Noncardiac Chest Pain
The term noncardiac chest pain generally means pain in the chest that mimics or may be confused with cardiac chest pain. Often the pain is caused by a disorder of the esophagus, stomach, or gallbladder. Diagnosis is particularly confusing in patients who have both cardiac and noncardiac chest pain. Much of the diagnostic confusion arises from the generous overlap in pain sensations entering the spinal cord from the heart, mediastinum, stomach, and other upper abdominal organs.
I.
The differential diagnosis of noncardiac chest pain is outlined in Table 22-1. Although this chapter deals mostly with esophageal causes of chest pain, one cannot neglect the numerous other causes in evaluating patients with chest pain. Also, it seems an inherent contradiction to say that cardiac chest pain should be a consideration in the differential diagnosis of noncardiac chest pain; yet some patients who are referred because they are thought to have noncardiac chest pain, but have not had an adequate cardiac evaluation, eventually are found to have cardiac disease or a combination of cardiac and noncardiac chest pain.
II. DIAGNOSIS.
Many patients with noncardiac chest pain already have had an evaluation for cardiac disease. This evaluation may have consisted of an electrocardiogram (ECG) only or may have been extensive, including stress testing and coronary arteriography. In any event, the patient’s major concern usually is whether he or she has heart disease. If the pain can be attributed to a noncardiac cause, the patient often feels better, even though in some instances little can be done to relieve the pain.
Cardiac causes of chest pain must first be excluded. This cannot always be done with absolute certainty, and in some patients a diagnosis of both cardiac and noncardiac chest pain is made. Furthermore, it appears that, in some of these patients, noncardiac pain can stimulate cardiac chest pain.
A. Clinical presentation
1. The character of the pain
may help differentiate cardiac from noncardiac pain. Cardiac pain typically is aggravated by stress and exercise and radiates to the neck, shoulder, and left arm. Chest wall and esophageal pain, however, also sometimes appear to be aggravated by stress and exercise. The pain of gastroesophageal reflux can radiate to the neck and jaw, but it rarely radiates down the arm.
2. Accompanying symptoms and relation of the pain to other events
can help differentiate the cause. Dysphagia in association with the pain points to an esophageal origin (see Chapter 21). If the dysphagia is for both liquids and solids, an esophageal motility disorder is likely. Pain after eating can be cardiac, but it is more likely to be of esophageal or perhaps gallbladder origin. Pressure over the site of pain that aggravates the pain suggests a chest wall source such as costochondritis or trauma, although chest wall tenderness has been described in cardiac pain.
B. Diagnostic studies
1. Exclusion of cardiac disease
a. X-ray and ECG. All patients should be evaluated with a chest x-ray and ECG. Some patients require exercise stress testing using standard ECG monitoring or thallium scanning.
TABLE 22-1 Diagnostic Considerations in Noncardiac Chest Pain | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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