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食管源性胸痛

Author
Donald O Castell, MD
Section Editor
Nicholas J Talley, MD, PhD
Deputy Editor
Shilpa Grover, MD, MPH, AGAF
Translators
常英, 主任医师

引言

非冠状动脉疾病所致的反复胸骨后疼痛是一个常见的临床问题(参见“心绞痛：心肌缺血所致胸痛”)。超过50%的因不明原因胸痛就诊于急诊科的患者，会排除冠状动脉疾病[1-3]。然而，这些患者通常在未作出诊断的情况下回家，对其胸痛的起源仍然困惑和担心。大多数此类患者最初是由心脏科医生或急诊科医生来进行评估的，而这些医生通常未继续评估胸痛可能的其他原因，因为冠状动脉疾病发生危及生命事件的总体风险要高得多[4]。

有大量的记录表明，这一大群不明原因胸痛的患者由于胸痛反复发作，不停地就医和使用急诊设施，带来了重大的经济负担[5]。即使这些患者知道冠状动脉造影检查阴性，也未能缓解他们的担忧或使情况持续改善。例如，一项报道调查了冠状动脉造影检查阴性的胸痛患者在初始评估超过一年之后的功能状态：结果发现，51%的患者不能工作，47%的患者由于胸痛而有活动受限，44%的患者仍认为自己有冠状动脉疾病[6]。

食管性胸痛的病理生理

自1892年William Osler首次提出食管痉挛可能引起胸痛的症状以来，反复发作的“非心源性”胸痛有潜在的食管性原因被认为是可能的[7]。因此，在随后数年间，经验性诊断“食管痉挛”已用于不明原因胸痛的患者。

然而，更近期的研究表明，真正的食管痉挛不太可能是反复发作的不明原因胸痛的原因。一项研究纳入了910例冠状动脉造影检查阴性的患者进行了食管动力检测，发现28%的患者食管动力异常，而其中仅10%的患者(即，患者总数的2.8%)有证据显示食管痉挛[8]。其他研究也已证实，不到10%的此类患者确认存在食管痉挛[9-11]。一项纳入140例非心源性胸痛患者的病例系列研究发现，最常见的食管运动异常是低压性下食管括约肌(61%的患者)，而胡桃夹食管和非特异性食管运动障碍分别仅见于10%的患者[11]。 (参见“弥漫性食管痉挛、胡桃夹食管和高压性食管下括约肌”)

食管源性胸痛可能起因于食管内的异常过程、痛阈下降导致食管对正常刺激的异常感知(即，食管高敏感性)或周围神经系统和中枢神经系统对刺激的异常传输。人们认为，食管的痛觉是源于酸性或高渗性物质对化学感受器的刺激、扩张或异常收缩对机械感受器的刺激，以及冷或热的食物对温度感受器的刺激[12]。

           

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Literature review current through: 2017-06 . | This topic last updated: 2016-05-17.
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