Differential diagnosis of chest pain

A constant unpleasant feeling of a lump in the throat, including when swallowing, associated with belching and lack of air, can be a manifestation of several different diseases. The sensation is often accompanied by discomfort when inhaling and a feeling of pressure.

Specialists from the First Family Clinic of St. Petersburg will help you find the true reasons for the sensation of a lump in your throat.

Painful swallowing

The content of the article

Painful swallowing (odynophagia) is a symptom that accompanies many diseases. It can be independent or coexist with dysphagia.

Pain when swallowing is felt at the level of the neck or in the chest area and is described by patients as painful squeezing, aching pain, a burning or tingling sensation. The pain may spread to the back.

Odynophagia often leads to weight loss. Her treatment is causal in nature.

Common causes of pain when swallowing:

• purulent sore throat;
• tongue abscess;
• peritonsillar abscess;
• epiglottis abscess;
• phlegmon of the floor of the mouth;
• throat cancer;
• laryngeal cancer;
• esophagitis (reflux, viral, fungal);
• foreign body in the throat or esophagus;
• damage to the wall of the throat or esophagus due to injury or a foreign body;
• Crohn's disease;
• scleroderma;
• Zenker's diverticulum;
• diphtheria of the pharynx;
• Plummer-Vinson syndrome;
• esophageal motility disorders.

Very hot or very cold drinks and foods can also cause a sore throat.

These are just some of the causes of a sore throat. In fact, there are several dozen diseases associated with this symptom.

Risk factors

Sometimes it is not clear what causes pain when swallowing. But some conditions that affect the esophagus have similar risk factors. These include:

1. Pressure on the esophagus
   : Constant coughing, frequent vomiting, lifting heavy objects, or frequent straining during bowel movements puts pressure on the muscles of the esophagus. This may increase the risk of developing a hiatal hernia.
2. Medicines
   : Medicines that irritate or relax the muscles of the esophagus may cause pain when swallowing. For example, benzodiazepines relax muscles, which allows acid to enter the esophagus and cause irritation. Nonsteroidal anti-inflammatory drugs such as aspirin can also irritate the esophagus, while opioids are a common cause of dysmotility problems.
3. Pregnancy
   : Acid reflux is common during pregnancy and can lead to GERD. In addition, frequent vomiting as a result of morning sickness can cause esophagitis.
4. Obesity
   : Increased body weight is a risk factor for hiatal hernia, acid reflux, and GERD. Losing weight helps relieve symptoms.
5. Smoking and alcohol
   : Smoking, secondhand smoke, and alcohol can also irritate the esophagus and are risk factors for acid reflux, GERD, and esophageal cancer.
6. Family history
   : Conditions such as EoE can run in families.

Non-cardiac chest pain

Chest pain can occur due to many reasons, since several important organs are located in this area - the heart, lungs, part of the spine, and the esophagus. This is a symptom:

• cardiovascular diseases;
• diseases of the respiratory system;
• diseases of the musculoskeletal system;
• diseases of the nervous system;
• gastrointestinal diseases.

In recent years, the term “non-cardiac chest pain” has come into use. It is defined as recurrent chest pain resembling angina pectoris, not associated with cardiovascular disease.

Non-cardiac chest pain may be a symptom of diseases related or not related to the gastrointestinal tract. A common cause of non-cardiac chest pain is GERD - gastroesophageal reflux disease. This disease most often occurs without changes visible during endoscopy (i.e. in the form of NERD - non-erosive gastroesophageal reflux disease).

Another reason is esophageal motility disorders..

The most common esophageal motility disorders in patients with this pain are nutcracker esophagus (spasm) and hypotension (related to hormonal factors) of the lower esophageal sphincter.

Differential diagnosis of chest pain

In the practice of a clinician, patients quite often complain of chest pain. This symptom should always alert the doctor. Delayed diagnosis of such serious diseases as myocardial infarction or dissecting aortic aneurysm can lead to the death of the patient; on the other hand, overdiagnosis can lead to unnecessary hospitalization, unnecessary expensive examinations and, as a result, lead to negative socio-economic and psychological consequences. The main causes of pain in the heart area are varied and, in addition to diseases of the heart and blood vessels, include pathology of other organs: the chest (lungs, pleura, mediastinum, diaphragm), digestive tract, musculoskeletal and nervous structures of the chest wall, as well as psychogenic conditions. Obviously, such a variety of causes of pain causes difficulties that a doctor may encounter when carrying out differential diagnosis.

I. It is fundamentally important to make a timely diagnosis in case of acute, unbearable pain in the heart area, which arose for the first time or sharply changed its character and forced the patient to seek medical help a few minutes or hours after its onset.

The main causes of such pain may be myocardial infarction, unstable angina, TEVLA and dissecting aneurysm of the thoracic aorta. All these diseases have an acute onset and in typical cases are characterized by burning chest pain lasting more than 30 minutes. , not amenable to the action of nitroglycerin and relieved only by narcotic analgesics. Pain is often accompanied by shortness of breath, cyanosis and arterial hypotension until the development of shock.

During myocardial infarction, pain has a characteristic irradiation of angina. Lasts more than 15-20 minutes, does not go away with nitroglycerin. Pallor, cold sticky sweat, nausea, vomiting, and arterial hypotension may be observed. In cases of complications of acute left ventricular failure, orthopnea with signs of pulmonary congestion is characteristic. The diagnosis is established on the basis of the characteristic dynamics of the ECG, the irradiation of pain and the content of cardiac-specific enzymes, troponins T and I in the blood. The larger the infarction, the higher the activity of the enzymes. The study of enzyme activity over time also makes it possible to estimate the duration of myocardial infarction. Echocardiography during myocardial infarction reveals disturbances in local myocardial contractility, allows one to determine the ejection fraction of the left ventricle, and identify complications such as rupture of the interventricular septum and acute mitral regurgitation. These data make it possible to differentiate myocardial infarction from unstable angina, which is not characterized by acute heart failure.

With massive pulmonary embolism, as with myocardial infarction, pain caused by pulmonary hypertension and distension of the pulmonary artery is localized behind the sternum but does not have typical irradiation. In cases of occlusion of small branches of the pulmonary artery with the development of infarction of a segment of the lung, it is associated with irritation of the pleura and appears several hours and even days after the onset of the disease. Distinctive clinical signs are a combination of pain with cyanosis and shortness of breath, increased central venous pressure in the absence of orthopnea and signs of venous congestion in the lungs. Often arterial hypotension, sometimes shortness of breath is accompanied by hemoptysis, although its absence in no way excludes the diagnosis of TEVLA. The anamnesis is often preceded by thrombophlebitis, previous surgery, and stay on bed rest. The diagnosis can be confirmed by an increase in the level of LDH, especially LDH-3, from the first day of the disease, with a normal level of CPK, as well as characteristic electrocardiographic and radiological changes, which, however, in some cases may be absent. To verify the diagnosis, lung scanning and pulmonary angiography can be used.

With dissection of the thoracic aorta, pain is caused by irritation of the nerve endings in the adventitia during the formation of a hematoma under the intima as a result of its tearing or bleeding from the vasa vasorum. The localization of this pain and some accompanying symptoms are determined by the spread of the hematoma with possible compression of the branches of the aorta and destruction of the aortic valve ring. The pain syndrome is characterized by retrosternal localization with irradiation to the back, sometimes the neck, head, abdomen and legs. In its intensity, it usually exceeds the pain of a heart attack and pulmonary embolism, and its elimination requires the administration of large doses of potent analgesics. Unlike these diseases, aortic dissection does not cause pain accompanied by cardiac or respiratory failure. An important diagnostic sign is unequal pulses in the carotid, radial and femoral arteries. Blood pressure is often elevated and, like the pulse, is not equal in both arms. Signs of aortic insufficiency, primarily auscultatory ones, have important differential diagnostic significance. In addition, dysphagia, blurred vision, focal neurological symptoms, hematuria, which, however, may be absent. Changes in ECG and enzyme activity are not typical. The diagnosis is made by detecting aortic dilatation on an x-ray and visualizing its dissection on an echocardiogram, preferably a transesophageal one. In unclear cases, magnetic resonance imaging can confirm the diagnosis.

It must be emphasized that the absence of burning unbearable pain does not exclude the possibility of the presence of the diseases discussed above. The pain can be short-term, recurring and of lesser intensity, and in case of myocardial infarction, sometimes completely absent (the so-called silent myocardial infarction)

II. Acute or subacute (up to about 1 month) recurring pain in the heart area of ​​lesser severity may include: new-onset angina or Prinzmetal's angina, acute pericarditis, myocarditis (less commonly), pneumothorax, dry pleurisy (or acute pneumonia involving the pleura), mediastinitis, tracheobronchitis, as well as injuries to the ribs and their cartilages on the left and Herpes zoster.

In differential diagnosis, first of all, it is necessary to distinguish between coronary pain, i.e., angina pectoris, and non-coronary pain, cardialgia, and clarify its genesis. Angina pectoris is caused by myocardial ischemia and has clearly defined and fairly constant clinical signs.

In contrast, cardialgia has much more varied manifestations. The pain is aching, prolonged, or stabbing (lasts for hours or even several days), occurs for no apparent reason at rest or is associated with breathing, coughing, a certain movement or position of the body, eating, and, as a rule, is not relieved by nitroglycerin. In some cases, pain is accompanied by nonspecific changes on the ECG, including the ST segment and T wave, which are associated with the underlying disease. The exclusion of the ischemic genesis of cardialgia and the possibility of its combination with coronary artery disease is carried out taking into account the dynamics during clinical observation and data from Holter ECG monitoring, stress tests and other additional research methods.

In acute pericarditis, pain is caused mainly by inflammation of the adjacent parietal pleura. In this regard, it is usually pronounced in infectious pericarditis, but has a significantly lower intensity or is completely absent in aseptic ones. Its distinctive features are the localization of pain behind the sternum in its lower part, sometimes also throbbing pain in the epigastrium and left shoulder due to irritation of small receptors of the phrenic nerve, and the absence of irradiation. The pain is dull, monotonous and, unlike angina, lasts for hours and even days. Due to its pleuritic component, it increases with deep breathing, swallowing, coughing, movements and lying down, decreasing in a sitting position with the torso tilted anteriorly. During an objective examination: - shortness of breath; - knees drawn up to the chest, body tilted forward; - enlargement near the heart sac, resulting in bulging of the chest in front, smoothing of the intercostal spaces; - the apical impulse ceases to be palpable (when tilted, it can be palpated); - increase in area cardiac dullness; - sharply weakened heart sounds (usually there is no pulsation in the area of ​​dullness); - echocardiography - weakening of the pulsatory movements of the heart; - ECG - decrease in voltage; - swelling of the venous trunks in the neck (when inhaling, they do not collapse as normal, but swell even more more); - compression of the inferior vena cava occurs, resulting in an enlargement of the liver; - venous pressure is sharply increased; - with the rapid development of effusion, collapse phenomena may occur.

Signs of the underlying disease, a complication of which is pericarditis, and sometimes a temperature reaction, have differential diagnostic significance. Characteristic features include friction noise of the pleura and, sometimes, the pericardium, concordant elevations of the ST segment in an arc downward on the ECG, and with the accumulation of exudate, corresponding signs, especially echocardiographic ones. It must be borne in mind that aseptic pericarditis can be an early or late complication of myocardial infarction.

EXAMINATION FOR CONSTANT CHEST PAIN

History and physical examination

Depending on the results obtained: · ECG · Chest X-ray · Chest CT · Gastrointestinal tract examination · X-ray of the spine, shoulder joints, ribs · EchoCG

Cardialgia with myocarditis of various origins is characterized by localization of pain in the region of the heart, a dull aching or, conversely, stabbing nature, duration (hours), lack of connection with physical activity and the absence of an effect from stopping movements and taking nitroglycerin. Of differential diagnostic importance is the connection of the disease with infection or exposure to a toxic substance with corresponding laboratory changes during this period. In the presence of nonspecific changes in the ST segment and T wave, they are characterized by their gradual formation and reverse dynamics over several days, in contrast to ischemic episodes that pass within 2-10 minutes. Other methods for detecting ischemia also give negative results.

In acute diseases of the respiratory system, pain is caused mainly by the involvement of the parietal pleura, trachea or large bronchi in the pathological process, while the pulmonary parenchyma and visceral pleura are devoid of pain receptors. Its distinctive features are localization in the projection of the lesion or, in case of irritation of the phrenic nerve, behind the sternum in its lower part, sharp, stabbing nature and connection with breathing, movement, cough. With pleurisy and pleuropneumonia, pain may intensify during palpation and is accompanied by shortness of breath, increased body temperature and, in some patients, signs of intoxication. Pleural friction noise is also characteristic of pneumonia - corresponding physical and radiological changes, as well as inflammatory changes in the blood.

With mediastinitis, the pain is also pleuritic in nature, however, its retrosternal localization and the feeling of tightness or pressure in the chest experienced by some patients require differential diagnosis with myocardial infarction.

Spontaneous pneumothorax can often be suspected in patients with bronchial asthma and emphysema. However, it sometimes develops in the absence of any lung disease. This is especially common among young, thin men. With spontaneous pneumothorax, the connection of pain with breathing and cough is usually noted only at the beginning of the disease. Subsequently, displacement of the mediastinal organs can cause dull, constant pain in the sternum and neck. The pain syndrome is accompanied by shortness of breath, which is usually more disturbing than pain, sometimes with a dry cough. Characterized by pronounced cyanosis; - pale face, covered with cold sweat; - soft, thread-like pulse; - blood pressure - low; - the affected half lags behind in the act of breathing, bulges; - smoothed intercostal spaces; - breathing is weakened or not audible at all; - with R- examination - the absence of a pulmonary pattern, the edge of a collapsed lung is determined, the shadow of the heart and blood vessels is deviated in the opposite direction; - increased shortness of breath and pain indicates a tension pneumothorax, in which emergency pleural puncture is indicated.

In acute tracheobronchitis, a burning sensation in the chest may be noted, which is associated with a cough and goes away when it is relieved.

With Herpes zoster, pain may precede the appearance of the rash by several days, making it difficult to determine its cause early. More often it is one-sided and is located in the zone of innervation of the intercostal nerves.

III. With chronic recurring pain in the heart , as with acute pain, differential diagnosis begins with the distinction between angina pectoris and cardialgia of various origins. Having leaned in favor of the diagnosis of angina pectoris, they move on to clarifying its cause.

Of the chronic diseases of the cardiovascular system, angina must first be differentiated from the widespread cardialgia associated with neurocirculatory dystonia, which is also called “non-cardiac chest pain” or “pain in the left breast.” It is usually associated with hyperventilation and symptoms of anxiety. Accompanied by palpitations, tremors, and agitation. Unlike angina, it occurs more often in women, especially young women, is localized in the left half of the chest and has the character of either a sharp stabbing, sometimes “piercing”, according to the patient, lasting several seconds, or a dull aching wave-like, lasting for hours or even several days .

With mitral valve prolapse, cardialgia has the same nature and, probably, genesis as with neurocirculatory dystonia. Nonspecific changes in the T wave and ST segment are also possible. The diagnosis is confirmed by echocardiography, and concomitant ischemic heart disease is excluded based on stress tests.

Cardialgia with rheumatic carditis has the same character as with myocarditis or neurocirculatory dystonia. The diagnosis can be confirmed by the connection between the development or relapse of the disease and streptococcal pharyngitis or tonsillitis, temperature reaction, articular syndrome, and signs of endocardial damage.

Systemic vasculitis. Vasculitis is supported by signs of systemic vascular damage in several areas, the features of which depend on the nosological form. Often – clinical and laboratory signs of inflammation.

Hypertension is characterized by: - ​​the presence of hypertensive crises in the analysis; - increased or rapid heartbeat; - visible or “internal” trembling; - coldness of the extremities; - fear of death.

Cardialgia in diseases of the musculoskeletal system and nervous structures is characterized by a connection with certain movements of the shoulder girdle and torso and intensification upon palpation of individual points of the chest wall. The pain is most often localized at the junction of the rib cartilage with the sternum and bony ribs. Patients are bothered by acute stabbing or dull aching pain that lasts for hours or even days. There may also be a feeling of tightness in the chest due to muscle spasm. On examination, local palpation pain of the chest in the projection of these joints is characteristic, which is occasionally accompanied by pronounced local signs of aseptic inflammation of the costal cartilages at the places of their attachment to the sternum - swelling, redness of the skin and hyperthermia. This symptom complex is called Tietze syndrome.

IV. Diseases of the digestive tract.

1) Burning chest pain occurs with spasm of the esophagus, peptic esophagitis and reflux esophagitis due to irritation of the esophageal mucosa by acidic gastric juice. It resembles anginal pain, is located behind the sternum and in the epigastrium, radiates to the lower jaw, and can be relieved with nitroglycerin. These diseases can be recognized by the association of pain with food intake and its reduction after several sips of water or taking antacids, as well as the presence of dysphagia.

With Mallory-Weiss syndrome (rupture of the mucous membrane at the junction of the esophagus with the stomach due to vomiting), intense chest pain occurs immediately after straining during prolonged vomiting and is accompanied by the appearance of blood in the vomit. Often happens with alcoholism.

Burning pain behind the sternum and in the epigastric region can also occur with a stomach ulcer. Its features are the appearance approximately 1 hour after eating and relief by taking milk or antacids. Fibrogastroscopy allows you to confirm the diagnosis of diseases of the esophagus and stomach.

Less commonly, difficulties arise when assessing pain in the lower part of the sternum and epigastric region, which appears 1-2 hours after eating, which is typical for cholecystitis and cholangitis.

With a hiatal hernia, pain or a feeling of discomfort behind the sternum occurs or intensifies immediately after eating, especially when moving to a horizontal position, weakening when standing, when walking, after belching, vomiting, or taking antacids. X-ray examination of the esophagus in a horizontal position confirms the diagnosis.

Vague pain or a feeling of discomfort behind the sternum in its lower part is noted during cardiospasm and sometimes causes difficulties in differential diagnosis with angina pectoris, as it is easily relieved by nitroglycerin. This disease can be suspected by the connection of pain with the act of swallowing (especially if the food is very hot or cold), anxiety and the presence of dysphagia, which is its early sign. The diagnosis is made after a thorough X-ray examination.

V. One of the causes of cardialgia is psychogenic conditions. In some cases they are accompanied by a feeling of a lump or tightness behind the sternum. The pain syndrome has no clear localization and can be very intense. Usually accompanied by palpitations, shortness of breath, weakness, tremors, agitation or anxiety. The pain is usually associated with emotional stress, but not with physical activity, lasts over 30 minutes, changing its intensity in waves. The conviction of such patients that they have heart disease, despite the absence of objective signs, sometimes leads to their disability.

In conclusion , it should be noted that a correct preliminary assessment of the pain syndrome subsequently determines the treatment tactics and prognosis of the disease. The most important characteristics of chest pain for differential diagnosis can be considered an assessment of the duration and depth of this symptom, analysis of provoking factors, circumstances of pain relief, localization and some other specific signs.

It must be remembered that to confirm the diagnosis, a modern arsenal of laboratory, radiation, functional, instrumental and other research methods must be used, taking into account the clinical situation.

Thus, timely differential diagnosis of chest pain requires the doctor to have sufficient theoretical knowledge and mastery of methods for examining patients.

Functional chest pain syndrome of esophageal origin

Functional chest pain syndrome of esophageal origin
The syndrome is expressed by repeated chest pain of a visceral nature without an apparent cause. When diagnosing, it is necessary to exclude GERD; for this, endoscopy and measurement of pH in the esophagus with an assessment of impedance, and disorders of esophageal motility using esophageal manometry are performed.

Up to 80% of patients with this syndrome also have other functional disorders, for example, irritable bowel syndrome (27%), bloating (22%).

The pathomechanism of this syndrome is unknown. It is assumed that pain arises from hypersensitivity to physiological stimuli associated with psychosomatic disorders.

Many studies using balloon esophageal dilatation and electrical stimulation techniques show that patients with noncardiac chest pain independent of GERD have a decreased pain threshold. Hypersensitivity is associated with poorly understood dysregulation of the visceral nervous system, susceptible to external influences and aggravated by mental disorders, for example, anxiety attacks, depression.

There is little research on this matter. The incidence of non-cardiac chest pain is 19-25%, which is identical to the pain associated with GERD. The problem affects men and women equally and decreases with age.

Diagnosis of non-cardiac chest pain

The gastroenterologist excludes heart disease. Pain associated with GERD is indicated by a number of symptoms: the appearance of heartburn or acid regurgitation, pain relief after taking antacids.

In patients with concomitant dysphagia or odynophagia, immediate endoscopy is indicated to exclude a neoplasm. But if your doctor has ordered such tests, there is no need to panic—epidemiological studies show that gastrointestinal neoplasms are relatively rare in patients with noncardiac chest pain.

Other alarming symptoms indicating an organic cause of pain:

• age >50 years;
• weight loss;
• frequent vomiting;
• vomiting blood or “coffee grounds”;
• anemia;
• tumor palpable in the abdominal cavity;
• the presence of a tumor in the upper gastrointestinal tract in relatives.

Treatment

Treating the underlying cause of chest pain while eating or drinking is the best way to relieve the symptom. But for ongoing symptoms, there are some strategies that can help reduce irritation in the esophagus. These include:

• eat less but often
• chew food thoroughly
• eat soft food
• avoid sour, spicy or minty foods
• avoiding caffeine and alcohol
• waiting several hours before lying down after eating
• to give up smoking
• avoiding allergens
• take the tablets with plenty of water and, if necessary, food to reduce the chance of irritation

People with acid reflux or GERD may also benefit from sleeping with their head slightly elevated.

Trial of proton pump inhibitor therapy

A test involving short-term therapy with high doses of a proton pump inhibitor for non-cardiac pain has both diagnostic and therapeutic value.

Patients are prescribed 60-80 mg/24 hours of omeprazole, esomeprazole or pantoprazole and 30-90/24 hours. lansoprazole. Duration of trial therapy is up to 28 days. The sensitivity of this test is estimated at 69–95% and specificity at 67–86%.

Patients who do not respond to treatment attempts with proton pump inhibitors should undergo the following procedures:

• daily impedance-pH-metry of the esophagus, which makes it possible to diagnose non-acid reflux, the symptoms of which persist after such treatment;
• esophageal manometry, diagnosing esophageal motility disorders;
• in cases of chest pain not associated with GERD or esophageal motility disorders, after excluding other causes, a consultation with a psychiatrist is prescribed.

Treatment depends on the type and severity of the condition causing chest pain.