Article Outline

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Gastroesophageal reflux disease affects 20%–30% of Western populations and is one of the most common diseases of mankind. A subset of these patients present with esophageal chest pain, which can mimic angina. Additional etiologies of this “noncardiac” chest pain may involve esophageal spasms from both circular and longitudinal muscles, inflammatory processes of the esophagus (infections, pill injury, eosinophilic esophagitis), and esophageal hypersensitivity. It is estimated that >500,000 new cases of chronic esophageal chest pain are diagnosed in the United States yearly. The quality of life of these individuals is often severely affected and considerable time and expense invested in seeking medical evaluation and treatment.

Dr Ravi Mittal, himself an internationally recognized investigator in esophageal pain, has edited a 200-page monograph on this perplexing clinical problem. He enlisted 18 authors who wrote 14 brief chapters highlighting the state of the art in this field. Plural Publishing prepared an eye-pleasing book with high-quality paper, consistent blue color scheme, and well-edited chapters that read smoothly throughout the monograph. The book is an “easy read” with multiple tables and figures and took this reviewer less than 3 hours to enjoy from cover to cover.

The contents are broken into 5 sections: Introduction, The Basics of Pain, Stimuli of Esophageal Pain, Peripheral and Central Mechanisms of Sensitivity and Hypersensitivity, and Diagnosis and Management of Esophageal Pain. The 2 chapters in the Introduction focus primarily on heartburn, with all its endoscopic and pH testing presentations, with unfortunately less attention given to primary esophageal chest pain. A chapter assessing the usefulness of evaluating these patients for cardiac and psychiatric causes of their pain would have been a nice addition for the clinical audience.

The next 3 sections incorporating nine chapters is the “meat” of the book, highlighting the available knowledge on the sources of esophageal pain, receptors, and peripheral/central pain pathways. The chapter by Roy Orlando gives an up-to-date review of the role of dilated intercellular spaces within the squamous epithelium as the potential site of entrance for acid and bile to trigger esophageal pain. Dr Mittal writes a lucid review of his 10 years investigating the role of longitudinal esophageal muscle in contributing to esophageal chest pain and heartburn. Our basic science colleagues will particularly enjoy these 9 chapters, but the information is also very readable and understandable for clinicians.

The book concludes with 3 chapters on diagnosis and management of esophageal pain. Dr Kahrilas' chapter on diagnostic strategy would have been helped by a clinical algorithm for diagnostic testing. Furthermore, the discussion was somewhat indecisive about whether to study these patients “off” or “on” proton pump inhibitors—a major question for most clinicians. The treatment chapter by Dr Satish Rao effectively used several tables to summarize the quality of drug trials in this field. However, his chapter could be improved with more details and illustrations on some of the newer treatments in this area, including selective serotonin reuptake inhibitors, hypotherapy, and the author's own experience using low doses of theophylline to block the adenosine receptor.

Bottom Line: This book will be useful to clinicians and investigators working in the area of esophageal chest pain. In fact, I do not know of a better review in this field. All GI libraries should have this book available for their trainees to read on this common clinical problem. On the other hand, the general gastroenterologists may find the pathophysiology sections too detailed and the clinical sections too simplified to be helpful when they encounter these difficult patients in their clinical practices.