Chest
Volume 73, Issue 1, January 1978, Pages 24-27
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Clinical Investigations
Atypical Chest Pain of Cardiac and Esophageal Origin

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Cardiac and esophageal causes of atypical pain in the chest are often a difficult diagnostic problem. The pain is considered atypical because of its unusual distribution or unusual precipitating and relieving factors. One hundred and five patients with such pain were evaluated by complete esophageal and cardiac investigation. Based on the results of the investigations, 43 patients were found to have esophageal disease, 12 had cardiac disease, 21 had both cardiac and esophageal disease, and 29 had neither disorder. When the 43 patients with atypical esophageal disease were compared with 100 consecutive patients who had gastroesophageal reflux, it was found that in the patients with atypical esophageal disease, pain in the arm was more frequent, pain precipitated by exercise occurred frequently, and relief from pain with administration of antacids was less reliable. These factors accounted for the labelling of the disorder as atypical. Further difficulty in diagnosis was noted with the use of the technique of perfusion with acid. Although typical esophageal pain may be reproduced by such perfusion, all components of pain and, particularly, the distribution of pain to the arm cannot be reliably reproduced. Based on this study, we believed that in the patient with atypical pain in the chest, both cardiac and esophageal disease must be carefully evaluated if diagnostic errors are to be avoided.

Section snippets

Study 1

One hundred and five consecutive patients with atypical pains in the chest have been studied to determine whether their pain was of esophageal or cardiac origin. In this study, esophageal and cardiac investigations were performed on all patients, and the subsequent diagnosis was based on the results of the tests conducted. History was evaluated using a prepared history sheet, and the questions that were asked indicated distribution of pain and precipitating and relieving factors, as well as

Study 1

In the 105 patients with atypical pain in the chest, the diagnosis of cardiac or esophageal disease was made from the results of the investigations performed, independent of the symptoms.

Group 1 (Esophageal Pain), These patients had a radiologically diagnosed hiatal hernia, manometric evidence of a hernia, or radiologic evidence of gastroesophageal reflux. A major component of their pain was reproduced by perfusion with esophageal acid. One patient had diffuse spasm of the esophagus, and in

Discussion

Atypical pain in the chest presents a common diagnostic problem. It is of importance because misdiagnosis leads to mismanagement, with the potential of serious complications. The reasons for labelling cardiac or esophageal pain as atypical are the distributions of pain or its precipitating and relieving factors.

Experience gained in the management of these 105 patients with atypical pain in the chest has shown that many of the patients were incorrectly diagnosed and treated over a period of

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Manuscript received January 24; revision accepted April 26.

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