The Pain of Pyloric Stenosis

Abstract

There are approximately 6,000,000 annual visits to the ED for chest pain in the US. However, only up to 30% of these patients have acute coronary syndromes. Other sources of chest pain can include vascular, pulmonary or gastrointestinal etiologies. Pyloric stenosis is one cause of gastrointestinal chest pain. H. pylori induced peptic ulcers are a known cause of pyloric stenosis. However, these secondary ulcers generally resolve with standard antimicrobial therapy. As a result, gastric outlet obstruction due to H. pylori induced pyloric stenosis is extremely rare. A 62 year old Hispanic male with a history of smoking presented with 3/10 chest tightness that was intermittent, sub-sternal and radiated to the right shoulder and back. It was associated with dyspnea and diaphoresis and exacerbated by oral intake. Additionally, he complained of right upper quadrant burning, vomiting after oral intake and a 30 lb weight loss over 4 months. Due to the presence of alarm symptoms a life threatening coronary syndrome was ruled out. Concomitant gastrointestinal evaluation showed dilation of the pancreatic duct on ultrasound. MRCP confirmed biliary and pancreatic ductal dilation with no clear etiology. Interestingly, an ERCP was unsuccessful due to severe pyloric stenosis. Subsequent upper endoscopy visualized severe gastritis in the antrum, body, and fundus of the stomach (Figure 1). A single ulcer was noted on the pylorus (Figure 2). The esophagus and stomach were dilated. Biopsy specimens showed active chronic gastritis with erosion and focal intestinal metaplasia. Presence of H. pylori was confirmed by immunohistochemistry (Figure 3). A gastric emptying study showed delayed emptying with reflux. The patient was managed with a standard triple therapy regimen. Although our patient presented with pain suspicious of cardiac origins, his true diagnosis was adult onset pyloric stenosis. An overlap in presentation can be seen in cardiac and gastrointestinal etiologies due to their anatomic proximity. A lack of accessibility to medical care resulted in our patients gastritis never being treated. It subsequently progressed, leading to ulceration which induced pyloric stenosis causing gastric outlet obstruction. As evidenced by this case, a high degree of suspicion must be maintained for gastrointestinal causes in patients presenting with non-cardiac chest pain.Figure 1Figure 2Figure 3