Gastrointestinal (GI), Gastric Chest Pain
The esophagus (food pipe) runs through the thoracic cavity and any disorder affecting this part of the gastrointestinal tract may cause chest pain. Apart from a portion of the stomach which can protrude into the thoracic cavity in the case of a hiatal hernia, the other main parts of the gatrointestinal tract are within the abdomen. However these associated organs and other sections of the GI tract located with the abdomen may cause referred pain to the chest.
Causes of GI Chest Pain
It is important to note if the chest pain is emanating and isolated to the chest cavity itself or if there is pain present elsewhere in the body as well. This will aid with a diagnosis. Most cases of GI chest pain is not life threatening and should only be considered once the causes of lung chest pain or heart chest pain have been excluded.
Gastroespohageal reflux (GERD)
This is one of the most common causes of chest pain related to gastrointestinal causes. It is often mistaken for heart chest pain and is one of the common reasons for late night visits to the emergency room.
The rising gastric acid irritates the lining of the esophagus (esophagitis) and is often felt as a burning sensation, hence the term heartburn. However this inflammation may also cause esophageal pain which may not be experienced as a burning sensation. Recurrent episodes of reflux may also cause visceral hypersensitivity so even eating or drinking afterwards may trigger pain.
The pain can vary in intensity and severity and may be aggravated when lying down. It is relived by the use of antacids and may be accompanied with other symptoms like nausea and/or vomiting, back pain and excessive belching.
Esophageal Motility Disorders
Impaired esophageal motility occurs when the muscle contractions of the esophagus (peristalsis) which is responsible for pushing food into the stomach is either too weak or too strong, delayed or uncoordinated. It may also be hampered by partial or complete obstruction of the esophagus. In terms of slow motility, the ball of food (bolus) causes prolonged stretching of the esophagus and this triggers pain. Some of the causes of impaired esophageal motility includes achalasia, diffuse esophageal spasm, esophageal cancer or compressions from surrounding structures like the heart, aorta or tumors outside of the esophagus.
With most cases of esophageal motility disorders, the condition may not appear with any other symptoms apart from pain after eating or while swallowing. There may be some difficulty in swallowing and the sensation that food is ‘stuck’ in the food pipe.
Esophageal Tear
A perforation or rupture of the esophagus is more likely than in other structures of the gastrointestinal tract as the esophagus has thin walls with a limited stretching ability. One of the most common causes is vomiting, especially when induced either by the use of emetics or forced by inserting foreign objects into the back of the mouth which is often done in eating disorders like bulimia. Other possible causes may be due to eating hard or sharp foods like bones from meat, foreign objects trapped in the esophagus or even after an endoscopy.
The pain due to an esophageal tear is sudden, sharp and of severe intensity. Other signs and symptoms may include an increase in heart rate (tachycardia), changes in blood pressure, pain when breathing and confusion. Swallowing even fluids can be painful and there may be signs of fresh blood in the mouth. An esophageal tear requires immediate medical attention.
Gas Bloating
There are a number of causes of gas within the gastrointestinal tract and this can result in stretching which triggers spasm of the gut wall. When occurring in the esophagus, the pain is relieved upon belching. Gas lower down in the gastrointestinal tract may not be easy to pass out through the mouth and the pain from the abdomen may be referred to the chest. Excessive gas tends to occur a short while after eating and even if there is a lack of belching, excessive flatulence may be noticed as the air has to be expelled from the gut.
Hiatal Hernia
This occurs when a portion of the stomach protrudes into the chest cavity through the ‘hole’ in the diaphragm (esophageal hiatus). Normally the esophagus (food pipe) enters the abdominal cavity through this opening and then joins the stomach. However if the muscles surrounding the hiatus are weakened, the opening becomes large enough for a small portion of the stomach to protrude through it.
The pain may vary in intensity and sensation and is often reported as a pain under the left ribcage, usually in the lower parts of the chest cavity. This pain is usually aggravated after eating, drinking or using stimulants or in certain positions. Heartburn, nausea and belching may also occur although there may be no symptoms with smaller hernias.
Peptic Ulcer
A peptic ulcer refers to an erosion in the wall of the esophagus (esophageal ulcer), stomach (gastric ulcer) or intestine (duodenal ulcer). These sores’ may cause pain that is referred up to the breastbone and can last for a few minutes to several hours. Eating often relieves the pain although this may aggravate it in cases of a duodenal ulcer.
Other signs and symptoms may include nausea or vomiting, lack or increase of appetite, weight loss, vomiting of blood or dark ‘old’ blood in the stool.
Pancreatitis
This is the inflammation of the pancreas which may be acute, especially after alcohol binges, or chronic as in pancreatic cancer or long term alcohol abuse. The inflamed pancreas may cause a disruption of both its endocrine or exocrine functions resulting in changes of the blood glucose levels, impaired digestion and reduced absorption of nutrients.
The pain associated with pancreatitis, particularly acute pancreatitis, is very severe abdominal pain that extends to the back and up to the chest. The abdominal and/ or chest pain is moderately relieved by bending forward or lying in the fetal position. There may be nausea and vomiting, fatty stools, loss of weight, reduced appetite, fever, abdominal swelling and/or tenderness.
Common Bile Duct Obstruction
This is a common duct shared by the liver and gallbladder as well as the pancreas towards the latter parts of the duct. Any obstruction, either by calculi (stones), cancer or inflammation may prevent bile or pancreatic digestive enzymes from entering the small intestines. This will cause right upper quadrant abdominal pain or epigastric pain, which may be referred up to the chest. Biliary tract disease, which may seen in certain liver disorders will also cause pain under the right rib cage.
The pain usually starts a short while after eating and is sometimes described as ‘liver pain’. Other symptoms may include jaundice, itchy skin, fever, pale colored stools, dark urine, nausea and/or vomiting.
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