Substernal Pain Research Articles

BARRETT'S ESOPHAGUS IN CHILDHOOD

Barrett's esophagus or columnar-lined esophagus (CLE) isa metaplasia state associated with gastroesophageal (GE) reflux and increased risk of esophageal adenocarcinoma in adults; in CLE, columnar epithelium replaces normal squamous lining. Previous reports of CLE in children are rare and usually based on single biopsy diagnosis. We report a detailed clinical and histologic study in 10 children with CLE, ages 6 1/2-13 yr., diagnosed between 1976-1983. All were males. 8 had mid or upper esophageal strictures, comprising 25% of all childhood strictures at UCLA during that period. All 10 had low lower esophageal sphincter pressures and or abnormal esophageal pH studies. Vomiting, dysphagia, substernal pain or cough were present for average 8 yr; 9 had severe vomiting or pneumonias below 1 yr. age. A single esophageal biopsy containing columnar epithelium may represent normality or hiatus hernia; in order to avoid this potential confusion, esophageal biopsies were taken under direct vision at endoscopy from several levels above the GE junction. The diagnostic criterion for CLE was the presence of columnar epithelium in 2 or more biopsies taken 2 cm or more above the anatomic GE junction. A total of 40 esophageal biopsies in 10 patients contained columnar epithelium; surface epithelium was gastric-type alone in 6 patients and gastric with intestinal-type in 4. These studies show that a) CLE should be considered in all children with mid or upper esophageal stricture and in those with longstanding symptoms of GE reflux; b) intestinal metaplasia appears to be less common in childhood CLE than in adults.

EXERCISE-INDUCED GASTROESOPHAGEAL REFLUX

The effect of exercise on gastroesophageal function was assessed in 7 children who were referred for evaluation of gastroesophageal reflux (GER). Four males and three females whose ages were 12.6 ± 4.4 yr were studied. Three patients presented with exercise-induced gastrointestinal symptoms (nausea, vomiting, substernal or epigastric pain). Cardiac or pulmonary disease was present in 3 children. Maximal treadmill exercise testing using the Bruce protocol with continuous monitoring of electrocardiogram and blood pressure was performed simultaneously with an esophageal pH probe study. Other diagnostic studies included upper GI series, 24-h pH probe, esophageal motility, gastroesophageal endoscopy, and biopsies. Results demonstrated that in one patient with exercise-induced gastrointestinal symptoms, significant symptomatic GER was present throughout strenuous exercise and during recovery ⩾ 40 min); no episodes of pathologic GER occurred throughout 24-h pH probe monitoring by Euler's criteria. Exercise-induced GER also was associated with biopsy-proven esophagitis. Motility studies demonstrated esophageal sphincter competency. None of the other patients demonstrated exercise-induced GER, despite the presence of pathologic GER. Physical work capacity was normal in all children. There were no pathologic ST changes associated with exercise. This is the first report of the association between exercise-induced gastrointestinal symptoms and GER. The pathophysiology of this entity is unknown. Exercise stress testing may aid in the diagnosis of exercise-induced GER.

Exercise and air pollution

Abstract Will the air quality in Los Angeles be a matter of concern for athletes participating in the 1984 Olympics? This question and corollaries of it are being asked with increasing frequency as the time of the Olympics nears. This review identifies the major pollutants that have been shown to produce physiological changes which can and may effect athletic performance. Ozone is the major contaminant of Los Angles air which in recent times has received major research interest. Specifically, ozone has been documented as a potent airway irritant capable of initiating its effects at concentrations as low as 0.30 ppm. Recent evidence indicates that, when integrated with the sustained high ventilation volumes of the elite athlete, ozone's airway constrictive effect is manifest at concentrations of 0.20 ppm. The effect of ozone causes an increase in breathing rate and a decrease in tidal volume for a given workload along with substernal pain. At the current ambient levels it is unlikely that sulphur dioxide w...

Adolescent Chest Pain

To the Editor.— I have some questions about Pantell and Goodman's article on adolescent chest pain. Was there any urine testing for cannabinoids? Were there inquiries regarding the use of marijuana? It's not unusual for teenagers to smoke this drug exclusively. In my pediatric practice, I have seen several adolescents with left-sided or substernal pain, in some instances not accompanied with chronic cough. The roentgenograms of the chest, EGG, tuberculosis tests, and other routine laboratory tests were negative, including some skin tests for respiratory allergies in a few.

Femoral and Skull Metastasis With Hypercalcemia

The most common initial symptom of esophageal neoplasm is dysphagia. When metastasis occurs, it is most frequent to neighboring lymph nodes, mediastinum, or viscera, eg, the lungs and liver, and only infrequently to bones. Even less frequently do these metastases occur with hypercalcemia. A 59-year-old woman was initially seen with hypercalcemia and bone pain in the hip and leg, which subsequently proved to be the site of metastatic spread secondary to squamous cell carcinoma of the esophagus. Until her death, approximately four months after the diagnosis, she never experienced dysphagia, epigastric or substernal pain, or regurgitation.

Diagnosis of hiatus hernia by computed tomography

Hiatus hernia and phrenic ampulla are serendipitous CT findings. They may be seen with or without oral contrast and should not be mistaken for abnormal masses in the oncologic patient. When oral contrast is used, esophageal reflux may be demonstrated and may be the cause of epigastric or substernal pain. Knowledge of the esophagogastric anatomy is essential in making the proper diagnosis. 13-mm collimator. Scans were obtained at 2 cm or less through the lower chest and abdomen following ingestion of 300 ml of a 5% Gastrografin (E. R. Squibb & Sons, Inc.) solution 30 min prior to the study and another 200 ml 5 min before scanning. This solution was given to the patient in the upright position and all scanning was performed with the patient supine. Thus, the recently ingested contrast gravitated to the dependent gastric fundus. Hiatus hernia alone was present in 6 patients, associated reflux was noted in 4, phrenic ampulla was demonstrated in 1, reflux alone was evident in 1, and one elderly patient exhibited a hiatus hernia with associated esophageal tertiary contractions and presbyesophagus. In the evaluation of patients with intra-abdominal disease, the demonstration of hiatus hernia is usually a serendipitous finding. Recognition of this entity is important, especially in oncologic practice, for it must not be mistaken for a soft-tissue tumor or adenopathy. Furthermore, awareness of the presence of a hiatus hernia would be important should the patient have or later develop epigastric symptoms, or those of esophageal reflux. This communication describes the anatomy at the distal esophageal level; the CT appearance of hiatus hernia, phrenic ampulla, and esophageal reflux; and confirmation of the CT findings by barium swallow. CT FINDINGS

Pathogenesis, Diagnosis, and Management of Reflux Esophagitis

The most common symptoms associated with reflux esophagitis are heart­ burn and regurgitation. Heartburn is usually described as a substernal or retrosternal burning pain or discomfort with a moving quality from the xyphoid area up toward the suprasternal notch. The pain may radiate up toward the neck and jaw as well as down into the epigastric area. Rarely, the pain may radiate into the arms and simulate the pain of cardiac origin (1). Heartburn is frequently associated with regurgitation of sour or bitter fluid. These symptoms are exacerbated by meals or postural changes, usu­ ally made worse when the patient is recumbent or tenses his abdominal muscles as in lifting. Most patients (84%) experience symptoms of reflux for more than one year before seeking medical attention (2). Intermittent dysphagia occurs frequently with the first swallows of every meal. The symptom is often reported by patients with severe reflux eso­ phagitis. They do not often have mechanical obstruction to the passage of food. Usually the dysphagia will be mild and nonprogressive with no asso­ ciated weight loss. This is the result of a motility disturbance within the body of the esophagus induced by reflux of gastroduodenal contents (3) and occurs most frequently with the first bolus swallowed. Persistent dysphagia of solids in a patient with reflux esophagitis should indicate to the clinician that a peptic stricture has formed or that a carcinoma may have developed within the esophagus. Anemia has been described as the presenting symp­ tom in some patients with reflux esophagitis; it is a result of low-grade

Marfan's syndrome

Asfaw I, Tintinalli JE: Marfan's syndrome. Ann Emerg Med 9:105-107, February 1 980. Marfan's syndrome; syndrome, Marfan's; aortic insufficiency, Marfan's syndro me I NTRODUCTION Judith Tintinalli, MD: The case for discussion today is that of a young woman with Marfan's syndrome and chest pain. The guest speaker is Ingida Asfaw, MD, associate professor of cardiothoracic surgery at Wayne State University. CASE REPORT James Bavinger, MD: This 20-year-old woman had been diagnosed to have Marfan's syndrome at the Mayo Clinic the previous day. She had returned to Michigan from Minnesota the night before admission, and while eating breakfast, she developed crushing substernal and back pain. She was immediately

Histoplasmosis with Symptomatic Lymphadenopathy: Clinical Evaluation by R. A. Goodwin, M.D.

A 27-year-old black man developed very sharp substernal pain in the chest associated with general malaise, headache, swelling of the lymph nodes in his neck, and a severe cough five weeks prior to admission. A chest roentgenogram was obtained and was said to have shown “a swelling above his heart.” The patient failed to keep a follow-up appointment and was not seen until two weeks prior to hospitalization

Esophageal-atrial perforation due to recurrent esophagitis 18 years after esophageal bypass surgery

A 62-year-old man presented with a grand mal seizure, progressive abdominal distention, and refractory hypotension 18 years after colonic bypass of a benign stricture of the low middle third of the esophagus. He died 3 hours after admission to the hospital. The patient had a history of liniment ingestion in childhood plus a long history of dysphagia and substernal pain. Autopsy disclosed a large ulcer of the anterior wall of the distal esophagus, which had eroded through the posterior wall of the left atrium. Histologic examination revealed chronic esophagitis with fibrous obliteration of the esophageal wall, pericardium, and left atrial myocardium near the site of perforation. Foreign material was present within small arteries of multiple viscera, and in several of these fragments transverse striations were demonstrated. Esophageal-atrial perforation is a rare but fatal complication of chronic esophageal ulceration. The clinical and pathological features of this and previously reported cases of nontraumatic esophageal-atrial perforation are reviewed.

Acute central chest pain in the elderly. A review of 296 consecutive hospital admissions during 1976 with particular reference to the possible role of beta-adrenergic blocking agents in inducing substernal pain

Two hundred and ninety-six patients were admitted to geriatric medical beds in Cardiff in 1976 with acute central chest pain. One hundred and eighty-six (63 per cent) had a confirmed acute myocardial infarction. Of the 37 per cent without evidence of cardiac infarction, 32 per cent were on beta-blocking drugs. The possible role of adrenergic blocking agents in producing acute central chest pain is discussed.

Prevention of Heart Disease in the Normal Subject with a Positive Exercise Test

The person who has asymptomatic myocardial ischemia is at high risk because he does not have the benefit of the warning signals afforded by the substernal pain that tells most patients with angina to stop what they are doing.

Angina-Like Syndrome with Diazoxide Therapy for Hypertensive Crisis

In 14 patients with hypertensive crisis treated with diazoxide, close monitoring of blood pressure, heart rate, and symptoms was performed. Standard 12-lead electrocardiograms were recorded before and after diazoxide. All patients showed a significant fall in blood pressure after drug administration. Seven patients (50%) showed significant ST-T changes after diazoxide. Six patients (43%) developed substernal discomfort demonstrated by substernal pain of tightness. Five patients (35%) had both chest discomfort and ST-T changes. One of these patients with substernal pain and ST elevation had evidence of acute myocardial infarction with serial enzyme studies. In the patients with significant ST-T changes, the average fall in blood pressure was significantly greater than the average fall in blood pressure in the patients without significant ST-T changes. These findings suggest that both ST-T changes and substernal discomfort were due to myocardial ischemia secondary to a sudden severe drop in blood pressure.

Reflux esophagitis: pathogenesis, diagnosis, and management.

Although the incidence of heartburn. and regurgitation in the general population is not known, symptomatic gastroesophageal reflux is being recognized with increasing frequency as a cause of substantial morbidity. Recent advances in the pathophysiology of gastroesophageal reflux and its consequences indicate that reflux esophagitis is the result of the failure of the lower esophageal sphincter (LES) to prevent the regurgitation of gastroduodenal secretions with subsequent esophageal mucosal injury. This new information, as well as the development of new esophageal diagnostic tests, have led to a more precise diagnosis and more rational management of this disease process. This review is concerned mainly with the clinical and the pathophysiologic aspects on which we currently base the diagnosis and management of reflux esophagitis. SYMPTOMS Heartburn, the most common symptom of reflux esophagitis, is usually described as a substernal burning pain or discomfort, with a moving quality from the xyphoid area up to the

Reflux Esophagitis

Although the incidence of heartburn. and regurgitation in the general population is not known, symptomatic gastroesophageal reflux is being recognized with increasing frequency as a cause of substantial morbidity. Recent advances in the pathophysiology of gastroesophageal reflux and its consequences indicate that reflux esophagitis is the result of the failure of the lower esophageal sphincter (LES) to prevent the regurgitation of gastroduodenal secretions with subsequent esophageal mucosal injury. This new information, as well as the development of new esophageal diagnostic tests, have led to a more precise diagnosis and more rational management of this disease process. This review is concerned mainly with the clinical and the pathophysiologic aspects on which we currently base the diagnosis and management of reflux esophagitis. SYMPTOMS Heartburn, the most common symptom of reflux esophagitis, is usually described as a substernal burning pain or discomfort, with a moving quality from the xyphoid area up to the

Sick sinus syndrome in children.

The ages of 6 male patients with the sick sinus syndrome ranged from 10-15 years when their symptoms began. At rest all had a heart rate of 60/min or less. Two had syncopal attacks which threatened life; 1 had only attacks of dizziness; the other 3 had no syncopal attacks but had recurrent attacks of supraventricular tachycardia ('brady-tachycardia syndrome') which were more resistant to drug therapy than is usual in childhood. They were not controlled or suppressed by digoxin when it was given. Substernal pain occurred in 2 patients who had syncope. In all patients the heart rate remained inappropriately slow after exercise and atropine. Cardiac pacemakers were used in the 2 patients with life-threatening syncope. Any patient who has dizziness or syncopal attacks and an inappropriately slow heart rate should have electrocardiograms recorded at rest and after exercise to record the heart rate and to look for abnormal P-waves.

Primary Pneumococcal Pericarditis

PURULENT pericarditis caused by Streptococcus pneumoniae is a rare disease, usually a complication of a primary lung infection with contiguous pleural involvement. 1 To our knowledge, only two cases of primary pneumococcal pericarditis have been reported in the English literature. Recently, we have seen three patients with pneumococcal pericarditis in whom no other site of pneumococcal infection was apparent. One patient was a 56-year-old man, another was a 2-year-old boy, and a third was a 53-year-old woman, whose case we are reporting in detail. Report of a Case A 53-year-old woman was admitted on Nov 3, 1974, with a sudden onset of substernal pain radiating to her neck and left arm. She gave a history of angina pectoris that usually was relieved by nitroglycerin, but the current bout of pain was unrelieved by this medication. On physical examination, the blood pressure was 120/70 mm Hg; pulse, 100 beats per minute

Pre- and postoperative manometric studies in diffuse esophageal spasm

Since January, 1972, the authors have operated upon 4 patients with idiopathic diffuse exophageal spasm. Clinical details and barium studies are included. Extramucosal myotomy extending from the gastric fundus to the aortic arch was done in each case. Pre- and postoperative manometric studies were carried out in all. After operation in each patient the dysphagia and substernal pain disappeared and in 3 patients radiological patterns changed. The myotomy was associated with marked fall of contractile wave pressures in the body of esophagus. The basal pressures of the esophageal body elevated, in 2 cases fell after the myotomy; in 2 with normal preoperative pressure it remained unchanged. At the lower esophageal sphincter the resting and yield pressures remained similar to the preoperative readings but the myotomy produced a disappearance of the relaxation and contraction pressure. The authors conclude that with myotomy they cannot correct the nature of the functional disorder but, by reducing the amplitude of the waves and lowering the resting pressure if elevated, they can relieve the patient's symptoms.

Diffuse Spasm of the Esophagus

During the past ten years 7 men and 15 women with diffuse esophageal spasm have been seen at the Duke University Medical Center. Dysphagia and severe substernal pain were the two characteristic symptoms. Eleven of the 22 patients were treated with a long esophageal myotomy. Two had a diverticulum of the lower esophagus excised in addition, while 6 had an associated sliding hiatal hernia repaired. Three patients in whom the diagnosis was made retrospectively all had an epiphrenic diverticulum excised without a myotomy; in 1 an esophageal leak occurred. These 3 patients still have mild symptoms of their diffuse esophageal spasm. The results of myotomy have been satisfactory. Although this operation does not correct the cause of the disorder, the improvement in symptoms makes it worthwhile in selected patients.

Sipple Syndrome and Acute Lymphoblastic Leukemia

ACUTE leukemia, to the best of our knowledge, has not been reported to occur with Sipple syndrome. Although acute lymphoblastic leukemia is not derived from neuroectoderm, it might arise in this setting because of excessive antigenic stimulation of the lymphoreticular system by products of synthesis released from medullary thyroid carcinoma. The presence or absence of chromosomal defects and the status of the immune system in patients with Sipple syndrome have not been established. These factors may also be important in the etiology of acute leukemia. In the following case, however, it must be admitted that acute lymphoblastic leukemia may have been only a fortuitous association. <h3>Report of a Case</h3> A 28-year-old man was admitted to Walter Reed General Hospital on June 21, 1966, with the chief complaints of severe dyspnea on exertion, dizziness, and blurred vision over the past few weeks. The patient had had episodes of palpitation, substernal pain,