What is pain in the esophagus ?

Non-cardiac chest pain is a term used to describe chest pain that resembles heart pain (also called angina) in patients who do not have heart disease ¹. The pain typically is felt behind the breast bone (sternum) and is described as oppressive, squeezing or pressure-like. It may radiate to the neck, left arm or the back (the spine). It may be precipitated by food intake. It lasts variable periods of time and it is not unusual for it to last hours. Patients may also complain of associated reflux symptoms such as heartburn (a burning feeling behind the breast bone) or fluid regurgitation (a sensation of stomach juices coming back toward the chest and even to the mouth frequently with a bitter or sour taste).

Because the pain is similar to heart pain or heart attack, patients and physicians frequently attribute this pain to the heart. In fact, many patients present to emergency rooms concerned about a heart attack and commonly undergo cardiac studies (such as EKGs, laboratory tests, stress test and even coronary angiography – where dye is injected into the heart vessels). After these cardiac tests fail to show evidence of heart disease, the patients receive the diagnosis of non-cardiac chest pain, leading the physician to examine other causes for this chest pain.

• Many people aren’t sure what’s wrong when they are having symptoms of a heart attack.

Heart attack treatment works best when it’s given right after symptoms occur.

• Don’t Wait–Get Help Quickly
• Quick Action Can Save Your Life !
  
• If you think you or someone else is having a heart attack, even if you’re not sure, don’t feel embarrassed to call your local emergency number right away !
• Do not drive to the hospital or let someone else drive you. Call an ambulance so that medical personnel can begin life-saving treatment on the way to the emergency room. Take a nitroglycerin pill if your doctor has prescribed this type of treatment.

Symptoms of a heart attack

• Remember acting fast at the first sign of heart attack symptoms can save your life and limit damage to your heart ². Treatment works best when it’s given right after symptoms occur.

• Not all heart attacks begin with the sudden, crushing chest pain that often is shown on TV or in the movies. In one study, for example, one-third of the patients who had heart attacks had no chest pain ³. These patients were more likely to be older, female, or diabetic.

The symptoms of a heart attack can vary from person to person. Some people can have few symptoms and are surprised to learn they’ve had a heart attack. If you’ve already had a heart attack, your symptoms may not be the same for another one. It is important for you to know the most common symptoms of a heart attack and also remember these facts:

• Heart attacks can start slowly and cause only mild pain or discomfort. Symptoms can be mild or more intense and sudden. Symptoms also may come and go over several hours.
• People who have high blood sugar (diabetes) may have no symptoms or very mild ones.
• The most common symptom, in both men and women, is chest pain or discomfort.
• Women are somewhat more likely to have shortness of breath, nausea and vomiting, unusual tiredness (sometimes for days), and pain in the back, shoulders, and jaw.

Some people don’t have symptoms at all. Heart attacks that occur without any symptoms or with very mild symptoms are called silent heart attacks.

What You Must Do If You Have Chest Pain ?

ALL patients suffering from chest pain must have thorough cardiac evaluations to ensure they do not have heart disease prior to being labeled as having non-cardiac chest pain. In addition, a variety of other disorders described below, both esophageal (origin from the esophagus) and non-esophageal must also be considered since specific treatment for these disorders are available.

Once cardiac tests have concluded that patients do not have heart disease, patients are commonly offered a treatment trial of acid suppressive inhibition medications (called a PPI – proton pump inhibitor – trial) for about 2 weeks. This is frequently referred as “a PPI trial” and can be both diagnostic and therapeutic since if it relieves the chest pain it suggests that acid-reflux is likely the cause. Thus, if pain is improved the treatment may be extended for a longer period of time such as 2 months. If the patient does not improve after “a PPI trial”, further testing may be done. Those studies may include a pH study of the esophagus (a test to actually measure the amount and determine if there is acid reflux) an upper endoscopy (a scope with a light that is introduced in the esophagus and stomach to check for other conditions that may cause chest pain), an esophageal motility test (a test to study the esophagus muscle contractions) and perhaps an ultrasound of the abdomen to examine the gallbladder for possible stones.

Why is heart pain and esophagus pain similar ?

The heart and the esophagus are located in the chest cavity (thorax) in close proximity (Figure 1). They receive very similar nerve supply. Thus, pain arising from either organ travel through the same nerve sensory fibers to the brain. As a result, the pain from either organ can have very similar features making it difficult to differentiate cardiac pain from esophageal (swallowing pipe) pain. It also indicates that a very common source of chest pain (non-cardiac) arises from the esophagus.

Figure 1. The heart and the esophagus are located in the chest in close proximity and also share same sensory nerves.

Risk Factors for Non-cardiac chest pain

Non-cardiac chest pain can occur in children as well as older patients, it also affects men and women and some studies have suggested a higher proportion of patients are female. The reasons some studies have found women may have a higher frequency of non-cardiac chest pain than men is not well understood.

Non-cardiac chest pain is a very common problem of international proportions. Population studies have shown that in the United States as many as 70 million patients (23% of the population) suffer from non-cardiac chest pain. Similar figures have been described in Australia (33%), Spain (8-28%), Argentina (24%), and South China (21%). No other specific risk factors have been identified.

What are the causes of Non-cardiac chest pain ?

The sources of non-cardiac chest pain can be grouped into esophageal and non-esophageal. Several studies have shown that approximately 60% or more of patients with non-cardiac chest pain suffer from acid reflux (mostly due to what is commonly referred to as Gastroesophageal Reflux Disease or GERD) ¹. Therefore, patients having chest pain who have had a negative cardiac evaluation are frequently referred to gastroenterologists (digestive disease specialists) to evaluate the esophagus as source of their chest pain.

Esophagus Sources of Pain

Gastroesophageal Reflux Disease (GERD) or acid reflux

By far the most common cause of esophageal non-cardiac chest pain is gastroesophageal reflux disease also known as GERD or acid reflux. Studies estimate that between 22-66% of patients have gastroesophageal reflux disease (GERD) as a source of non-cardiac chest pain. In addition to chest pain, patients may complain of heartburn and or regurgitation or chest pain alone may be due gastroesophageal reflux disease (GERD).

Esophagitis

Esophagitis is present when the lining of the esophagus becomes swollen, inflamed, or irritated ⁴.

Esophagitis is often caused by stomach fluid that flows back into the food pipe. The fluid contains acid, which irritates the tissue. This problem is called gastroesophageal reflux disease (GERD).

An autoimmune disorder called eosinophilic esophagitis also causes this condition.

The following increase your risk of this condition:

• Alcohol use
• Cigarette smoking
• Surgery or radiation to the chest (for example, treatment for lung cancer)
• Taking certain medicines without drinking plenty of water. These medicines include alendronate, doxycycline, ibandronate, risedronate, tetracycline, potassium tablets, and vitamin C
• Vomiting

People who have a weakened immune system may develop infections. Infections may lead to swelling of the food pipe. Infection may be due to:

• Fungi or yeast (most often Candida)
• Viruses, such as herpes or cytomegalovirus

Symptoms of Esophagitis

The infection or irritation may cause the food pipe to become inflamed. Sores called ulcers may form.

Symptoms may include:

• Cough
• Difficulty swallowing
• Painful swallowing
• Heartburn (acid reflux)
• Hoarseness
• Sore throat

Treatment of Esophagitis

Treatment depends on the cause. Common treatment options are:

• Medicines that reduce stomach acid in case of reflux disease
• Antibiotics to treat infections
• Medicines and diet changes to treat eosinophilic esophagitis
• Medicines to coat the lining of the food pipe to treat damage related to pills

Esophageal contraction disorders as cause of pain

Other esophageal causes of chest pain include disorders of esophagus muscle (esophageal motility disorders) such as uncoordinated muscle contractions (esophageal spasm), contractions of extremely high pressure (nutcracker esophagus), and occasionally a disorder characterized by absence of esophageal muscle contraction due to loss of nerve cells of the esophagus (achalasia) ¹. It is important to recognize particularly achalasia since is a treatable disorder.

Visceral (esophageal) Hypersensitivity

Patients with non-cardiac chest pain may also have “visceral hypersensitivity” that is an esophagus where the smallest change in pressure or exposure to acid may result in tremendous pain ¹. This is best explained by describing an experiment: when a small balloon is placed inside the (esophagus) and distended, patients with non-cardiac chest pain perceive the distension of the balloon at very low volumes. This is unlike healthy control subjects who do not experience this pain at all or may only have pain when the balloon distension reaches very large volumes. This phenomenon has been termed “Esophageal or visceral hypersensitivity” (enhanced esophageal perception or sensitivity to balloon distension). Although the cause of this increased sensitivity to balloon distension is unknown, there are treatment modalities that can be used to improve this exaggerated pain perception.

Treatment for Esophagus Sources of Pain

Patients may be treated as if the non-cardiac chest pain was a result of having gastroesophageal reflux disease (GERD):

• Once cardiac and other life-threatening conditions have been excluded and, based on the notion that the most common cause of non-cardiac chest pain is gastroesophageal reflux disease (GERD), a treatment trial is frequently considered.

Patients are often prescribed a proton pump inhibitor (PPI) also called a PPI trial. They must be taken at least 30-60 minutes before breakfast. It has been shown that this approach produces an approximately 80% response rate for patients with gastroesophageal reflux disease (GERD)-related non-cardiac chest pain.

If the patient responds, the treatment can be continued for at least 8 weeks at a reduced dose such as Omeprazole (or equivalent PPI medication ) 20 mg twice daily about 40 min prior to meals. Other equivalent PPI’s can also be employed and include: Esomeprazole, Lansoprazole, Rabeprazole, and Pantoprazole.

For patients not responding to a PPI, gastroesophageal reflux disease (GERD) is the unlikely source of pain:

For these patients, other medications are available. These medications are felt to produce their favorable effect by reducing pain transmission from the esophagus to the brain. The medications often used are low doses and are from the class of drugs known as tricyclic antidepressants (TCAs), and not used at the high doses employed for the treatment of depression.

Commonly used agents are amitriptyline, nortriptyline, desipramine, imipramine and trazodone. The two most commonly used agents are imipramine and trazodone. While for the most part they are safe, side effects may include sleepiness, dry mouth, blurred vision and urinary retention. Trazodone can also cause a sustained erection (called priapism), which is considered a medical emergency.

Other categories of antidepressants – such as “selective serotonin reuptake inhibitors” or SSRI” – can be tried if TCA are not tolerated because of side effects. Two recent reports suggest that the SSRI Sertraline may also have a beneficial effect in the treatment of non-cardiac chest pain. This medicine was found to be more effective than placebo (a sugar pill or an inert substance) in the treatment of non-cardiac chest pain. New studies are also being done to explore other SSRI’s like paroxetin, fluoxetin and citalopram. Also recent studies have found potential benefit with the Serotonin and Noradrenalin Reuptake Inhibitor (SNRI) called Venlafaxine. For patients not responding to either acid inhibition trial or TCA or other antidepressants, esophageal motility testing (a study done to evaluate the muscle contractions of the swallowing pipe) may be done to look for other uncommon causes of chest pain such as achalasia. This is particularly important since achalasia is a treatable disorder.

A number of studies continue to be done to better understand the mechanism(s) of pain in non-cardiac chest pain. Furthermore, new treatment agents are being investigated. A recent study suggested that receptors in the esophagus, such as the so called adenosine receptors, may account for visceral pain in non-cardiac chest pain. Using a medication that acts on these receptors (Theophilline) a group of investigators showed it may be effective for the treatment of non-cardiac chest pain. However, side effects of this particular agent may limit its use. Thus, in the future newer medications that act on these adenosine receptors but that have a better margin of safety may provide new opportunities for the treatment of this challenging condition.

Non-esophageal Causes of non-cardiac chest pain

Non-cardiac chest pain is a common disorder with esophageal causes (described above) and non-esophageal related causes.

Non-esophageal sources that can cause non-cardiac chest pain include:

• Musculo-skeletal conditions of the chest wall or spine,
• Pulmonary (lung) disorders,
• Pleural illness (the layers of tissue that cover the lungs),
• Pericardial conditions (the layer of tissue that protects the heart) and
• Even digestive disorders such as ulcers, gallbladder, pancreatic diseases and rarely tumors (particularly in patients past age 50).
• Stress.
• Panic Attack

What is Pericarditis

Pericarditis is a condition in which the sac-like covering around the heart (pericardium) becomes inflamed ⁵.

Causes of Pericarditis

The cause of pericarditis is unknown or unproven in many cases. It mostly affects men ages 20 to 50 years.

Pericarditis is often the result of an infection such as:

• Viral infections that cause a chest cold or pneumonia
• Infections with bacteria (less common)
• Some fungal infections (rare)

The condition may be seen with diseases such as:

• Cancer (including leukemia)
• Disorders in which the immune system attacks healthy body tissue by mistake
• HIV infection and AIDS
• Underactive thyroid gland
• Kidney failure
• Rheumatic fever
• Tuberculosis (TB)

Other causes include:

• Heart attack
• Heart surgery or trauma to the chest, esophagus, or heart
• Certain medicines, such as procainamide, hydralazine, phenytoin, isoniazid, and some drugs used to treat cancer or suppress the immune system
• Swelling or inflammation of the heart muscle
• Radiation therapy to the chest.

Figure 2. Pericarditis

Symptoms of Pericarditis

Chest pain is almost always present. The pain:

• May be felt in the neck, shoulder, back, or abdomen
• Often increases with deep breathing and lying flat, and may increase with coughing and swallowing
• Can feel sharp and stabbing
• Is often relieved by sitting up and leaning or bending forward

You may have fever, chills, or sweating if the condition is caused by an infection.

Other symptoms may include:

• Ankle, feet, and leg swelling
• Anxiety
• Breathing difficulty when lying down
• Dry cough
• Fatigue

Exams and Tests for Pericarditis

When listening to the heart with a stethoscope, the health care provider can hear a sound called a pericardial rub. The heart sounds may be muffled or distant. There may be other signs of excess fluid in the pericardium (pericardial effusion).

If the disorder is severe, there may be:

• Crackles in the lungs
• Decreased breath sounds
• Other signs of fluid in the space around the lungs

The following imaging tests may be done to check the heart and the tissue layer around it (pericardium):

• Chest MRI scan
• Chest x-ray
• Echocardiogram
• Electrocardiogram
• Heart MRI or heart CT scan
• Radionuclide scanning

To look for heart muscle damage, the provider may order a troponin I test. Other laboratory tests may include:

• Antinuclear antibody (ANA)
• Blood culture
• CBC
• C-reactive protein
• Erythrocyte sedimentation rate (ESR)
• HIV test
• Rheumatoid factor
• Tuberculin skin test

Treatment for Pericarditis

The cause of pericarditis should be identified, if possible.

High doses of nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen are often given with a medicine called colchicine. These medicines will decrease your pain and reduce the swelling or inflammation in the sac around your heart.

If the cause of pericarditis is an infection:

• Antibiotics will be used for bacterial infections
• Antifungal medicines will be used for fungal pericarditis

Other medicines that may be used are:

• Corticosteroids such as prednisone (in some people)
• “Water pills” (diuretics) to remove excess fluid

If the buildup of fluid makes the heart function poorly, treatment may include:

• Draining the fluid from the sac. This procedure, called pericardiocentesis, may be done using an echocardiography-guided needle.
• Cutting a small hole (window) in the pericardium (subxiphoid pericardiotomy) to allow the infected fluid to drain into the abdominal cavity

Surgery called pericardiectomy may be needed if the pericarditis is long-lasting, comes back after treatment, or causes scarring or tightening of the tissue around the heart. The operation involves cutting or removing part of the pericardium.

Outlook (Prognosis) for Pericarditis

Pericarditis can range from mild illness that gets better on its own, to a life-threatening condition. Fluid buildup around the heart and poor heart function can complicate the disorder.

The outcome is good if pericarditis is treated right away. Most people recover in 2 weeks to 3 months. However, pericarditis may come back. This is called recurrent, or chronic, if symptoms or episodes continue.

Scarring and thickening of the sac-like covering and the heart muscle may occur when the problem is severe. This is called constrictive pericarditis. It can cause long-term problems similar to those of heart failure.

Stress

Some of patients with non-cardiac chest pain have also been found to suffer from stress that leads to disturbances such as depression, anxiety or panic disorder. It is unclear whether the stress disorder came first or the chest pain led to the appearance of an emotional disorder. Treatment of these conditions is an important component of treating chest pain.

Management of stress

If patients do not respond to the above approach or they suffer from depression, anxiety, and/or panic disorder, they should be referred for appropriate psychiatric consultation and treatment. Several recent studies have also found that Cognitive Behavioral Therapy (CBT) or “talk therapy” and relaxation training techniques is effective in improving non-cardiac chest pain when compared to patients on a waiting list. Other brief preliminary reports have also found that hypnosis may also help selected patients with non-cardiac chest pain.

Panic Attack

Panic disorder is a type of anxiety disorder in which you have repeated attacks of intense fear that something bad will happen ⁶.

A panic attack is a sudden episode of intense fear that triggers severe physical reactions when there is no real danger or apparent cause ⁷. Panic attacks can be very frightening. When panic attacks occur, you might think you’re losing control, having a heart attack or even dying.

Many people have just one or two panic attacks in their lifetimes, and the problem goes away, perhaps when a stressful situation ends. But if you’ve had recurrent, unexpected panic attacks and spent long periods in constant fear of another attack, you may have a condition called panic disorder.

Although panic attacks themselves aren’t life-threatening, they can be frightening and significantly affect your quality of life. But treatment can be very effective.

Panic attacks typically begin suddenly, without warning. They can strike at any time — when you’re driving a car, at the mall, sound asleep or in the middle of a business meeting. You may have occasional panic attacks or they may occur frequently.

For some people, panic disorder may include agoraphobia — avoiding places or situations that cause you anxiety because you fear not being able to escape or get help if you have a panic attack. Or you may become reliant on others to be with you in order to leave your home.

If you’ve had signs or symptoms of a panic attack, make an appointment with your primary care provider. After an initial evaluation, your doctor may refer you to a psychiatrist or psychologist for treatment.

Symptoms of Panic attack

A panic attack begins suddenly, and most often peaks within 10 to 20 minutes. Some symptoms continue for an hour or more. A panic attack may be mistaken for a heart attack.

A person with panic disorder often lives in fear of another attack, and may be afraid to be alone or far from medical help.

People with panic disorder have at least 4 of the following symptoms during an attack:

• Chest pain or discomfort
• Dizziness or feeling faint
• Fear of dying
• Fear of losing control or impending doom
• Feeling of choking
• Feelings of detachment
• Feelings of unreality
• Nausea or upset stomach
• Numbness or tingling in the hands, feet, or face
• Palpitations, fast heart rate, or pounding heart
• Sensation of shortness of breath or smothering
• Sweating, chills, or hot flashes
• Trembling or shaking

Panic attacks may change behavior and function at home, school, or work. People with the disorder often worry about the effects of their panic attacks.

People with panic disorder may abuse alcohol or other drugs. They may feel sad or depressed.

Panic attacks cannot be predicted. At least in the early stages of the disorder, there is no trigger that starts the attack. Recalling a past attack may trigger panic attacks.

Exams and Tests for Panic attack

Many people with panic disorder first seek treatment in the emergency room. This is because the panic attack often feels like a heart attack.

The health care provider will perform a physical exam and a mental health assessment.

Blood tests will be done. Other medical disorders must be ruled out before panic disorder can be diagnosed. Disorders related to substance use will be considered because symptoms can resemble panic attacks.

Treatment for Panic attack

The goal of treatment is to help you function well during everyday life. Using both medicines and talk therapy works best.

Certain medicines, usually used to treat depression, may be very helpful for this disorder. They work by preventing your symptoms or making them less severe. You must take these medicines every day. DO NOT stop taking them without talking with your provider.

Medicines called sedatives or hypnotics may also be prescribed.

• These medicines should only be taken under a doctor’s direction.
• Your doctor will prescribe a limited amount of these drugs. They should not to be used everyday.
• They may be used when symptoms become very severe or when you are about to be exposed to something that always brings on your symptoms.
• If you are prescribed a sedative, do not drink alcohol while on this medicine.

Talk therapy (cognitive-behavioral therapy, or CBT) helps you understand your behaviors and how to change them. During therapy you will learn how to:

• Understand and control distorted views of life stressors, such as other people’s behavior or life events.
• Recognize and replace thoughts that cause panic and decrease the sense of helplessness.
• Manage stress and relax when symptoms occur.
• Imagine the things that cause the anxiety, starting with the least fearful. Practice in real-life situations to help you overcome your fears.

The following may also help reduce the number or severity of panic attacks:

• Not drinking alcohol
• Eating at regular times
• Getting plenty of exercise
• Getting enough sleep
• Reducing or avoiding caffeine, certain cold medicines, and stimulants

Support Groups for Panic Attack and Panic Disorder

You can ease the stress of having panic disorder by joining a support group. Sharing with others who have common experiences and problems can help you not feel alone.

Support groups are usually not a good substitute for talk therapy or taking medicine, but can be a helpful addition.

Resources for more information include:

• Anxiety and Depression Association of America: www.adaa.org
• National Institute of Mental Health: www.nimh.nih.gov/health/publications/panic-disorder-when-fear-overwhelms/index.shtml

1. Non-cardiac Chest Pain. American College of Gastroenterology. http://patients.gi.org/topics/non-cardiac-chest-pain/[↩][↩][↩][↩]
2. National Institutes of Health. National Heart, Lung and Blood Institute. Heart Attack. https://www.nhlbi.nih.gov/health/health-topics/topics/heartattack[↩]
3. National Institutes of Health. National Heart, Lung and Blood Institute. What Are the Symptoms of a Heart Attack ? https://www.nhlbi.nih.gov/health/health-topics/topics/heartattack/signs[↩]
4. Esophagitis. Medline Plus. https://medlineplus.gov/ency/article/001153.htm[↩]
5. Pericarditis. Medline Plus, U.S. National Library of Medicine. https://medlineplus.gov/ency/article/000182.htm[↩]
6. Panic disorder. Medline Plus, U.S. National Library of Medicine. https://medlineplus.gov/ency/article/000924.htm[↩]
7. Panic attacks and panic disorder. Mayo Clinic. http://www.mayoclinic.org/diseases-conditions/panic-attacks/basics/definition/CON-20020825?p=1[↩]