Gastroenterology

Gastroenterology

Volume 130, Issue 5, April 2006, Pages 1459-1465
Gastroenterology

Introduction
Functional Esophageal Disorders

https://doi.org/10.1053/j.gastro.2005.08.060Get rights and content

Functional esophageal disorders represent processes accompanied by typical esophageal symptoms (heartburn, chest pain, dysphagia, globus) that are not explained by structural disorders, histopathology-based motor disturbances, or gastroesophageal reflux disease. Gastroesophageal reflux disease is the preferred diagnosis when reflux esophagitis or excessive esophageal acid exposure is present or when symptoms are closely related to acid reflux events or respond to antireflux therapy. A singular, well-defined pathogenetic mechanism is unavailable for any of these disorders; combinations of sensory and motor abnormalities involving both central and peripheral neural dysfunction have been invoked for some. Treatments remain empirical, although the efficacy of several interventions has been established in the case of functional chest pain. Management approaches that modulate central symptom perception or amplification often are required once local provoking factors (eg, noxious esophageal stimuli) have been eliminated. Future research directions include further determination of fundamental mechanisms responsible for symptoms, development of novel management strategies, and definition of the most cost-effective diagnostic and treatment approaches.

Section snippets

Definition

Retrosternal burning in the absence of GERD that meets other essential criteria for the functional esophageal disorders typifies this diagnosis. Constraints in the ability to fully recognize the presence or importance of GERD in individual subjects likely result in a heterogeneous subject group.1

Epidemiology

Heartburn is reported by 20%–40% of subjects in Western populations, depending on thresholds for a positive response. Studies using both endoscopy and ambulatory pH monitoring to objectively establish

Definition

This disorder is characterized by episodes of unexplained chest pain that usually are midline in location and of visceral quality and therefore potentially of esophageal origin. The pain easily is confused with cardiac angina and pain from other esophageal disorders, including achalasia and GERD.

Epidemiology

Inferential data extracted from cardiac evaluations for chest pain indicate that this is a common disorder. Findings on 15%–30% of coronary angiograms performed in patients with chest pain are normal.13

Definition

The disorder is characterized by a sensation of abnormal bolus transit through the esophageal body. Thorough exclusion of structural lesions, GERD, and histopathology-based esophageal motor disorders is required for establishing the diagnosis.

Epidemiology

Little information is available regarding the prevalence of functional dysphagia, largely because of the degree of exclusionary evaluation required. Between 7% and 8% of respondents from a householders survey reported dysphagia that was unexplained by

Definition

Globus is defined as a sense of a lump, a retained food bolus, or tightness in the throat. The symptom is nonpainful, frequently improves with eating, commonly is episodic, and is unassociated with dysphagia or odynophagia. Globus is unexplained by structural lesions, GERD, or histopathology-based esophageal motility disorders.

Epidemiology

Globus is a common symptom and is reported by up to 46% of apparently healthy individuals, with a peak incidence in middle age.14 It is uncommon in subjects younger than

Recommendations for Future Research

Despite their high prevalence rates, functional esophageal disorders have not been well studied. In particular, highly effective management approaches have not been established. Several areas requiring additional research were identified.

  • 1

    Studies validating the diagnostic criteria are needed, and a method for improving the accuracy of symptom-based criteria while limiting exclusionary workup would be welcomed.

  • 2

    The fundamental mechanisms of symptom production remain poorly defined. Further

References (44)

  • C.D. Lind

    Dysphagiaevaluation and treatment

    Gastroenterol Clin North Am

    (2003)
  • N.B. Vakil et al.

    Dysphagia in patients with erosive esophagitisprevalence, severity, and response to proton pump inhibitor treatment

    Clin Gastroenterol Hepatol

    (2004)
  • E.G. Hewson et al.

    Manometry and radiology. Complementary studies in the assessment of esophageal motility disorders

    Gastroenterology

    (1990)
  • W.K. Deschner et al.

    Manometric responses to balloon distention in patients with nonobstructive dysphagia

    Gastroenterology

    (1989)
  • I.J. Deary et al.

    Globus pharyngisdevelopment of a symptom assessment scale

    J Psychosom Res

    (1995)
  • M.B. Harris et al.

    Life events and difficulties in relation to the onset of globus pharyngis

    J Psychosom Res

    (1996)
  • Functional esophageal disorders. In: Drossman DA, Corazziari E, Delvaux M, Spiller R, Talley NJ, Thompson WG, Whitehead...
  • D. Sifrim

    Acid, weakly acidic and non-acid gastroesophageal refluxdifferences, prevalence and clinical relevance

    Eur J Gastroenterol Hepatol

    (2004)
  • S.D. Martinez et al.

    Non-erosive reflux disease (NERD)—acid reflux and symptom patterns

    Aliment Pharmacol Ther

    (2003)
  • R.G.P. Watson et al.

    Double blind cross-over placebo controlled study of omeprazole in the treatment of patients with reflux symptoms and physiological levels of acid reflux—the “sensitive esophagus.”

    Gut

    (1997)
  • J. Dent et al.

    Symptom evaluation in reflux diseaseworkshop, background, process, terminology, recommendations, and discussion outputs

    Gut

    (2004)
  • J. Dent et al.

    An evidence-based appraisal of reflux disease management—The Genval Workshop Report

    Gut

    (1999)
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