RESUMEN
STUDY OBJECTIVE: To study mechanisms of gastroesophageal reflux-induced bronchoconstriction during intraesophageal infusions. DESIGN: Prospective study blinded to the subject. SETTING: Outpatient pulmonary function laboratory at a 908-bed university hospital. PARTICIPANTS: Forty-seven adult subjects divided into four groups: asthmatics with reflux, 20; asthmatics, 7; gastroesophageal refluxers, 10; and normal controls, 10. Asthmatics were defined by American Thoracic Society criteria, and refluxers were defined by symptoms and 24-hour pH monitoring. INTERVENTIONS: Dual antimony esophageal pH probe placed just below the upper esophageal sphincter and 5 cm above the lower esophageal sphincter. Intraesophageal infusions of normal saline solution followed by 0.1N hydrochloric acid then normal saline solution were given for 15 to 18 min. Spirometry and specific airway resistance (SRaw) were performed after placement of pH probes, insertion of esophageal infusion tube, and after each infusion. Bernstein tests were assessed during esophageal infusions. MEASUREMENTS AND RESULTS: Peak expiratory flow rate (PEF) decreased with intraesophageal acid in all four groups (p < 0.014). Esophageal acid clearance improved PEF in all groups except the asthmatics with reflux group that had a further decrease in PEF. These effects were not dependent on a positive Bernstein test or evidence of proximal reflux. The asthmatics with reflux group also had an increase in SRaw with intraesophageal acid, which continued to increase despite acid clearance. CONCLUSIONS: Intraesophageal acid infusions caused a decrease in PEF in all groups without evidence of microaspiration, implying a vagally mediated reflex may be involved. Esophageal mucosal inflammation, assessed by a positive Bernstein test, was not required. Asthmatics with reflux also had further decline in PEF despite acid clearance.
Asunto(s)
Broncoconstricción/efectos de los fármacos , Reflujo Gastroesofágico/complicaciones , Ácido Clorhídrico , Adulto , Análisis de Varianza , Asma/complicaciones , Asma/epidemiología , Asma/fisiopatología , Distribución de Chi-Cuadrado , Enfermedad Crónica , Esófago , Reflujo Gastroesofágico/epidemiología , Reflujo Gastroesofágico/fisiopatología , Humanos , Ácido Clorhídrico/administración & dosificación , Concentración de Iones de Hidrógeno , Estudios Prospectivos , Pruebas de Función Respiratoria/estadística & datos numéricosRESUMEN
The symptom index is a quantitative measure developed for assessing the relationship between gastroesophageal reflux and symptoms. Controversy exists, however, over its accuracy and the appropriate threshold for defining acid-related symptoms of heartburn and chest pain. Therefore, a retrospective review was done of 153 consecutive patients referred to our esophageal laboratory. Three groups were identified: patients with normal 24-hr pH tests and no esophagitis, patients with abnormal 24-hr pH tests and no esophagitis, and patients with abnormal 24 hr pH values and endoscopic esophagitis. If symptoms occurred during the pH study, a symptom index (number of acid related symptoms/total number of symptoms x 100%) was calculated separately for heartburn and chest pain. Heartburn and chest pain episodes were similar among the three groups. However, the mean symptom index for heartburn was significantly (P < 0.001) higher in the patient groups with abnormal pH values [abnormal pH/no esophagitis: 70 +/- 7.1% (+/- SE); abnormal pH/esophagitis: 85 +/- 4.6%] as compared to those with normal studies, ie, functional heartburn (26 +/- 10.7%). The mean symptom index for chest pain was similar for all three groups. Using receiver operating characteristic curves, a heartburn symptom index > or = 50% had excellent sensitivity (93%) and good specificity (71%) for acid reflux disease, especially if patients complain of multiple episodes of heartburn. In contrast, an optimal symptom index threshold for defining acid-related chest pain episodes could not be defined.
Asunto(s)
Dolor en el Pecho/etiología , Reflujo Gastroesofágico/diagnóstico , Pirosis/etiología , Índice de Severidad de la Enfermedad , Adulto , Anciano , Esofagitis/diagnóstico , Esofagoscopía , Femenino , Humanos , Concentración de Iones de Hidrógeno , Masculino , Persona de Mediana Edad , Curva ROC , Estudios Retrospectivos , Sensibilidad y EspecificidadRESUMEN
This paper describes the first controlled study of the relationships among stress, psychological traits associated with chronic anxiety, acid reflux parameters, and perceptions of reflux symptoms. Seventeen subjects with symptomatic reflux disease were studied using a 2 (high vs. low gastrointestinal susceptibility score) x 2 (stress vs. neutral tasks) x 3 (periods 1, 2, or 3) experimental design. It was found that the stress tasks produced significant increases in systolic and diastolic blood pressure, pulse rates, and subjective ratings of anxiety and reflux symptoms. The stress tasks, however, did not influence objective parameters of acid reflux (total acid exposure, number of reflux episodes, duration of longest reflux episode). Moreover, the effect of stress on reflux ratings was due primarily to the responses of the subjects with high gastrointestinal susceptibility scale scores. These subjects' reflux ratings remained at high levels during all stress periods, whereas subjects in all other experimental conditions reported decreased reflux symptoms across periods. These results suggest that reflux patients who are chronically anxious and exposed to prolonged stress may perceive low intensity esophageal stimuli as painful reflux symptoms. Future effort should be devoted to examining the efficacy of anxiolytic and behavioral therapies with these reflux patients.
Asunto(s)
Reflujo Gastroesofágico/psicología , Estrés Psicológico/psicología , Adaptación Fisiológica/fisiología , Adulto , Anciano , Ansiedad/fisiopatología , Ansiedad/psicología , Presión Sanguínea/fisiología , Enfermedad Crónica , Femenino , Reflujo Gastroesofágico/etiología , Reflujo Gastroesofágico/fisiopatología , Humanos , Concentración de Iones de Hidrógeno , Masculino , Persona de Mediana Edad , Pulso Arterial/fisiología , Estrés Psicológico/complicaciones , Estrés Psicológico/fisiopatologíaRESUMEN
It is imperative to assess the psychosocial factors that may influence the subjective experiences and pain behavior of persons with chronic unexplained chest pain. Both psychologists and physicians tend to rely on self-report measures of psychological distress, which provide little unique information about patients with chronic chest pain to differentiate them from patients with other painful disorders such as irritable bowel syndrome, gastroesophageal reflux disease, or coronary artery disease. However, assessment of pain-coping strategies, spouse responses to the patient's pain behaviors, and pain thresholds for esophageal balloon distention do differentiate patients with chronic chest pain from healthy controls and patients with various other chronic pain disorders. Specifically, chronic chest pain patients tend to use relatively passive pain-coping strategies such as praying and hoping, and to report relatively high levels of spouse reinforcement of pain behaviors. Finally, in response to esophageal balloon distention, chronic chest pain patients display low pain thresholds that do not generalize to stimulation by mechanical finger pressure. Preliminary evidence suggests these low thresholds are due primarily to a tendency to set low standards for making pain judgments regarding esophageal stimuli of moderate-to-high intensity levels.