Dag Arne Lihaug Hoff

Validation of the GerdQ questionnaire for the diagnosis of gastro-oesophageal reflux disease

The diagnosis of gastro‐oesophageal reflux disease (GERD) remains a challenge as both invasive methods and symptom‐based strategies have limitations. The symptom‐based management of GERD in primary care may be further optimised with the use of a questionnaire.

A multimodal laser Doppler and endosonographic distension device for studying mechanosensation and mucosal blood flow in the oesophagus

Abstract  We describe the development of a multimodal device combining bag distension, manometry, high frequency intraluminal ultrasound, laser Doppler flowmetry and symptom registration. Bench tests showed that the different modalities did not influence each other. During bag distension we obtained high quality images of the oesophageal wall for computing biomechanical parameters, and laser Doppler signals showing variation in mucosal perfusion. We conclude that the principle of measurement is sound and that the device can provide a basis for further studies.

Sensation evoked by esophageal distension in functional chest pain patients depends on mechanical stress rather than on ischemia

Background  Functional chest pain is commonly reproduced by bag distension in the esophageal body. It is unknown whether such pain is primarily associated with mechanical stress and strain (force‐deformation) or with changes in mucosal perfusion.

Central response to painful electrical esophageal stimulation in well-defined patients suffering from functional chest pain.

Functional chest pain (FCP) of presumed esophageal origin is considered a common cause for chest pain in which central nervous system hyperexcitability is thought to play an important role. We aimed to compare cerebral responses with painful esophageal stimuli between FCP patients and healthy subjects (HS).

Do patients with functional chest pain have neuroplastic reorganization of the pain matrix? A diffusion tensor imaging study

Abstract Background and aims 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. Methods 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. Results 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). Conclusions This explorative study suggests that microstructural reorganization of the central pain neuromatrix may not be present in well-characterized FCP patients. Implications This finding, together with recent neurophysiologal evidence, challenges the theory of visceral hypersensitivity due to changes in the central nervous system in FCP patients.

Correct use of proton pump inhibitors for gastro-oesophageal reflux disease.

Gastro-oesophageal reflux disease is the most common disease affecting the upper gastrointestinal tract and affects all age groups, from infants to the aged. Approximately 8 % of adults meet the diagnostic criteria for GORD. In many cases the symptoms act as a constraint on everyday living and quality of life (1), and the indirect costs to society in terms of reduced productivity may be substantial (2). The disease is chronic in most cases, but often with varying need for treatment over time. The most effective medical treatment for acid reflux is proton pump inhibitors (PPI), which inhibit the acid secretion of the stomach more strongly and with a longer duration of action than other available drugs (3). The consumption of these medicines in Norway is lower than elsewhere in Europe, but has increased by up to 10 % annually in the period 2003 – 2008 (4). Both overuse and under-use are undesirable, and it is important that the drugs be used optimally. This article is intended to provide practice advice on the use of proton pump inhibitors for acid reflux disease and is based on searches in PubMed, the authors’ own clinical experience and research, and Norwegian reimbursement rules for prescription drugs.

Pharmacological and other treatment modalities for esophageal pain.

Treatment of esophageal pain remains a major challenge for the clinician. Although many patients have heartburn and may respond to proton pump inhibitors, there in an unmet need for other treatment modalities in patients where there are no obvious pathological findings. Although analgesics are the mainstay in esophageal pain treatment, many patients are nonresponders to these drugs. The current concise review focuses on other systems affecting pain processing, where better understanding may serve as a framework for therapy. These are the parasympathetic nervous system, exercise, and personality profiles. Finally, treatment with analgesics for functional chest pain remains a challenge, and an overview of treatment with antidepressive drugs is provided.

Esophageal multimodal stimulation and sensation

Esophageal mechanosensation describes the relationship between a mechanical stimulation of the esophageal wall, such as bag distension, and the reaction to the stimulation perceived or unperceived. When studying mechanosensation in esophageal disease, it is important to recognize that symptoms might be due to alterations at different levels of the neuromuscular system, such as alterations at the mechanoreceptor level or in the afferent mechanosensory pathways, or irregularities in the homeostatic state. One might ask if it is possible to provoke, record, and describe the multidimensional responses behind a mechanosensory experience? It is a complex system and, at a minimum, a multidisciplinary approach is needed to avoid erroneous conclusions. The multimodal study design, taking the mode, location, and parameters of stimulation into consideration, together with controlled recording of assessment parameters, is an approach that seems rational and valid. Gastrointestinal (GI) physicians of the 21th century need to have knowledge of advances in the evaluation of GI mechanical function and what provokes symptoms. Hereby, it is possible to fully appreciate the slowly emerging awareness of how GI pain symptoms should be explored and explained to patients.