What proportion of pseudoanginas are due to reflux ?

D.O. Castell (Philadelphia)

Over the past decade investigators in this field have become aware that GE reflux is much more common in patients with angina-like chest pain than had been previously appreciated. This awareness has resulted from the improved technology and ready availability of ambulatory prolonged intra-esophageal pH monitors.

This phenomenon was first predicted by a report in 1982 [1] indicating that 46 p. cent of patients with noncardiac chest pain had abnormal 24-hour pH recordings. It is likely that this early study represented a selected group of patients since the investigators were pioneers in the development of pH monitoring. Subsequent studies have, however, begun to confirm that reflux is a prominent factor in many of these patients. In an initial study from our laboratory we showed that 24 p. cent of patients with noncardiac chest pain had an abnormal 24-hour pH recording [2].

As one begins to investigate this relationship it becomes apparent that it is more complex than initially considered. Firstly, in order to use a 24-hour monitoring system, one should restrict themselves to selecting patients who have regular pain events, preferably occurring on a daily basis. This only represents approximately 50 p. cent of the patients seen in our laboratory.

Secondly, one must decide whether to accept a pH study as being diagnostic if the total percent of esophageal acid exposure is excessive even though there is no specific association between reflux episodes and pain events during the monitoring.

Because of this problem, we have used the « symptom index » as a way to assess the specific association between reflux episodes and pain events. It seems more appropriate to only make a diagnosis of definite reflux related chest pain when the specific association of reflux and pain is demonstrated during monitoring; i.e. a positive « symptom index ».

Using this criterion, our more recent studies have suggested that approximately 37 p. cent of patients with noncardiac chest pain have a reflux-related etiology. A recent report by Schofield et al. has shown that 42 p. cent of patients with angiographically-negative exertional chest pain had GE reflux during exercise-induced pain [3].

References

1. DeMeester TR, O'Sullivan GC, Bermudez G, Midell A, Cimochowski G, O'Drobinak J (1982) Esophageal function in patients with angina-type chest pain and normal coronary angiograms. Ann Surg 196: 488-498.

2. Peters LJ, Maas LC, Petty DA, Wu WC, Castell DO, Richter JE (1988) Spontaneous noncardiac chest pain : Evaluation by 24-hour ambulatory esophageal motility and pH monitoring. Gastroenterology 94: 878-886.

3. Schofield PM, Whorwell PJ, Brooks NH, Bennett DH, Jones PE (1989) Esophageal function in