Review article

Visceral hypersensitivity in noncardiac chest pain

In the etiology of functional chest pain (FCP), parental personality traits are worth considering in the context of the biopsychosocial model. The αlpha factor sub-dimension of the five-factor personality model (5FPM) includes agreeableness, conscientiousness, and neuroticism. There is increasing evidence that this dimension may be related to psychosomatic diseases. It was aimed to investigate how maternal personality traits affect adolescents with FCP. The hypothesis was determined that adolescents diagnosed with FCP can have lower quality of life and be more depressive/anxious and their mothers can have factor-α personality traits and be more depressive/anxious.

The sample of this single-center, cross-sectional, case-control study consisted of 25 adolescents with FCP and their parents. The control group consisted of 35 age and sex matched healthy adolescents and their parents. Psychopathology was screened using the Kiddie Schedule for Affective Disorders and Schizophrenia-Present and Lifetime Version (K-SADS-PL) and psychiatric comorbidities were excluded. The Child Depression Inventory (CDI), the Spielberger State-Trait Anxiety Inventory (STAI), and KINDL forms were completed by the adolescents. The Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Five-Factor Personality Inventory short form (FFPI) were completed by the parents.

Mothers of adolescents with FCP scored significantly higher compared with mothers of healthy controls in agreeableness and conscientiousness and scored significantly lower in neuroticism. Higher levels of mothers’ neuroticism scores were associated with higher CDI and STAI-1 scores in FCP group. Agreeableness (Exp (B) = 10.097; p = .004; confidence interval [CI] = 2.049-49.745) and conscientiousness (Exp (B) = 16.414; p = .011; CI = 1.902-141.682) were statiscally significant in regression model.

This study showed for the first time that mother's alpha factor personality traits may be one of the factors that contribute to the presence of FCP.

In functional chest pain (FCP) of presumed esophageal origin central nervous system hyperexcitability is generally believed to play an important role in pain pathogenesis. However, this theory has recently been challenged. Using magnetic resonance diffusion tensor imaging, the aim was to characterize any microstructural reorganization of the pain neuromatrix in FCP patients.

13 FCP patients and 20 matched healthy controls were studied in a 3T MR scanner. Inclusion criteria were relevant chest pain, normal coronary angiogram and normal upper gastrointestinal evaluation. Apparent diffusion coefficient (ADC) (i.e. mean diffusivity of water) and fractional anisotropy (FA) (i.e. directionality of water diffusion as a measure of fiber organization) values were assessed in the secondary sensory cortex, cingulate cortex, insula, prefrontal cortex, and amygdala.

Overall, including all regions, no difference in ADC and FA values was found between the patients and controls (P = 0.79 and P = 0.23, respectively). Post-hoc tests revealed no difference in ADC and FA values of the individual regions. However, a trend of patients having increased ADC in the mid insula grey matter and increased FA in the mid insula white matter was observed (both P = 0.065).

This explorative study suggests that microstructural reorganization of the central pain neuromatrix may not be present in well-characterized FCP patients.

This finding, together with recent neurophysiologal evidence, challenges the theory of visceral hypersensitivity due to changes in the central nervous system in FCP patients.

Los cambios, avances y descubrimientos en la Enfermedad por Refujo Gastroesofágico (ERGE) hacen necesario actualizar el Consenso Mexicano realizado en 2002.

Realizar un nuevo Consenso Mexicano de la ERGE.

Los coordinadores generales del proyecto seleccionaron a 6 expertos en la ERGE, quienes realizaron una amplia revisión bibliográfica para elaborar enunciados referentes a los aspectos principales de la ERGE. Estos se sometieron a la consideración de especialistas dedicados al estudio de esta enfermedad. Mediante el método Delphi modificado y 3 rondas de voto reiterativo anónimo por parte de todos los participantes, se llegó a la aprobación definitiva. Se utilizó una escala de 6 puntos: A- totalmente de acuerdo, B-de acuerdo con reservas menores, C-de acuerdo con reservas mayores, D-en desacuerdo con reservas mayores, E-en desacuerdo con reservas menores o F-totalmente en desacuerdo. Se consideró que se llegaba a consenso cuando el acuerdo (A, B ó C), por parte de los participantes era de 67,00% o mayor.

Al finalizar todas las rondas de votación, se obtuvieron 160 enunciados en los cuales hubo consenso. La mayor parte de ellos obtuvieron votaciones cercanas al 90,00% de acuerdo.

El Consenso Mexicano de la ERGE 2011 es una herramienta de consulta actualizada, práctica y que ofrece la opinión de los expertos mexicanos respecto a los nuevos conocimientos globales de este padecimiento. Permite además la homogeneidad en criterios diagnósticos y terapéuticos en beneficio de nuestros pacientes.

The changes, advances, and new discoveries regarding different aspects of gastroesophageal reflux disease (GERD) have made it necessary to update the Mexican Consensus published in 2002.

To elaborate a new Mexican Consensus on GERD.

The general project coordinators selected six GERD experts to carry out an extensive review of the literature for the purpose of elaborating statements on the principal aspects of GERD. These were then placed under the consideration of specialists in the study of this disease. Definitive approval by all participants was reached using the modified Delphi method with three rounds of anonymous and iterative voting. The following scale was employed: A- in complete agreement; B- in agreement, but with minor concerns; C- in agreement, but with major concerns; D- in disagreement, but with major concerns; E- in disagreement, but with minor concerns; or F- in complete disagreement. Consensus was declared when 67.00% or more of the participants concurred on a category of agreement (A, B, or C).

A consensus was reached on 160 of the statements upon completion of the voting rounds, with 90.00% concurrence for the majority of them.

The 2011 Mexican Consensus on Gastroesophageal Disease is a practical and up-to-date consultation tool, providing the opinion of Mexican experts on all the new information available about this disease. It allows there to be homogeneity in diagnostic and therapeutic criteria, all of which serves to benefit our patients.

Nutcracker esophagus (NE) is a frequent primary motility disorder of the distal esophagus, and the relationship with acid exposure remains controversial. We studied simultaneous distal esophageal hypercontractility (EH) using two sensors at 8 and 3 cm above the lower sphincter (LES) and abnormal exposure to acid (pH DeMeester score).

From 400 screened patients with chest pain and heartburn, 54 (age 44.5 ± 8.8 years and 74% females) had abnormal manometry and underwent acid exposure measurement. Frequencies of the EH disorder were classic NE (EH_{3 cm}) found in 29 (40.8%) patients, diffuse (EH_{3,8 cm}) in 30 patients (42.3%), and upper segmental (EH_{8 cm)} in 12 patients (16.9%).

We found a positive correlation among age with high amplitude in EH_{3 cm} and EH_{3,8 cm}. DeMeester’s score (DMS) had the lowest value for EH_{3,8 cm} (2.58 ± 0.23) compared with EH_{8 cm} (3.78 ± 0.3, p <0.003) and EH_{3 cm} (3.12 ± 0.2, p <0.06). Surface response for joint effect of age and DMS on amplitude at EH_{3 cm} confirmed the highest amplitude was for older age and lower DMS.

EH_{3 cm} and EH_{3,8 cm} were common for esophageal motility and were inversely associated with DMS. Meanwhile, acid exposure was higher in younger patients and hypercontractility was more frequent in older subjects. The former group may benefit more from proton pump inhibitors and the latter from visceral analgesics or possibly both.

Early animal and human evidence existed for a postsynaptic dorsal column (PSDC) pathway for visceral nociception that, when lesioned, decreased pain of terminal illness. There have been recent anecdotal reports in the literature that spinal cord stimulation (SCS) reduces pain of visceral nociception. We present here a review of the literature supporting a hypothesis that SCS might work by modulating information through the spinothalamic tracts (STT) and PSDC.

A review of the relevant literature regarding nociception, nociceptive transmission, visceral sensitization, and the “brain-gut” axis; and SCS was performed as a foundation for this hypothesis. Key words used for this review of databases and nonindexed relevant journals included visceral pain, visceral nociception, visceral hyperalgesia, visceral neuropathic pain, visceral sensitization, “brain-gut” axis, SCS, PSDC pathway, and STTs.

An abundance of both clinical and scientific literature suggests the neuropathic and sensitized nature of chronic visceral nociception. There is also evidence that there may be an interaction between the PSDC pathway and lateral spinothalamic tracts (LSTT) that might be operant in the preclinical and anecdotal clinical evidence that SCS ameliorates the pain of visceral nociception.

Chronic visceral nociception may be secondary to visceral sensitization and hyperalgesia and can be affected by the spinal cord and brain, the “brain-gut” axis. There is preclinical evidence and clinical anecdotes that this nociceptive information is transmitted in the central nervous system through the PSDC pathway and LSTT and that SCS decreases pain of visceral nociception. It may be that SCS works by modulation of the above pathways.

Background & Aims: Esophageal hypersensitivity is thought to be important in the generation and maintenance of symptoms in noncardiac chest pain (NCCP). In this study, we explored the neurophysiologic basis of esophageal hypersensitivity in a cohort of NCCP patients.

Methods: We studied 12 healthy controls (9 women; mean age, 37.1 ± 8.7 y) and 32 NCCP patients (23 women; mean age, 47.2 ± 10 y). All had esophageal manometry, esophageal evoked potentials to electrical stimulation, and NCCP patients had 24-hour ambulatory pH testing.

Results: The NCCP patients had reduced pain thresholds (PT) (72.1 ± 19.4 vs 54.2 ± 23.6, P = .02) and increased P1 latencies (P1 = 105.5 ± 11.1 vs 118.1 ± 23.4, P = .02). Subanalysis showed that the NCCP group could be divided into 3 distinct phenotypic classifications. Group 1 had reduced pain thresholds in conjunction with normal/reduced latency P1 latencies (n = 9). Group 2 had reduced pain thresholds in conjunction with increased (>2.5 SD) P1 latencies (n = 7), and group 3 had normal pain thresholds in conjunction with either normal (n = 10) or increased (>2.5 SD, n = 3) P1 latencies.

Conclusions: Normal esophageal evoked potential latencies with reduced PT, as seen in group 1 patients, is indicative of enhanced afferent transmission and therefore increased esophageal afferent pathway sensitivity. Increased esophageal evoked potential latencies with reduced PT in group 2 patients implies normal afferent transmission to the cortex but heightened secondary cortical processing of this information, most likely owing to psychologic factors such as hypervigilance. This study shows that NCCP patients with esophageal hypersensitivity may be subclassified into distinct phenotypic subclasses based on sensory responsiveness and objective neurophysiologic profiles.