Alimentary Tract
Does this patient have oesophageal motility abnormality or pathological acid reflux?

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Abstract

Background and aims.

The diagnostic values of particular symptoms centred on oesophagus, among patients with suspected oesophageal motility abnormality or pathological acid exposure, are not yet fully understood. The aim of this study was to determine the predictive accuracy of these symptoms in diagnosis of oesophageal motility disorder or pathological acid exposure.

Patients and methods.

A total of 462 patients who had undergone conventional oesophageal manometry and ambulatory 24-h pH monitoring to investigate a clinical suspicion of oesophageal motility disorder and pathological acid exposure were enrolled in this study. According to their principal complaints, the patients were divided into the dysphagia category, the non-cardiac chest pain category, the gastrooesophageal reflux disease-related symptom category and the extraoesophageal symptom category.

Results.

Two hundred and two (44%) out of 462 patients yielded abnormal findings on manometry and/or pH monitoring. Dysphagia was associated with a likelihood ratio (LR) of 2.11 [95% confidence interval (CI), 1.02–4.00)] in patients exhibiting a combination of oesophageal motility abnormality and pathological acid exposure. During oesophageal manometry, the dysphagia substantially increased the likelihood of classic achalasia (LR, 6.24; 95% CI, 3.32–8.78) and diffuse oesophageal spasm (LR, 3.58; 95% CI, 1.03–7.12). When the patients with dysphagia were divided into two groups according to the severity of their symptoms, classic achalasia was significantly frequent in patients with severe dysphagia (P = 0.016). On the other hand, non-cardiac chest pain was the clinical factor that reduced the likelihood of classic achalasia (LR, 0.22; 95% CI, 0.04–0.93). The distribution of pathological acid exposure was significantly frequent between the groups of patients with and without gastrooesophageal reflux disease-related symptom (P = 0.011).

Conclusion.

A small number of oesophageal symptoms are helpful in predicting the likelihood of abnormal findings on oesophageal tests among patients with a clinical suspicion of oesophageal motility disorder and pathological acid exposure. The most useful finding is a severe dysphagia, which is likely to have classic achalasia.

Introduction

Since the introduction of conventional oesophageal manometry and ambulatory 24-h pH monitoring, interest in and understanding of oesophageal motility abnormality and pathological acid exposure have considerably increased [1], [2], [3]. Although oesophageal symptoms cannot be, in general, regarded as harbingers of oesophageal motility abnormality or pathological acid exposure, sophisticated diagnostic methods do not diminish the clinical importance of a thorough medical history.

The information about the sensitivity, positive predictive value (PPV) and likelihood ratio (LR) of oesophageal motility abnormality and pathological acid exposure in respect of oesophageal symptoms may play an important role not only for the prediction of oesophageal motility abnormality or pathological acid exposure in patients with such complaints, but also in the process of referring patients for costly and laborious examinations [1], [2], [3], [4]. However, the sensitivity, PPV and LR of oesophageal motility abnormality and pathological acid exposure with regard to oesophageal symptoms are not yet fully understood [2], [3], [4], [5], [6], [7]. Although some previous reports have addressed the subject, most of these studies limited their assessments to patients who had undergone either manometry or pH monitoring alone, or to patients with individual symptoms, including non-cardiac chest pain, dysphagia or some extraoesophageal manifestations [2], [3], [4], [5], [8], [9], [10].

The aim of this study was to determine the predictive accuracy of symptoms centred on the oesophagus in diagnosis of oesophageal motility disorder or pathological acid exposure in 462 Korean patients who had undergone conventional oesophageal manometry and ambulatory 24-h pH monitoring to investigate a clinical suspicion of oesophageal motility abnormality and pathological acid exposure.

Section snippets

Subjects

In the 8-year span from May 1995 to August 2003, the medical records of 550 consecutive patients who had undergone conventional oesophageal manometry and ambulatory 24-h pH monitoring at the gastrointestinal motility laboratory of the Samsung Medical Centre, in Seoul, Korea, were reviewed. Among them, patients who had undergone manometry and pH monitoring to investigate a clinical suspicion of oesophageal motility abnormalities and pathological acid exposure within 1 month were included in this

Results

The baseline characteristics of the patients and distribution of normal and abnormal findings of oesophageal tests with regard to symptoms centred on the oesophagus are shown in Table 2. Non-cardiac chest pain was the most common complaint, and was noted in 184 out of 462 patients (40%). Abnormal results of oesophageal tests were noted in 202 of the total patients (44%). However, the sensitivities, PPVs and LRs of all symptom categories were inconclusive as to which oesophageal symptoms were

Discussion

The diagnostic value of particular oesophageal symptoms among patients with suspected oesophageal motility abnormality or pathological acid exposure is still unknown [2], [3], [4], [5], [6], [7]. The aim of this study was to determine the predictive accuracy of oesophageal symptoms with regard to the diagnosis of oesophageal motility abnormality or pathological acid exposure. When oesophageal motility abnormalities or pathological acid exposure were suspected from the patient history or

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