Background/Aims: Ineffective esophageal motility (IEM) is the most frequently encountered esophageal manometric abnormality. Nonobstructive dysphagia is frequently associated with severe esophageal peristaltic dysfunction. This study aims to evaluate the presenting symptoms and association between dysphagia and specific manometric findings in patients with IEM. Methods: We retrospectively reviewed 228 IEM patients diagnosed on high-resolution manometry at an academic institution (2010-2013). We collected data regarding the main presenting symptoms and manometric findings: bolus transit, distal esophageal pressure amplitude, and lower esophageal sphincter (LES) resting and relaxation pressure. Results: Dysphagia was the main presenting symptom (25%) in IEM patients. Bolus transit was incomplete in either liquid or viscous swallows (30%) and incomplete in both liquid and viscous swallows (59%) in IEM patients. The LES resting pressure and LES relaxation pressure were elevated (9% and 36%, respectively) in IEM patients. There was no significant difference between dysphagia and either poorly relaxing LES (P = 0.725) or defective bolus transit (DBT) to liquid and viscous swallows (P = 0.372) compared to the rest of the IEM patients. However, there was a significant association between dysphagia and the combination of poorly relaxing LES and DBT in liquid and viscous swallows (P = 0.006). Subgroup analysis comparing dysphagia with heartburn/regurgitation demonstrated a similar significant association between dysphagia and the combination of poorly relaxing LES and DBT during viscous and liquid swallows (P = 0.016). Conclusions Dysphagia is a variable symptom associated with complex esophageal motility abnormalities. IEM patients with a combination of poorly relaxing LES and DBT are more likely to have dysphagia.

Extraesophageal symptoms and signs of gastroesophageal reflux disease (GERD), such as throat clearing, globus sensation, hoarseness, cough, asthma, pulmonary fibrosis, otitis, sinusitis, and dental erosions, are common and pose diagnostic and therapeutic challenges. Proton pump inhibitors (PPIs) are the mainstay of treatment for GERD, but have demonstrated a limited effectiveness for extraesophageal symptoms and signs in several meta-analyses. Potassium-competitive acid blockers (P-CABs) offer more rapid and sustained acid inhibition than PPIs; therefore, P-CABs may have the potential to be at least as good or superior to PPIs in relieving extraesophageal symptoms and signs of GERD. To date, there have been 4 prospective randomized trials demonstrating similar efficacy of P-CABs to PPIs in the treatment of extraesophageal symptoms and signs, but more rapid and greater efficacy in patients with severe symptoms. Therefore, P-CABs appear to have a treatment role in extraesophageal symptoms and signs of GERD. However, considering that P-CABs are not superior to PPIs, large-scale, multi-center studies with double dose P-CABs over a prolonged period of time may elucidate a subgroup of patients in whom P-CABs are beneficial in ameliorating extraesophageal symptoms and signs.

Gastroesophageal reflux disease (GERD) is a complex condition with diverse clinical presentations, ranging from typical heartburn and regurgitation symptoms to extraesophageal manifestations and alarm symptoms. Determining which patients should be tested first versus those who should receive empirical treatment remains a key clinical challenge. If not recently performed, initial patient testing, commonly involving upper endoscopy, is recommended for patients presenting with alarm or refractory symptoms and for those at high risk for Barrett’s esophagus. Additionally, testing should be prioritized for patients with underlying comorbidities, such as scleroderma, increased body mass index, or a suspected large hiatal hernia. Older patients with atypical symptom presentations and those with extraesophageal symptoms or signs, especially in the absence of typical GERD symptoms, should also be referred for endoscopy if recent endoscopic results are not available. In contrast, patients with typical GERD symptoms in the absence of alarm features and those with extraesophageal symptoms accompanied by typical GERD symptoms could begin empirical treatment with a proton pump inhibitor (PPI) or potassium competitive acid blocker (PCAB). For individuals without alarm symptoms who do not respond to once-daily PPI therapy, escalation to twice-daily PPI therapy or switching to a PCAB, without further testing, is appropriate. Overall, an individualized approach is recommended, with patient presentation guiding the decision to test or treat first.

Gastroesophageal reflux disease (GERD) is a complex condition with diverse clinical presentations, ranging from typical heartburn and regurgitation symptoms to extraesophageal manifestations and alarm symptoms. Determining which patients should be tested first versus those who should receive empirical treatment remains a key clinical challenge. If not recently performed, initial patient testing, commonly involving upper endoscopy, is recommended for patients presenting with alarm or refractory symptoms and for those at high risk for Barrett’s esophagus. Additionally, testing should be prioritized for patients with underlying comorbidities, such as scleroderma, increased body mass index, or a suspected large hiatal hernia. Older patients with atypical symptom presentations and those with extraesophageal symptoms or signs, especially in the absence of typical GERD symptoms, should also be referred for endoscopy if recent endoscopic results are not available. In contrast, patients with typical GERD symptoms in the absence of alarm features and those with extraesophageal symptoms accompanied by typical GERD symptoms could begin empirical treatment with a proton pump inhibitor (PPI) or potassium competitive acid blocker (PCAB). For individuals without alarm symptoms who do not respond to once-daily PPI therapy, escalation to twice-daily PPI therapy or switching to a PCAB, without further testing, is appropriate. Overall, an individualized approach is recommended, with patient presentation guiding the decision to test or treat first.

Extraesophageal symptoms and signs of gastroesophageal reflux disease (GERD), such as throat clearing, globus sensation, hoarseness, cough, asthma, pulmonary fibrosis, otitis, sinusitis, and dental erosions, are common and pose diagnostic and therapeutic challenges. Proton pump inhibitors (PPIs) are the mainstay of treatment for GERD, but have demonstrated a limited effectiveness for extraesophageal symptoms and signs in several meta-analyses. Potassium-competitive acid blockers (P-CABs) offer more rapid and sustained acid inhibition than PPIs; therefore, P-CABs may have the potential to be at least as good or superior to PPIs in relieving extraesophageal symptoms and signs of GERD. To date, there have been 4 prospective randomized trials demonstrating similar efficacy of P-CABs to PPIs in the treatment of extraesophageal symptoms and signs, but more rapid and greater efficacy in patients with severe symptoms. Therefore, P-CABs appear to have a treatment role in extraesophageal symptoms and signs of GERD. However, considering that P-CABs are not superior to PPIs, large-scale, multi-center studies with double dose P-CABs over a prolonged period of time may elucidate a subgroup of patients in whom P-CABs are beneficial in ameliorating extraesophageal symptoms and signs.

Gastroesophageal reflux disease (GERD) is a complex condition with diverse clinical presentations, ranging from typical heartburn and regurgitation symptoms to extraesophageal manifestations and alarm symptoms. Determining which patients should be tested first versus those who should receive empirical treatment remains a key clinical challenge. If not recently performed, initial patient testing, commonly involving upper endoscopy, is recommended for patients presenting with alarm or refractory symptoms and for those at high risk for Barrett’s esophagus. Additionally, testing should be prioritized for patients with underlying comorbidities, such as scleroderma, increased body mass index, or a suspected large hiatal hernia. Older patients with atypical symptom presentations and those with extraesophageal symptoms or signs, especially in the absence of typical GERD symptoms, should also be referred for endoscopy if recent endoscopic results are not available. In contrast, patients with typical GERD symptoms in the absence of alarm features and those with extraesophageal symptoms accompanied by typical GERD symptoms could begin empirical treatment with a proton pump inhibitor (PPI) or potassium competitive acid blocker (PCAB). For individuals without alarm symptoms who do not respond to once-daily PPI therapy, escalation to twice-daily PPI therapy or switching to a PCAB, without further testing, is appropriate. Overall, an individualized approach is recommended, with patient presentation guiding the decision to test or treat first.

Gastroesophageal reflux disease (GERD) is a complex condition with diverse clinical presentations, ranging from typical heartburn and regurgitation symptoms to extraesophageal manifestations and alarm symptoms. Determining which patients should be tested first versus those who should receive empirical treatment remains a key clinical challenge. If not recently performed, initial patient testing, commonly involving upper endoscopy, is recommended for patients presenting with alarm or refractory symptoms and for those at high risk for Barrett’s esophagus. Additionally, testing should be prioritized for patients with underlying comorbidities, such as scleroderma, increased body mass index, or a suspected large hiatal hernia. Older patients with atypical symptom presentations and those with extraesophageal symptoms or signs, especially in the absence of typical GERD symptoms, should also be referred for endoscopy if recent endoscopic results are not available. In contrast, patients with typical GERD symptoms in the absence of alarm features and those with extraesophageal symptoms accompanied by typical GERD symptoms could begin empirical treatment with a proton pump inhibitor (PPI) or potassium competitive acid blocker (PCAB). For individuals without alarm symptoms who do not respond to once-daily PPI therapy, escalation to twice-daily PPI therapy or switching to a PCAB, without further testing, is appropriate. Overall, an individualized approach is recommended, with patient presentation guiding the decision to test or treat first.

Extraesophageal symptoms and signs of gastroesophageal reflux disease (GERD), such as throat clearing, globus sensation, hoarseness, cough, asthma, pulmonary fibrosis, otitis, sinusitis, and dental erosions, are common and pose diagnostic and therapeutic challenges. Proton pump inhibitors (PPIs) are the mainstay of treatment for GERD, but have demonstrated a limited effectiveness for extraesophageal symptoms and signs in several meta-analyses. Potassium-competitive acid blockers (P-CABs) offer more rapid and sustained acid inhibition than PPIs; therefore, P-CABs may have the potential to be at least as good or superior to PPIs in relieving extraesophageal symptoms and signs of GERD. To date, there have been 4 prospective randomized trials demonstrating similar efficacy of P-CABs to PPIs in the treatment of extraesophageal symptoms and signs, but more rapid and greater efficacy in patients with severe symptoms. Therefore, P-CABs appear to have a treatment role in extraesophageal symptoms and signs of GERD. However, considering that P-CABs are not superior to PPIs, large-scale, multi-center studies with double dose P-CABs over a prolonged period of time may elucidate a subgroup of patients in whom P-CABs are beneficial in ameliorating extraesophageal symptoms and signs.

Gastroesophageal reflux disease (GERD) is a complex condition with diverse clinical presentations, ranging from typical heartburn and regurgitation symptoms to extraesophageal manifestations and alarm symptoms. Determining which patients should be tested first versus those who should receive empirical treatment remains a key clinical challenge. If not recently performed, initial patient testing, commonly involving upper endoscopy, is recommended for patients presenting with alarm or refractory symptoms and for those at high risk for Barrett’s esophagus. Additionally, testing should be prioritized for patients with underlying comorbidities, such as scleroderma, increased body mass index, or a suspected large hiatal hernia. Older patients with atypical symptom presentations and those with extraesophageal symptoms or signs, especially in the absence of typical GERD symptoms, should also be referred for endoscopy if recent endoscopic results are not available. In contrast, patients with typical GERD symptoms in the absence of alarm features and those with extraesophageal symptoms accompanied by typical GERD symptoms could begin empirical treatment with a proton pump inhibitor (PPI) or potassium competitive acid blocker (PCAB). For individuals without alarm symptoms who do not respond to once-daily PPI therapy, escalation to twice-daily PPI therapy or switching to a PCAB, without further testing, is appropriate. Overall, an individualized approach is recommended, with patient presentation guiding the decision to test or treat first.

Background/Aims: Noncardiac chest pain (NCCP) of esophageal origin is a challenging clinical problem of diverse etiology that affects more than 80 million Americans yearly. We assess the prevalence and impact of psychological disorders on NCCP of esophageal origin, describe possible mechanisms associated with this condition, and review psychological therapy options. Methods: Online search using PubMed and Medline from January 1, 1966, to April 30, 2023. Results: Psychological disorders have been reported in up to 79% of patients with NCCP of esophageal origin. Several psychological disturbances have been identified with this condition, including depression, anxiety, panic disorder, phobias, and obsessivecompulsive and somatoform disorders. It is unclear whether the psychological disorders trigger the chest pain or vice versa. Multiple psychological mechanisms have been linked to chest pain and may contribute to its pathogenesis and severity. These mechanisms include cardiophobia, poor coping strategies, negative social problem solving, stress and perceived control, hypervigilance to cardiopulmonary sensations, altered pain perception, and alexithymia. Psychological therapies for NCCP of esophageal origin include cognitive behavioral therapy, hypnotherapy, physical and relaxation training, breathing retraining, and alternative medicine. Among the therapeutic options, cognitive behavioral therapy has been shown to be an effective treatment for NCCP of esophageal origin. Conclusion This review raises awareness about the high prevalence of psychological disorders in NCCP of esophageal origin and highlights the need for clinical trials and trained therapists to address the management of this taxing clinical problem.