Evaluation of the adult with chest pain of esophageal origin
- Donald O Castell, MD
Donald O Castell, MD
- AGA Peer Reviewer
- Professor of Medicine
- Director, Esophageal Disorders Program
- Medical University of South Carolina
Recurring substernal chest pain that is not due to coronary artery disease is a common clinical problem [1-4]. Recurrent unexplained chest pain can significantly impact patient quality of life and represents a major economic burden because of continued utilization of clinician and emergency facilities [5,6].
This topic will review the pathophysiology, etiology, and evaluation of chest pain of presumed esophageal origin. Common causes of chest pain in primary care practice and the diagnostic approach to chest pain are discussed elsewhere. (See "Outpatient evaluation of the adult with chest pain" and "Evaluation of the adult with chest pain in the emergency department".)
Among outpatients who present with chest pain, approximately one-third to one-half of patients have musculoskeletal chest pain, 10 to 20 percent have a gastrointestinal cause, 10 percent have stable angina, 5 percent have respiratory conditions, and approximately 2 to 4 percent have acute myocardial ischemia (including myocardial infarction) [7-10]. The prevalence of noncardiac chest pain in the community is 13 percent and is similar in men and women .
Gastroesophageal reflux disease is the most likely cause for recurring unexplained chest pain of esophageal origin . Approximately 50 percent of patients with recurrent noncardiac chest pain have abnormal esophageal acid exposure [13-15]. While an empiric diagnosis of "esophageal spasm" was previously applied to patients with unexplained noncardiac chest pain of esophageal origin, underlying esophageal motility disorders (eg, achalasia, distal esophageal spasm, nutcracker esophagus) are rare [13,16,17]. A study of 910 patients with negative coronary angiograms undergoing esophageal motility testing found that 28 percent of patients had abnormal motility and only 3 percent had evidence of esophageal spasm . (See "Clinical manifestations and diagnosis of gastroesophageal reflux in adults" and "Esophageal motility disorders: Clinical manifestations, diagnosis, and management" and "Achalasia: Pathogenesis, clinical manifestations, and diagnosis".)
Gastroesophageal reflux — Chest pain due to gastroesophageal reflux disease (GERD) can mimic angina pectoris and may be described as squeezing or burning, located substernally. It can last minutes to hours, and resolves spontaneously or with antacids. It may occur after meals, awaken patients from sleep, and be exacerbated by emotional stress. (See "Clinical manifestations and diagnosis of gastroesophageal reflux in adults", section on 'Clinical features'.)
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- Gastroesophageal reflux
- Non-reflux esophagitis
- Eosinophilic esophagitis
- Esophageal motility disorder
- Functional chest pain
- INITIAL ASSESSMENT
- Physical examination
- Laboratory testing
- DIAGNOSTIC STRATEGIES AND INITIAL MANAGEMENT
- Alarm signs and symptoms
- Patients with alarm features
- - Early upper endoscopy
- Patient without alarm features
- - Trial of acid suppression
- - Diagnostic evaluation
- Esophageal impedance and pH monitoring
- Esophageal manometry
- Upper endoscopy
- SUBSEQUENT MANAGEMENT
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS