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Functional esophageal disorders / General approach to functional esophageal disorders
General approach to functional esophageal disorders
The physiological mechanisms responsible for these symptoms are poorly understood, but a combination of physiologic and psychosocial factors probably contributes to both provoke and escalate symptoms to a level for which medical aid is required. A single, well-defined pathogenetic mechanism has not been found yet for any of these disorders. A combination of sensory and motor abnormalities involving both central and peripheral neural components (esophageal nerve sensitivity and/or altered cortical processing) has been put forward by some investigators(1).
| Several diagnostic requirements are common for all functional esophageal disorders(1): | |
| 1. | Exclusion of structural or metabolic disorders that might be producing the symptoms is essential. |
| 2. | An arbitrary requirement of at least 3 months of symptoms with onset at least 6 months before diagnosis is applied in order to establish a degree of chronicity. |
| 3. | Exclusion of gastroesophageal reflux disease (GERD) as an explanation for symptoms. |
| 4. | A pathology-based motor disorder with a known histopathologic basis (e.g., achalasia, scleroderma esophagus) must not be the primary cause of symptoms. |
An important modification in the threshold for the third common criterion has been introduced(3): Now, a diagnosis of GERD can be made when there is enough evidence for a relationship of symptoms to acid reflux events, found either by analytical determination of abnormal esophageal acid exposure time on ambulatory esophageal pH monitoring or by patient-reported outcome of therapeutic antireflux trials.
Functional esophageal disorders are represented by chronic symptoms of esophageal diseases (heartburn, chest pain, dysphagia, globus), even though they have no identifiable structural or metabolic basis. In other words, these typical esophageal symptoms are not explained by structural disorders, histopathology-based motor disturbances, or gastroesophageal reflux disease(1).
GERD should be excluded as an explanation for esophageal symptoms.
| Functional esophageal disorders include(1) | |
| 1. | Functional heartburn |
| 2. | Functional chest pain of presumed esophageal origin |
| 3. | Functional dysphagia |
| 4. | Globus |
Functional heartburn is defined as a "retrosternal burning in the absence of GERD that meets other essential criteria for the functional esophageal disorders typifies this diagnosis"(1). Functional chest pain of presumed esophageal origin is a disorder characterized by "episodes of unexplained chest pain that usually are midline in location and of visceral quality and therefore potentially of esophageal origin". This pain can be easily confused with cardiac angina and pain from other esophageal disorders, including achalasia and GERD(1). Although as in the other functional esopagheal disorders treatment remains empirical, some interventions in this syndrome have been established. Functional chest pain is characterized by "a sensation of abnormal bolus transit through the esophageal body"(1). Finally, globus 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"(1). Globus is a frequent symptom, unexplained by organic pathology.
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