A 64-year-old woman has a 10-year history of retrosternal pain. The pain is often present in bed at night and may be precipitated by bending down. Occasionally, the pain comes on after eating and on some occasions it appears to have been precipitated by exercise.
The pain has been described as having a burning and a tight quality to it. The pain is not otherwise exacerbated by respiratory movements or position.
Her husband has angina and on one occasion she took one of his glyceryl trinitrate tablets. She thinks that this probably helped her pain since it seemed to go off a little faster than usual. She has also bought some indigestion tablets from a local pharmacy and thinks that these probably helped also.
She is 1.62 m (5 ft 4 in) tall and weighs 82 kg, giving her a body mass index of 31.3 (recommended range 20–25) There are no abnormalities to find in the cardiovascular,respiratory or gastrointestinal systems.
• Her chest X-ray is normal and the electrocardiogram is shown in figure.
• She had an exercise electrocardiogram (ECG) performed and she was able to perform 8-min exercise. Her heart rate went up to 130/min with no change in the ST segments on the ECG and normal heart and blood-pressure responses.
• The haemoglobin, renal and liver function are normal.
• What is the likely diagnosis?
• What would be appropriate management?
A number of features in the history make oesophageal reflux a likely diagnosis. The character and position of the pain and the relation to lying flat and to bending mean reflux is more likely. She is overweight, increasing the likelihood of reflux. The improvement with glyceryl trinitrate and with proprietary antacids is inconclusive. The ECG shows one ventricular ectopic and some T-wave changes in leads I, aVl, V5 and V6 which would be compatible with myocardial ischaemia but are not specific. The exercise ECG was negative which reduces the likelihood of ischaemic heart disease although it certainly does not rule it out.
Other causes of chest pain are less likely with the length of history.
In view of the long history and the features suggesting oesophageal reflux, it would be reasonable to initiate a trial of therapy for oesophageal reflux with regular antacid therapy,
H2-receptor blockers or a proton pump inhibitor (omeprazole or lansoprazole). If the pain responds to this form of therapy, then additional actions such as weight loss (she is well above ideal body weight) and raising the head of the bed at night should be added. If doubt remains, a barium swallow should show the tendency to reflux and a gastroscopy would show evidence of oesophagitis. There is a broad association between the presence of oesophageal reflux, evidence of oesophagitis at endoscopy and biopsy, and the symptoms of heart burn.
However, each can occur independently of the others.
Recording of pH in the oesophagus over 24 h can provide additional useful information. It is achieved by passing a small pH-sensitive electrode into the oesophagus through the nose. This provides an objective measure of the amount of acid reaching the oesophagus and the times when this occurs.
This woman had an endoscopy which showed oesophagitis, and treatment with omeprazole and an alginate relieved her symptoms. Attempts at weight loss were not successful.
• In non-specific chest pain with a normal ECG, the oesophagus is a common source of the pain.
• 24-h pH recording in the oesophagus provides further information on acid reflux.