Gastroenterology

Gastroenterology

Volume 150, Issue 6, May 2016, Pages 1368-1379
Gastroenterology

Section II: FGIDs: Diagnostic Groups
Esophageal
Esophageal Disorders

https://doi.org/10.1053/j.gastro.2016.02.012Get rights and content

Functional esophageal disorders consist of a disease category that presents with esophageal symptoms (heartburn, chest pain, dysphagia, globus) that are not explained by mechanical obstruction (stricture, tumor, eosinophilic esophagitis), major motor disorders (achalasia, esophagogastric junction outflow obstruction, absent contractility, distal esophageal spasm, jackhammer esophagus), or gastroesophageal reflux disease. Although mechanisms responsible are unclear, it is theorized that visceral hypersensitivity and hypervigilance play an important role in symptom generation, in the context of normal or borderline function. Treatments directed at improving borderline motor dysfunction or reducing reflux burden to subnormal levels have limited success in symptom improvement. In contrast, strategies focused on modulating peripheral triggering and central perception are mechanistically viable and clinically meaningful. However, outcome data from these treatment options are limited. Future research needs to focus on understanding mechanisms underlying visceral hypersensitivity and hypervigilance so that appropriate targets and therapies can be developed.

Section snippets

Definition

Functional chest pain is defined as recurring, unexplained, retrosternal chest pain of presumed esophageal origin, not explained on the basis of reflux disease, other mucosal or motor processes, and representing pain different from heartburn. Functional chest pain is a subset within the broad umbrella of noncardiac chest pain (NCCP). History and physical examination do not reliably segregate esophageal from cardiac chest pain, stressing the need for an initial cardiac evaluation in appropriate

Definition

Functional heartburn is defined as retrosternal burning discomfort or pain refractory to optimal antisecretory therapy in the absence of GERD, histopathologic mucosal abnormalities, major motor disorders, or structural explanations. The definition of functional heartburn has evolved over the years. The so-called acid sensitive esophagus initially included in the functional heartburn group in ROME II, was revised further by ROME III as a part of the nonerosive reflux disease (NERD) spectrum.1

Definition

Reflux hypersensitivity identifies patients with esophageal symptoms (heartburn or chest pain) who lack evidence of reflux on endoscopy or abnormal acid burden on reflux monitoring, but show triggering of symptoms by physiologic reflux. Some patients fulfilling criteria potentially could respond to antireflux measures, however, the underlying pathogenesis is more consistent with esophageal hypersensitivity from a functional basis. Furthermore, overlap could exist between true GERD and reflux

Definition

Globus sensation is a persistent or intermittent nonpainful sensation of a lump or foreign body in the throat.1 The symptom is nonpainful, commonly episodic, located in the midline between the thyroid cartilage and sternal notch, unassociated with dysphagia or odynophagia, and frequently improves with eating and swallowing. The diagnosis of globus requires the absence of structural lesions, mucosal abnormalities such as a gastric inlet patch, GERD, or major motor disorders.

Epidemiology

Globus sensation is a

Definition

Functional dysphagia is defined as a sensation of abnormal bolus transit through the esophageal body in the absence of structural, mucosal, or motor abnormalities to explain the symptom. The diagnosis of functional dysphagia requires thorough exclusion of oropharyngeal mechanisms of dysphagia, structural lesions in the tubular esophagus, GERD, EoE, and major motor disorders.

Epidemiology

The true prevalence of functional dysphagia is unknown. A population survey of functional disorders estimated that 7%–8%

Recommendations For Future Research

Despite their high prevalence rates and increasing awareness, functional esophageal disorders have not been well studied. Therefore, effective management approaches have been difficult to establish. Several areas requiring additional research are identified.

  • 1.

    Studies validating the diagnostic criteria are needed and methods for improving the accuracy of symptom-based criteria are encouraged.

  • 2.

    The fundamental mechanisms of symptom production remain poorly defined. Further application of new

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    Conflicts of interest The authors disclose no conflicts.

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