Exertional esophageal pH-metry and manometry in recurrent chest pain.
OBJECTIVE
To investigate the diagnostic efficacy of 24-h and exertional esophageal pH-metry and manometry in patients with recurrent chest pain.


METHODS
The study included 111 patients (54% male) with recurrent angina-like chest pain, non-responsive to therapy with proton pump inhibitors. Sixty-five (59%) had non-obstructive lesions in coronary artery angiography, and in 46 (41%) significant coronary artery narrowing was found. In all patients, 24-h esophageal pH-metry and manometry, and treadmill stress tests with simultaneous esophageal pH-metry and manometry monitoring were performed. During a 24-h examination the percentage of spontaneous chest pain (sCP) episodes associated with acid reflux or dysmotility (symptom index, SI) was calculated. Patients with SI > 50% for acid gastroesophageal reflux (GER) were classified as having GER-related sCP. The remaining symptomatic individuals were determined as having non-GER-related sCP. During the stress test, the occurrence of chest pain, episodes of esophageal acidification (pH < 4 for 10 s) and esophageal spasm with more than 55% of simultaneous contractions (exercise-provoked esophageal spasm or EPES) were noted.


RESULTS
Sixty-eight (61%) individuals reported sCP during 24-h esophageal function monitoring. Eleven of these (16%) were classified as having GER-related sCP and 53/68 (84%) as having non-GER-related sCP. The exercise-provoked chest pain during a stress test occurred in 13/111 (12%) subjects. In order to compare the clinical usefulness of 24-h esophageal function monitoring and its examination limited only to the treadmill stress test, the standard parameters of diagnostic test evaluation were determined. The occurrence of GER-related or non-GER-related sCP was assumed as a "gold standard". Afterwards, accuracy, sensitivity and specificity were calculated. These parameters expressed a prediction of GER-related or non-GER-related sCP occurrence by the presence of chest pain, esophageal acidification and EPES. Accuracy, sensitivity and specificity of chest pain during the stress test predicting any sCP occurrence were 28%, 35% and 80%, respectively, predicting GER-related sCP were 42%, 0% and 83%, respectively, and predicting non-GER-related sCP were 57%, 36% and 83%, respectively. Similar values were obtained for exercise-related acidification with pH < 4 longer than 10 s in the prediction of GER-related sCP (44%, 36% and 92%, respectively) and EPES in relation to non-GER-related sCP (48%, 23% and 84%, respectively).


CONCLUSIONS
The presence of chest pain, esophageal acidification and EPES had greater than 80% specificity to exclude the GER-related and non-GER-related causes of recurrent chest pain.
Budzyński
Jacek
J
Division of Vascular Diseases and Internal Medicine, Dr Jan Biziel University Hospital No. 2 in Bydgoszcz, Ujejskiego 75 Street, 85-168 Bydgoszcz, Poland. budz@cps.pl
D000328:Adult; D000368:Aged; D002637:Chest Pain / Q000175:diagnosis* / Q000209:etiology; D004947:Esophagus / Q000378:metabolism*; D015444:Exercise; D005260:Female; D005764:Gastroesophageal Reflux / Q000150:complications / Q000503:physiopathology; D006801:Humans; D006863:Hydrogen-Ion Concentration; D008297:Male; D008365:Manometry; D008875:Middle Aged; D012008:Recurrence
JAMA. 2009 Apr 8;301(14):1468-74
19351944
Kardiol Pol. 2005 Jan;62(1):52-4
15815780
Arch Med Res. 2003 Sep-Oct;34(5):388-93
14602505
Dig Dis Sci. 1993 May;38(5):795-802
8482176
JAMA. 1989 Jun 23-30;261(24):3599-601
2724505
Surgery. 1991 Oct;110(4):753-61; discussion 761-3
1925964
Br Med J (Clin Res Ed). 1987 Jun 6;294(6585):1459-61
3111585
Am J Gastroenterol. 2008 Jul;103(7):1631-7
18557714
Am J Med. 1991 May;90(5):576-83
2029015
Eur J Appl Physiol. 2004 Apr;91(4):429-34
14634826
Ann Intern Med. 1996 Jun 1;124(11):959-69
8624063
Int J Cardiol. 2005 Sep 15;104(1):67-72
16137512
Clinics (Sao Paulo). 2009;64(8):785-90
19690664
N Z Med J. 2006 Mar 10;119(1230):U1877
16532043
Am J Gastroenterol. 2008 Sep;103(9):2200-8
18684174
Aliment Pharmacol Ther. 2007 May 1;25(9):1003-17
17439501
Clin Gastroenterol Hepatol. 2009 Jul;7(7):743-8
19281866
J Cardiovasc Electrophysiol. 2006 Jun;17(6):602-7
16836706
Gut. 2001 Nov;49(5):706-12
11600476
Eur Heart J. 1996 Mar;17(3):407-13
8737215
Gastroenterology. 1990 Nov;99(5):1257-64
2210233
Dig Dis Sci. 2000 Dec;45(12):2451-4
11258574
Int J Cardiol. 2007 May 16;118(1):62-8
16891012
Gastroenterology. 1988 Apr;94(4):878-86
3345887
Am J Gastroenterol. 2007 Mar;102(3):668-85
17335450
Indian J Gastroenterol. 2008 Nov-Dec;27(6):227-31
19405255
Gut. 1992 Jan;33(1):79-86
1740283
Neurogastroenterol Motil. 2006 Jun;18(6):408-17
16700719
Am J Gastroenterol. 2004 Oct;99(10):1998-2006
15447763
Hepatogastroenterology. 1999 May-Jun;46(27):1759-64
10430339
Neurogastroenterol Motil. 1995 Mar;7(1):23-30
7627863
J Clin Gastroenterol. 2006 Oct;40(9):828-32
17016140
South Med J. 2003 Nov;96(11):1128-32
14632362
Gastroenterol Clin North Am. 2008 Dec;37(4):775-91, vii
19028317
Gastroenterol Clin Biol. 1993;17(1):4-8
8467970
Dig Dis Sci. 1989 Nov;34(11):1651-5
2582977
Gastroenterology. 1986 Jun;90(6):1978-84
3699414
Dig Dis Sci. 1994 Feb;39(2):402-9
8313825
Rev Esp Enferm Dig. 2004 Sep;96(9):606-8; 609-11
15506904
Eur J Gastroenterol Hepatol. 1998 Nov;10(11):941-5
9872616
Dis Esophagus. 2005;18(6):374-7
16336607
Int J Cardiol. 2008 Jul 4;127(2):233-9
17689732
Am J Gastroenterol. 2008 Oct;103(10):2446-53
18684197
Neurogastroenterol Motil. 2010 May;22(5):520-6, e116
20067548
Dig Dis Sci. 1993 Feb;38(2):220-4
8425434
Neurogastroenterol Motil. 2008 Sep;20(9):989-97
18466221
Best Pract Res Clin Gastroenterol. 2009;23(3):369-86
19505665
Dysphagia. 2010 Mar;25(1):66-9
19653039
Am J Gastroenterol. 2008 Nov;103(11):2685-93
18775017
Dig Dis Sci. 2005 Jan;50(1):100-2
15712645
Phys Sportsmed. 2009 Apr;37(1):54-63
20048488
Aliment Pharmacol Ther. 2006 Mar;23 Suppl 1:40-9
16483269
Br J Surg. 1994 Oct;81(10):1462-4
7820472
Aliment Pharmacol Ther. 2006 Jul 15;24(2):361-70
16842463
Dig Dis Sci. 1994 Jan;39(1):193-8
8281857
World J Gastroenterol. 2009 Apr 14;15(14):1764-8
19360921
Gut. 1990 Jul;31(7):738-44
2370009