The Esophagus: The Neglected Chest Organ?

Abstract

The thoracic cavity's organs include the heart, the lung and the esophagus. The American College of Chest Physicians (and the journal Chest, as its official publication) are predominated by cardiologists, pulmonologists and cardiothoracic surgeons whose primary orientation is that of either the cardiac or pulmonary subsystems. However, it seems timely to remind “chest” physicians that physiology and pathology of the esophagus are important considerations because of their impact on the other thoracic organs. Coronary angiography in some patients (10 to 15 percent) with chest pain considered typical for angina will rule out important coronary artery disease. Many of these patients can eventually be proved to have esophageal disorders causing their symptoms. In some cases, an esophageal motility disorder is found,1Brand DL Martin D Pope CE Esophageal manometries in patients with angina-like chest pain.Dig Dis. 1977; 22: 300-304Crossref Scopus (197) Google Scholar, 2Janssens J VanTrappen G Ghillebert G 24-hour recording of esophageal pressure and pH in patients with noncardiac chest pain.Gastroenterol. 1986; 90: 1978-1984Crossref PubMed Scopus (219) Google Scholar and on other occasions, gastroesophageal reflux is the culprit.2Janssens J VanTrappen G Ghillebert G 24-hour recording of esophageal pressure and pH in patients with noncardiac chest pain.Gastroenterol. 1986; 90: 1978-1984Crossref PubMed Scopus (219) Google Scholar Both these disorders are eminently treatable and it is not acceptable simply to dismiss patients with the information that they do not have coronary artery disease and therefore their chest pain is not important. One follow-up study3Ockene IS Shay MJ Alpert JS Weiner BH Dalen JE Unexplained chest pain in patients with normal coronary arteriograms. A follow-up study of functional status.N Engl J Med. 1980; 303: 1249-1252Crossref PubMed Scopus (305) Google Scholar showed that pain persists in the majority of these patients and half of them are so incapacitated that they are not able to return to work or their normal life-style. Accordingly, the cardiologist who clears the heart as the cause of chest pain must not stop but must continue the evaluation with a diagnostic evaluation of other organ systems, including the esophagus. It is also quite clear that esophageal disorders can be responsible for pulmonary disease. The patient presenting with evidence of destructive aspiration, in the absence of neurologic impairment or alcohol abuse, probably has reflux disease and should be evaluated for that. This, however, is a small group of patients. More common are patients who present with cough and wheezing and are considered to have atypical asthma. It is possible by analysis of these patients with esophageal pH monitoring to show that in some the symptoms are precipitated and caused by episodes of gastroesophageal reflux.4Pellegrini CA DeMeester TR Johnson LF Skinner DB Gastroesophageal reflux and pulmonary aspiration: Incidence, functional abnormality, and results of surgical therapy.Surgery. 1979; 86: 110-119PubMed Google Scholar This does not necessarily mean that gross aspiration is taking place, as both microaspiration and reflux acidification of the esophagus can cause reflex bronchoconstriction and asthmatic symptoms.5Tuchman DN Boyle JT Pack AI Schwartz J Kokonos M Spitzer AR et al.Comparison of airway responses following tracheal or esophageal acidification in the cat.Gastroenterol. 1984; 87: 872-881PubMed Google Scholar Correction of the reflux in these patients can eliminate their pulmonary symptoms. Pulmonologists should be alert that when patients present in an atypical fashion, at atypical ages, or when symptoms are related to factors that exacerbate reflux, then that diagnosis should be considered and investigated. In 1989, the Fifth Conference of The International Society for Diseases of the Esophagus will take place in Chicago under the sponsorship of The American College of Chest Physicians. We hope that the members of the ACCP and readers of this journal will see this as an opportunity to clarify the interrelationships between the three chest organs for the mutual benefit of physicians and patients.