non-cardiac chest pain

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non-cardiac chest pain

Internal medicine Chest pain that simulates cardiac nosologies, but is unrelated to cardiovascular disease; 50% of Pts with NCCP have known reflex and may have postprandial or noctural Sx. See Gastroesophageal reflux disease.
Non-cardiac chest pain shamelessly taken, virtually verbatim from www.vnh.org/GMO/
ClinicalSection/08Chestpain.html, from Dept Navy, Bureau of Med & Surg; Internally Peer Reviewed
Sources of chest pain The heart, great vessels, pericardium; GI tract; lungs & pleura; chest wall
How to minimize YOUR risks of managing Acute chest pain Identification of ischemic chest pain requires a high index of suspicion; when the diagnosis of acute MI is overlooked and Pts are sent home–the mortality during the next 72 hrs is about 25%–how did you spell  that phrase again, “…out-of-court settlement.”–vs ± 6% for Pts with infarction who are hospitalized; being liberal in admissions for evaluation of CAD; incidence of acute MI in Pts hospitalized with acute chest pain is between 25 and 30%; despite conservative admission rates, clinicians misdiagnose ±5-10% of Pts with acute MI–ie, you're in good company if you screw up
History The Hx rules decision making; elements of the Hx important in discriminating cardiac from noncardiac chest pain are quality, severity, duration and frequency; knowledge of exacerbating features and maneuvers that ameliorate the discomfort are helpful; cardiac risk factors should not overly influence clinical thinking; the presence of risk factors simply implies that a person is more likely to develop overt signs of ASHD in the future, but are not exclusionary criteria
Pain character Chest pain due to coronary ischemia is classically a dull heavy pressure–but Pts have been pretty colorful in use of adjectives to describe this pain; they may have classic pain, DON'T expect a classic description of anginal pain; the pain may be confined to the chest or accompanied by aching in one or both arms, more often the left; neck or mandibular pain or aching confined to the shoulder, wrist, elbow, or forearm may manifest solely or with typical chest pressure; small zones of pain are generally not of myocardial origin; radiation of pain to the digits, brief zaplets of pain or discomfort that persists for days are not due to myocardial ischemia; effort or emotional stress commonly provokes angina; angina may occur at rest if perfusion is compromised; pain subsides within 1 to 5 mins if the triggering activity is discontinued; nitroglycerin hastens this relief
EKG The 12-lead ECG has limited value in excluding the presence of CAD; excluding the Dx of angina pectoris or acute MI because of a normal ECG is as great an error as inferring a diagnosis of CAD from the incorrect interpretation of nonspecific electrocardiographic abnormalities
Cocaine Cocaine causes ↓ coronary blood flow due to vasoconstriction; rhabdomyolysis, a complication of cocaine use, provides another mechanism for the chest pain; all chest painers should be questioned about cocaine use and, when appropriate, have a urine drug screen
GI tract Pain from the GI tract, especially the esophagus, may give rise to angina-like chest discomfort; GERD is the most common esophageal cause of noncardiac chest pain; it is described as a burning sensation or squeezing pain located in the retrosternal area between the xyphoid and suprasternal notch; listen for clues about association of Sx with meals, posture, and relief by belching or antacids; medical management involves dietary modifications, smoking cessation, and histamine type 2 (H2) antagonists or antacids; GI referral is warranted when these interventions are unsuccessful in alleviating Sx; the pain of peptic ulcer disease may also occur high in the epigastrium or lower chest; relationship
to meals and relative nonresponse to nitroglycerine helps distinguish this pain from
angina pectoris
Esophagus spasm Diffuse esophageal spasm is a neuromuscular disorder characterized by chest pain and difficulty in swallowing; NOTE Nitroglycerin promptly relieves esophageal spasm causing confusion in the diagnosis; vigorous disordered contractions in the body of the esophagus are induced by ingestion of cold liquids or normal swallowing during a meal; anxiety and stress are also common precipitating factors; there is usually no exertional component but ↑ abdominal pressure from lifting, sit-ups, or running can cause reflux; diagnosis rests on history and verification of esophageal spasm by manometric studies
Pulmonary origin Pain of pulmonary origin characteristically has a distinct pleuritic quality varying with the respiratory cycle; intercostal nerves supply sensory afferents to the costal parietal pleura; inflammation arising from this region is appreciated in the adjacent chest wall; referred pain originating in the diaphragm is appreciated in the ipsilateral shoulder; differentiating features of pulmonic from musculoskeletal pain are the more intense nature of pleuritic pain and the worsening of musculoskeletal pain by extension, abduction, or adduction of the arm and shoulder; pain centered around involved muscle groups may also distinguish musculoskeletal from pleuritic chest pain; (a) Spontaneous pneumothorax tends to occur in young adult males producing sharp pleuritic chest discomfort and dyspnea; (b) Pulmonary embolus may produce pleuritic pain, however, dyspnea, and tachypnea are most frequent. Inciting factors for pulmonary embolus include the post-operative period after long recumbent or inactive periods and following trauma where the same immobility may result in venous stasis and thrombosis.
Chest wall Tietze's syndrome or costochondritis is a self-limiting discomfort. Its quality is sharp or burning and is exacerbated by mechanical activity of the chest wall, specifically respiration; the second or third costal cartilages on either side are the most common area of involvement, but any of the costochondral articulations can be involved; NSAIDs or aspirin may offer temporary relief but reassurance tends to be as useful.
Etc Rarely, no etiology is found on standard evaluation of chest pain from the cardiology or GI consultation; one should then rule out panic disorder, visceral hypersensitivity in irritable bowel syndrome, and other exotica