What are the next steps in managing symptoms like dysphagia or chest pain with a negative esophageal motility test?

Management of Dysphagia or Chest Pain with Negative Esophageal Motility Test

For patients with persistent dysphagia or chest pain and a negative esophageal motility test, a trial of empiric acid suppression therapy with twice-daily proton pump inhibitors (PPIs) is strongly recommended as the next step in management, especially after cardiac causes have been ruled out. 1

Diagnostic Considerations

When esophageal motility testing is negative but symptoms persist, consider:

• Gastroesophageal reflux disease (GERD): The most likely cause for recurring unexplained chest pain of esophageal origin 1

  • GERD-related chest pain can mimic myocardial ischemia
  • May present as squeezing or burning sensation
  • Often occurs after meals or at night
  • Can worsen with stress 1

• Upper endoscopy evaluation: Should be considered when an esophageal cause of chest pain is suspected 1

  • Pay particular attention to obtaining multiple esophageal mucosal biopsies (at least 5) to evaluate for eosinophilic esophagitis 1
  • Especially important with symptoms of dysphagia 1

• Symptoms requiring urgent endoscopic evaluation (within 2 weeks): 1

  • Dysphagia
  • Odynophagia
  • Gastrointestinal bleeding
  • Unexplained iron deficiency anemia
  • Weight loss
  • Recurrent vomiting 1

Treatment Algorithm

1. First-line approach: Empiric acid suppression therapy

   • Twice-daily PPI therapy for suspected reflux chest pain syndrome (Grade A recommendation) 1
   • A 4-week trial is recommended 1
   • This approach is supported by meta-analyses of placebo-controlled trials 1

2. If symptoms persist despite PPI therapy:

   • Consider pH or impedance-pH monitoring to exclude refractory reflux symptoms 1
   • This testing should be performed with the patient off acid suppressive therapy 1

3. For functional or non-GERD related symptoms:

   • Consider referral to a cognitive-behavioral therapist for patients with recurrent chest pain presentations with no evidence of physiological cause (Class 2a, Level B-R recommendation) 1
   • Psychological factors such as anxiety, panic disorder, depression, and somatoform disorders may contribute to symptoms 1

4. For hypercontractile motility disorders that may have been missed on initial testing:

   • Consider additional manometric maneuvers such as rapid drink challenge 2, 3
   • Further testing with functional lumen imaging may be warranted before considering invasive treatment 2

Special Considerations

• Rule out cardiac causes first: The morbidity and mortality associated with ischemic heart disease is substantially greater than that of GERD 1

• Opioid-induced esophageal dysmotility: Increasingly prevalent and can mimic symptoms of other motility disorders 4

• Functional esophageal disorders: Often overlap with and mimic hypercontractile motility disorders 4

• Avoid unnecessary interventions: Recent research suggests hypercontractile motility disorders may be overdiagnosed, leading to unnecessary and irreversible interventions 4

• Conservative management: Invasive interventions are rarely indicated for hypercontractile motility disorders, which typically respond to lifestyle modifications 4

Common Pitfalls

• Failing to adequately rule out cardiac causes before attributing chest pain to esophageal origin 1

• Premature adoption of invasive treatments for suspected motility disorders without adequate diagnostic confirmation 4, 2

• Overlooking eosinophilic esophagitis, which requires specific biopsy protocols during endoscopy 1

• Performing impedance-pH studies while the patient is on PPI therapy, which makes interpretation difficult due to unclear normative data 1

• Neglecting psychological factors that may contribute significantly to persistent symptoms 1