, esophagitis, stricture) and cardiovascular disease as the etiology of these symptoms. Patients with persistent symptoms may then be referred for specialized testing of the esophagus, including esophageal manometry. Disorders of esophageal motility, which include achalasia, diffuse esophageal spasm, nutcracker esophagus, hypertensive lower esophageal sphincter, and ineffective motility are often identified in these patients. Unfortunately, the etiology of these disorders has not been well characterized and the treatment has not been standardized. This review will briefly discuss the impact, etiology, and diagnosis of esophageal motility disorders, and then focus on the medical management of these disorders using evidence from well-designed, prospective studies, where available.
Twenty seven children who had been diagnosed as having idiopathic chest pain were investigated to find out if the pain was of gastrointestinal origin. The symptoms had lasted from two weeks to eight months. In 21 of the 27 children (78%) the chest pain had a gastrointestinal cause: 16 had oesophagitis, four had gastritis, and one had diffuse oesophageal spasm. All patients responded to medical treatment of their gastrointestinal symptoms, resulting in disappearance of the chest pain.
In a retrospective study of chest pain, 267 children were identified. This gave an occurrence rate (per patient visit) of 0.249%. Male patients were identified as often as female patients, and teenagers as often as children less than age 12 years. Chest pain was found to be present for more than 1 month in 8.6% and for more than 1 year in 7.8%. Idiopathic chest pain was the most common diagnosis made, followed by functional pain (anxiety related) and musculoskeletal pain. Laboratory tests were not helpful in establishing the etiology of chest pain.
One hundred adolescents with chest pain were prospectively analyzed to determine the etiology, functional consequences, and illness attributions of patients seen in a general pediatric clinic. The typical patient had frequent pain (63% had two or more episodes weekly) of moderate duration (51% of the pain lasted longer than six minutes) that had been occurring for many months (36% had pain occurring longer than 6 months). Stressful events, such as a death in the family, major illness, an accident, family separations, and school changes occurred in 31% of patients. The most frequently diagnosed condition was musculoskeletal problems (31%) including costochondritis (14%), chest wall syndrome (13%), skeletal trauma (2%), and ribcage anomalies (2%). Hyperventilation accounted for 20% of diagnoses and 5% had breast-related problems. Thirty-nine percent of patients had pain not readily classifiable. Serious underlying illness was a rare cause of chest pain, although several patients had associated organic disease not responsible for their chest pain. More than two thirds of patients restricted physical activities; more than 40% were absent from school. When patients were questioned about their understanding of their illness, 44% were afraid that they were experiencing a heart attack, 12% worried about heart disease, and 12% feared cancer. Chest pain is a prevalent problem that is usually benign but is commonly misunderstood and causes considerable dysfunction and anxiety in adolescents.
Records from 910 patients referred to our clinical esophageal manometry laboratory for evaluation of noncardiac chest pain between January 1983 and December 1985 were reviewed and compared with records from 251 patients referred for dysphagia. Evaluation included baseline esophageal manometry, acid perfusion test, and edrophonium provocation. In the chest-pain group, 655 patients (72%) had normal esophageal motility and 255 (28%) had abnormal motility. Nutcracker esophagus was present in 48% of abnormal tracings, suggesting that it is a manometric marker for noncardiac chest pain. Of the total chest-pain group, 243 patients (27%) had their pain reproduced during provocative testing ("definite" esophageal pain); 192 patients (21%) had baseline manometric abnormalities but no pain during provocative testing ("probable" esophageal chest pain). The highest percentage of positive provocative responses (34%) occurred in patients with nutcracker esophagus on baseline manometry. Manometric abnormalities were statistically commoner (p < 0.001) in patients with dysphagia, occurring in 53%. Achalasia (36%) and nonspecific esophageal motility disorders (38%) were the commonest abnormalities in this group, with nutcracker esophagus being infrequent (10%).
Although esophageal manometry is widely used in clinical practice, the normal range of esophageal contraction parameters is poorly defined. Therefore, 95 healthy volunteers (mean age: 43 years; range 22–79 years) were studied with a low-compliance infusion system and 4.5-mm-diameter catheter. All subjects were given 10 wet swallows (5 cc H2O) and 38 subjects also were given 10 dry swallows. Results: Amplitude, but not duration, was greater (P<0.05) after wet compared to dry swallows. Both distal mean contractile amplitude and duration of wet swallows significantly increased with age and peaked in the fifties. Double-peaked waves frequently occurred after both wet (11.3%) and dry (18.1%) swallows, but triple-peaked waves were rare (<1%). Nonperistaltic contractions were more common (P<0.001) after dry compared to wet swallows (18.1% vs 4.1%). This difference resulted from frequent simultaneous contractions after dry swallows (12.6% vs 0.4%). Conclusions: (1) Distal esophageal contractile amplitude and duration after wet swallows increases with age. (2) Triple-peaked waves and wet-swallow-induced simultaneous contractions should suggest an esophageal motility disorder. Double-peaked waves are a common variant of normal. (3) Dry swallows have little use in the current evaluation of esophageal peristalsis.
By means of structured personal home interviews, health problems and physician care obtained for those problems were studied in an area probability sample of 562 non-Hispanic, black adolescents, drawn from a single health district in a major city in the Northeastern U.S. Physician care was represented by a ratio score: the number of health problems for which the adolescent had seen a physician divided by the total number of health problems he reported. On the basis of these scores, adolescents were separated into “high” and “low” physician care groups and compared with regard to: kinds of health problems, general health status, demographic and family background characteristics, health attitudes and behavior and psychosocial attitudes. Bivariate and then multivariate analyses were performed. A major finding indicated a relationship between lack of medical care and activity limitation or chronic impairment as early as the adolescent years. In multivariate analysis, the variable which accounted more than any other for the difference between black adolescents with “high” and “low” physician care scores was the combination of having a private physician and a mother born outside the southern U.S. Generally the findings supported the model of significant psycho-sociocultural influences, over and above need for care and availability of services, in explaining medical utilization.
The histologic features of the distal esophagus were examined in multiple biopsy specimens from 15 asymptomatic control patients and 40 patients with clinical evidence of reflux esophagitis. The coexistence in at least two biopsy specimens of lamina propria papillary height that was greater than 50% of the epithelial thickness, and basal cell layer proliferation that was greater than 15% of the epithelial thickness was noted in 95% of patients with reflux esophagitis and in none of the asymptomatic patients. Most importantly, both changes were present in a similar percentage of the 20 patients with clinical evidence of mild esophagitis and endoscopically normal appearing esophagus. These changes provide objective evidence that contributes greatly to the diagnosis of reflux esophagitis in the presence of endoscopically normal esophagus.
Chest pain in adolescents and children is usually not of cardiac origin. Of cardiac conditions commonly linked to chest pain in childhood, mitral valve prolapse (MVP) is the most prevalent, but this association has recently been questioned. In light of recent reports of gastroesophageal sources of chest pain in adults with MVP, we performed a comprehensive gastroesophageal evaluation of 17 preadolescents and adolescents with mitral valve prolapse who had chest pain as their presenting symptom. Evaluation consisted of esophageal manometry, Bernstein test, esophageal pH probe, and/or esophagogastroscopy. Fourteen of the 17 patients had at least one abnormal finding. Five patients had esophagitis, five had gastritis, one had high-amplitude esophageal contractions, one had abnormal esophageal manometry with positive Bernstein test, one had esophageal reflux and positive Bernstein test, and one had abnormal manometry with esophageal reflux. The 13 patients with esophagitis, gastritis, reflux, or positive Bernstein test were treated with antacid, with resolution of chest pain in 12 patients. Two of these patients underwent follow-up endoscopy with documentation of improvement. The patient with high-amplitude esophageal contractions was treated with dicyclomine, which resulted in resolution of chest pain. The observation that the chest pain was not related to mitral valve prolapse is important in clinical practice and raises further questions as to whether mitral valve prolapse causes chest pain.
Sixteen patients with asthma and chest pain of greater than 2 months duration underwent gastroenterological evaluation utilizing fiber-optic esophagogastroduodenoscopy (EGD), esophageal manometry, and Bernstein testing. Eleven of 16 patients (75%) had endoscopic and histologic evidence of esophagitis. One patient with esophagitis exhibited high-amplitude peristaltic contractions during motility testing. Four of these 11 patients (36%) had a positive Bernstein test. Extended intraesophageal pH monitoring of seven patients with esophagitis revealed significant gastroesophageal reflux (GER) in all of these patients. Chest pain was associated with an episode of GER in three patients (43%). Nine of 11 patients (82%) with esophagitis responded to medical therapy, resulting in resolution of esophageal inflammation and chest pain. One patient required Nissen fundoplication surgery after failure of medical therapy, and one patient who refused surgery progressively developed more severe esophagitis during 9 months of medical therapy. Children with asthma may have chest pain due to gastroesophageal reflux-associated esophagitis that usually responds to medical therapy.
Fourty-four unselected patients with noncardiac chest pain were studied using conventional manometry with additional edrophonium provocation and 24-hour ambulatory esophageal pH and pressure recording with a system developed by our group. New, fully automated techniques of statistical analysis of the complete set of esophageal pressure and pH signals were used to examine the temporal relation between pain, esophageal motility disturbances, and gastroesophageal reflux. The analysis used the 97.5th percentile of amplitude and duration of all esophageal contractions in each patient as well as a chi 2 test of the distribution of contraction types to determine whether a pain episode was related to abnormal motility or not. The edrophonium test results were positive in 2 patients. Only 25 patients (56.8%) had at least one pain episode (total, 111 episodes) during 24-hour recording. Thirty-three percent of the pain episodes were related to reflux and 23.4% to abnormal motility, and 43.2% were not related to an esophageal function disturbance. In the patient-oriented analysis in this study, it was required for a positive correlation that the symptom index (percentage of related pain episodes) was higher than 75%. It was found that the pain was related to reflux in 2 patients (4.6%), to reflux and motor abnormalities in 4 (9.2%), and to motor abnormalities in 2 patients (4.6%). In 36 patients (81.8%), no relation with an esophageal abnormality could be established, either because the patients had no pain during the 24-hour study, or because the pain seemed unrelated to reflux or abnormal motility.
Five adolescents, 13-18 years of age, underwent esophageal manometric studies because of chronic symptoms suggestive of esophageal dysfunction. Four of five patients had episodic nonexertional midchest pain; two patients experienced intermittent dysphagia. The manometric findings for these adolescents were consistent with a primary motility disorder known as diffuse esophageal spasm, a condition not previously reported in this age group. This represents approximately 1% of all pediatric patients undergoing esophageal manometry at our institution for the past 5 years. They have been followed for at least 2 years and three have experienced gradual resolution of their symptoms with normalization of manometric findings. Our report emphasizes two main points: (a) Diffuse esophageal spasm may cause chest pain and dysphagia in adolescents; and (b) the clinical history and esophageal manometric findings establish the diagnosis of diffuse esophageal spasm.
To evaluate the importance of esophageal abnormalities as a potential cause of recurrent noncardiac chest pain.
We discuss the rapidly evolving new knowledge in this field after analyzing the literature in English published since 1979.
We reviewed 117 articles on recurring chest pain and paid specific attention to the following nine controversial issues: the potential mechanisms of esophageal pain, the differentiation of cardiac and esophageal causes, the evaluation of new esophageal motility disorders, the use of esophageal tests in evaluating noncardiac chest pain, the usefulness of techniques for prolonged monitoring of intraesophageal pressure and pH, the relation of psychologic abnormalities to esophageal motility disorders, the possible mechanisms for decreased visceral pain thresholds in these patients, the relation of esophageal chest pain to the irritable bowel syndrome, and the appropriate therapies for these patients.
Through our review of the literature, we identified areas of concordance and disagreement. These areas are discussed and an overall perspective is provided.
Continuing attempts to develop rational diagnostic and therapeutic approaches to patients with noncardiac chest pain should include a multidisciplinary approach involving basic scientists, gastroenterologists, psychologists, and other clinical experts in the field of pain research.
When a patient presents with chest pain, the first order of business is likely to be differentiation of cardiac from noncardiac etiology. Recently, there has been increasing attention focused on disorders of esophageal motility. At least 10 discrete entities have now been identified. Their pathogenesis and diagnostic characteristics are discussed in this first segment of a two-part article.
Noncardiac chest pain can be a diagnostic dilemma because patients rarely experience spontaneous chest pain in the laboratory. Therefore, we studied 24 patients with chronic, daily, substernal chest pain with a prototype 24-h ambulatory esophageal motility and pH system. Spontaneous chest pain episodes were correlated with pH less than 4 and abnormal motility changes (mean amplitude and duration, maximum amplitude and duration, or percentage of abnormal peristalsis) defined as exceeding the patient's normal esophageal motility pattern. Twenty-two patients experienced a total of 92 spontaneous chest pain episodes. Eleven chest pain episodes (12%) occurred during abnormal motility, whereas 18 episodes (20%) were associated with pH less than 4 and four episodes (4%) had both abnormalities. The majority of chest pain episodes, 59 events (64%), did not have any association with motility or pH. Abnormal maximum duration and amplitude were the motility changes most frequently associated with chest pain. Overall, 13 of 22 patients (59%) had at least one chest pain episode correlating with abnormal motility or pH (range 33%-100%). Therefore, we conclude that ambulatory esophageal motility and pH monitoring is useful in the evaluation of noncardiac chest pain. pH abnormalities (20%) are more commonly associated with chest pain than motility abnormalities (12%). However, the majority of chest pain episodes (64%) did not correlate with either abnormality and may be the result of lowered esophageal pain threshold for distention, i.e., the "irritable esophagus."
Previous studies of childhood chest pain have been retrospective or considered only limited age groups or referred patients. In this study, all children who were admitted to the emergency department with chest pain were evaluated prospectively. Patients with ill-defined chest pain had ECGs and echocardiograms performed. A total of 407 children were evaluated. The most common causes of the pain were idiopathic (21%) and musculoskeletal (15%). Cardiac problems were found in 4%. Chest pain was acute (of less than 48 hours' duration) in 43% and chronic (of greater than 6 months' duration) in 7%. Pain caused 30% of children to stay out of school and 31% to awaken from sleep. Chest wall tenderness was the most common abnormality. ECGs were obtained in 47%; results of 31/191 were abnormal but only 4/191 ECG abnormalities were related to the diagnosis. Echocardiograms were obtained in 34%; results of 17/139 were abnormal (12/139 showed mitral valve prolapse). Young children are more likely to have cardiorespiratory problems; children older than 12 years of age are more likely to have psychogenic pain. The description and location of the pain and the patient's sex are not related to the diagnosis. Nonorganic disease is related to a family history of heart disease or chest pain or having chronic pain. Organic disease is related to pain of acute onset, abnormal physical examination results, pain that awakens the child from sleep, and the presence of fever. Laboratory tests are rarely helpful in evaluating children with chest pain. Chest pain in children is usually benign. Psychogenic pain and idiopathic pain are less common than previously believed.
Unlabelled:
Although esophageal manometry is widely used in clinical practice, the normal range of esophageal contraction parameters is poorly defined. Therefore, 95 healthy volunteers (mean age: 43 years; range 22-79 years) were studied with a low-compliance infusion system and 4.5-mm-diameter catheter. All subjects were given 10 wet swallows (5 cc H2O) and 38 subjects also were given 10 dry swallows.
Results:
Amplitude, but not duration, was greater (P less than 0.05) after wet compared to dry swallows. Both distal mean contractile amplitude and duration of wet swallows significantly increased with age and peaked in the fifties. Double-peaked waves frequently occurred after both wet (11.3%) and dry (18.1%) swallows, but triple-peaked waves were rare (less than 1%). Nonperistaltic contractions were more common (P less than 0.001) after dry compared to wet swallows (18.1% vs 4.1%). This difference resulted from frequent simultaneous contractions after dry swallows (12.6% vs 0.4%).
Conclusions:
Distal esophageal contractile amplitude and duration after wet swallows increases with age. Triple-peaked waves and wet-swallow-induced simultaneous contractions should suggest an esophageal motility disorder. Double-peaked waves are a common variant of normal. Dry swallows have little use in the current evaluation of esophageal peristalsis.
Sixty patients with anginalike chest pain of noncardiac origin were studied to determine the diagnostic value of 24-h ambulatory esophageal pH and pressure monitoring. The results of these 24-h studies were compared with those obtained by established methods, including x-rays, endoscopy with biopsy, conventional esophageal manometry, and acid perfusion test. Esophageal origin of the chest pain was considered to be likely if the familiar pain sensation was reproduced by the acid perfusion test, or if the pain occurred during an episode of gastroesophageal reflux, severe motor disorders, or both. When the results of established methods were combined and interpreted according to predetermined criteria, esophageal origin of the pain was shown to be likely in 27% of the patients. The 24-h recordings, alone, showed the esophagus to be the likely cause of the pain in 35% of the patients. Combination of all conventional examinations and of 24-h recordings made esophageal origin of the pain likely in 48% of the patients.
Four adolescents with achalasia were treated with nifedipine. All the patients' symptoms improved dramatically. On manometric evaluation, following oral nifedipine, the lower esophageal sphincter pressure decreased approximately 50%. No change in esophageal peristaltic activity was noted. Side effects were minimal; two patients had mild headache initially. Nifedipine, which is commonly used in adult patients with achalasia, may be beneficial for short-term symptomatic relief in children until more definitive therapy can be performed.
Records from 910 patients referred to our clinical esophageal manometry laboratory for evaluation of noncardiac chest pain between January 1983 and December 1985 were reviewed and compared with records from 251 patients referred for dysphagia. Evaluation included baseline esophageal manometry, acid perfusion test, and edrophonium provocation. In the chest-pain group, 655 patients (72%) had normal esophageal motility and 255 (28%) had abnormal motility. Nutcracker esophagus was present in 48% of abnormal tracings, suggesting that it is a manometric marker for noncardiac chest pain. Of the total chest-pain group, 243 patients (27%) had their pain reproduced during provocative testing ("definite" esophageal pain); 192 patients (21%) had baseline manometric abnormalities but no pain during provocative testing ("probable" esophageal chest pain). The highest percentage of positive provocative responses (34%) occurred in patients with nutcracker esophagus on baseline manometry. Manometric abnormalities were statistically commoner (p less than 0.001) in patients with dysphagia, occurring in 53%. Achalasia (36%) and nonspecific esophageal motility disorders (38%) were the commonest abnormalities in this group, with nutcracker esophagus being infrequent (10%).
In a retrospective study of chest pain, 267 children were identified. This gave an occurrence rate (per patient visit) of 0.249%. Male patients were identified as often as female patients, and teenagers as often as children less than age 12 years. Chest pain was found to be present for more than 1 month in 8.6% and for more than 1 year in 7.8%. Idiopathic chest pain was the most common diagnosis made, followed by functional pain (anxiety related) and musculoskeletal pain. Laboratory tests were not helpful in establishing the etiology of chest pain.
Discussed are the diagnostic and therapeutic issues of cardiac disease in the pediatric age group that have the potential to result in ischemic ventricular dysfunction. The discussion then turns to the nontraumatic thoracic, gastrointestinal, and psychogenic disturbances that are likely to produce symptoms of chest pain. In this context, the question of when to refer, when to reassure, when to begin a diagnostic evaluation, and when to institute longitudinal follow-up are addressed.
Records of 67 pediatric patients with a primary complaint of chest pain were reviewed to determine the frequency of associated cardiac disease. Only four of 67 (6%) had chest pain associated with cardiac diseases that usually cause chest pain. Fifty-seven (85%) patients had chest pain in which no clear cause could be determined. Of these 57, 20 patients also had isolated congenital cardiac anomalies, i.e., atrial septal defect. A causal relationship of these lesions to the chest pain could not be established.
Thirty-four of the 37 patients with chest pain and no cardiac abnormalities were evaluated by telephone at a mean of 13 months after their clinic assessment. Twenty-nine of the 34 were either asymptomatic or had reduced symptoms. There was no correlation between duration of symptoms prior to their clinical study and the persistence of chest pain at follow-up.
From this study, we conclude that chest pain in pediatric patients is infrequently due to cardiac disease even when associated with previously unsuspected, isolated congenital cardiac lesions. Idiopathic chest pain tends to be self-limited.
Thirty-four consecutive patients referred to a gastroenterology clinic with suspected esophageal motility abnormality as a cause of their chest pain or dysphagia, or both, were prospectively studied in an 18-mo period. Peristaltic response to 10 wet (5 ml H2O) swallows was recorded in all studies with a low-compliance infusion system. To provoke symptoms and motility abnormalities after baseline evaluation, all patients had acid infusions (0.1 N HCl) and administration of edrophonium (80 micrograms/kg i.v.), pentagastrin (6 micrograms/kg s.c.), and bethanechol (40 micrograms/kg s.c.). Tracings were coded, read, and interpreted blindly. Baseline tracings were abnormal in 23 of 34 patients (68%), including increased amplitude peristaltic contractions ("nutcracker esophagus") in 10 and nonspecific esophageal motor disorders in 13. Acid infusion produced substernal burning in 3 of 33 patients, in motility change in 1 patient. Edrophonium produced chest pain with manometric changes in 6 of 34 (18%) patients. Pentagastrin produced chest pain with manometric change in 1 patient. Bethanechol produced chest pain with manometric change in 2 patients. One patient with low amplitude had elevation of esophageal baseline and multiple simultaneous contractions but no chest pain (subsequently developed achalasia). It was concluded that (a) abnormal motility is a common finding in a symptomatic group of patients with presumed esophageal motility disorder, (b) the "nutcracker" esophagus is the most frequent defect, and (c) attempted provocation of symptoms with acid or drugs is not generally effective; however, edrophonium is the best tolerated and most effective of currently available drugs.
Clinical features, radiographic and esophageal manometry findings, and treatment results in 16 patients less than 15 years old with achalasia are described. Esophageal manometry performed in 15 patients showed results similar to those found in adults: (1) increased resting lower esophageal sphincter pressure, (2) incomplete or failure of relaxation of the lower esophageal sphincter on swallowing, and (3) ineffective or absence of peristalsis in all. The most common symptoms in the 16 patients were: dysphagia in 15, postprandial vomiting in 13, and retrosternal pain in five. The average duration from onset of symptoms to diagnosis was 28 months. The esophagram was diagnostic in all patients. Pneumatic dilation was the initial treatment in eight and was successful for more than 1 year in five. Two patients required two dilations and were then symptom-free for more than 1 year, but required a Heller myotomy. The remaining patients underwent Heller myotomy following failure of the second dilation. Three patients underwent myotomy and two patients had myotomy with fundoplication as initial treatment; only one remained symptomatic. Esophageal dilation using a pneumatic dilator should be the initial treatment of choice in school-aged children. However, if more than two dilations are required within 1 year, surgical management is recommended.
One hundred adolescents with chest pain were prospectively analyzed to determine the etiology, functional consequences, and illness attributions of patients seen in a general pediatric clinic. The typical patient had frequent pain (63% had two or more episodes weekly) of moderate duration (51% of the pain lasted longer than six minutes) that had been occurring for many months (36% had pain occurring longer than 6 months). Stressful events, such as a death in the family, major illness, an accident, family separations, and school changes occurred in 31% of patients. The most frequently diagnosed condition was musculoskeletal problems (31%) including costochondritis (14%), chest wall syndrome (13%), skeletal trauma (2%), and ribcage anomalies (2%). Hyperventilation accounted for 20% of diagnoses and 5% had breast-related problems. Thirty-nine percent of patients had pain not readily classifiable. Serious underlying illness was a rare cause of chest pain, although several patients had associated organic disease not responsible for their chest pain. More than two thirds of patients restricted physical activities; more than 40% were absent from school. When patients were questioned about their understanding of their illness, 44% were afraid that they were experiencing a heart attack, 12% worried about heart disease, and 12% feared cancer. Chest pain is a prevalent problem that is usually benign but is commonly misunderstood and causes considerable dysfunction and anxiety in adolescents.
Ten per cent of patients with angina pectoris have normal coronary arteries and cardiac function and, despite this reassurance, continue to have chest pain. Since pain of cardiac or esophageal origin is clinically difficult to differentiate, 50 patients with severe chest pain, normal cardiac function, and normal coronary arteriography with ergotamine provocation were evaluated with a symptomatic questionnaire and esophageal function test. On 24-hour esophageal pH monitoring, 23 patients had abnormal reflux, and 27 were normal. There was no difference in the incidence and severity of chest pain, esophageal symptoms, or medication taken between refluxers and nonrefluxers. Ten refluxers and ten nonrefluxers had chest pain on exercise electrocardiography. Thirteen refluxers documented chest pain during the pH monitoring period, and in 12 it coincided with a reflux episode. Fifteen nonrefluxers documented chest pain during the monitoring period, and in only one did it coincide with a reflux episode. Of the 23 refluxers, 12 were treated with medical therapy and 11 by a surgical antireflux procedure, and all followed for two to three years. Ten (91%) of the 11 surgically treated patients are totally free of chest pain compared with five (42%) of the 12 medically treated patients. All 12 patients who had chest pain coincide with a documented reflux episode responded positively to antireflux therapy, eight surgical and four medical. It is concluded that 46% of patients complaining of angina pectoris with normal cardiac function and coronary arteriography have gastroesophageal reflux as a possible etiology. Seventy-three per cent of these patients have total abolition of chest pain by either surgical or medical antireflux therapy. Patients whose experience of chest pain coincided with a documented reflux episode on 24-hour esophageal pH monitoring had a 100% response to medical or surgical therapy. Overall, surgical therapy gave better results (91%) but was associated with an 18% temporary morbidity. Objective evaluation of reflux status and its correlation to the symptom of chest pain by 24-hour pH monitoring allows for selective therapy in these difficult to manage patients.
Ten consecutive patients (ages 10 to 17) with achalasia of the esophagus diagnosed by radiographic, manometric, and endoscopic criteria were treated by forceful dilatations of the lower esophageal sphincter. A good to excellent response was seen in eight of the ten patients, manifested by disappearance of vomiting, improvement in dysphagia, and weight gain. A decrease in resting gastroesophageal sphincter pressure was documented in four patients tested. Short-term complications of fever or chest pain were seen following three of 18 procedures; however, barium swallow was negative for perforation and symptoms resolved spontaneously without treatment. Our findings suggest that pneumatic dilatation may produce similar results as surgical esophagomyotomy (Heller procedure) without the immediate operative morbidity, cost, and potential long-term effects.
One hundred adolescent clinic patients who complained of chest or upper abdominal pain were evaluated. Seventy-nine were found to have only tender costal cartilages. Costochondritis pain originates in the anterior chest wall and may radiate into the chest, back, or abdomen. It is reproducible by palpating the affected costal cartilage. Costochondritis was more often unilateral than bilateral (P = 0.001), and in unilaterally affected patients (P less than 0.005), is involved the left side more than the right. The left fourth sternocostal cartilage was involved most frequently. A simple program of mild analgesics and reassurances was sufficient treatment in all cases. These findings suggest that chest pain and upper abdominal pain in adolescents rarely arise from serious problems. Adolescents are normally hypersensitive about physical symptoms, but they can be effectively reassured and an expensive diagnostic and treatment program can be avoided.
Chest pain and dysphagia in adolescents caused by diffuse esophageal spasm Tanca C: Who sees the doctor? A study of urban black adolescents Brown RT: Chostochondritis in adolescents
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Milov DE, Cynamon HA, Andres JM: Chest pain and dysphagia in adolescents caused by diffuse esophageal spasm. J Pediatr Gastroenterol Nutr 9:450-453, 1989 21. Brunswick AP, Bovie JM, Tanca C: Who sees the doctor? A study of urban black adolescents. Soc Sci Med 13A:45-46, 22. Brown RT: Chostochondritis in adolescents. J Adolesc Health Care 1:198-201, 1981
Esophageal manometry in 95 healthy adult volunteers: Variability of pressure with age and fre-quency of abnormal contractions Esophageal Motility Testing
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Richter JE, Wu WC, Johns DN, Blackwell JN, Newson JL, Castell JA, Castell DO: Esophageal manometry in 95 healthy adult volunteers: Variability of pressure with age and fre-quency of abnormal contractions. Dig Dis Sci 32:583-592, 11. Castell DO, Richter JE, Dalton CB, (eds). Esophageal Motility Testing. New York, Elsevier, 1987
Who sees the doctor? A study of urban black adolescents
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