A gastroenterologists view of chest pain

Abstract

Esophageal disorders are common, but have been underemphasized as causes of chest pain in patients with “chest pain and normal coronary arteries,” as well as in patients with documented coronary disease. Reasons include failure to pursue evaluation once cardiac sources have been excluded; the atypical nature, location and/or radiation of pain in many patients, leading one away from proper consideration of the esophagus as a pain source; performing tests (upper GI series, fiberoptic endoscopy, oral cholecystography) that have low sensitivity for the detection of the diseases most likely to be the cause of chest pain (gastroesophageal reflux disease, the primary esophageal motility disorders). Esophageal motility testing, esophageal acid perfusion, acid reflux testing and the use of pharmacologic agents to induce chest pain and dysmotility are of greater value. In general, these tests can be performed in less than two hours. In some instances, prolonged recording of distal esophageal pH and/or motility may help identify gastroesophageal reflux or a painful primary esophageal motility disorder as the cause of chest pain. Treatment of gastroesophageal reflux disease is effective in most patients. One must be especially aggressive in the treatment of reflux in patients with coexistent coronary disease. The aim of treatment should be to eliminate pain episodes, since in these patients, pain emanating from an acid-sensitive esophagus may be confused with angina or, in some instances, actually induce myocardial ischemia. While therapy in the painful primary esophageal motility disorders is less effective than for reflux disease, several newer treatments show promise.