2. NONCARDIAC CHEST PAIN
- Heartburn refers to the sensation of a burning feeling originating in the upper abdomen which rises up the chest toward the throat.
- Heartburn tends to occur after eating certain foods (trigger foods) and can be related to exercise and posture.
- Some people experience symptoms on a daily basis, whereas many other will describe episodic symptoms.
- Heartburn affects as many as 20% of the population, although only a smaller percentage will describe their symptoms as troublesome.
- Heartburn typically occurs within an hour of eating. Foods can trigger symptoms by 3 main mechanisms.
1. Certain foods cause heartburn by causing transient relaxation of the lower oesophageal sphincter, thereby allowing reflux of stomach contents into the lower oesophagus.
2. Some foods worsen heartburn by causing the stomach to produce an increased amount of acid.
3. Other foods worsen symptoms of heartburn by leading to increased oesophageal sensitivity.
- Mechanical factors also aggravate heartburn. Eating a large meal within 3 hours of lying down, exercise and bending over, as well as obesity can contribute to stomach contents entering the distal oesophagus.
TRIGGER FOODS LEADING TO HEARTBURN
Some of the following foods have been shown to trigger heartburn symptoms. This list is only meant to be a general guide to increase awareness about what foods may be triggering symptoms.
- spicy foods
- citrus fruits
- fatty and deep fried foods
- onion, garlic and capsicum
- fizzy drinks
- chocolate and peppermint
- caffeinated drinks such as tea and coffee
WAYS TO REDUCE HEARTBURN
- try to work out what foods are causing heartburn and limit intake of these foods!
- try not to eat a large meal just before sleeping. In particular, try to avoid eating a large meal within 3 hours before sleeping. Elevating the head of the bed can also be helpful. This is best done by placing some blocks under the feet of the bed. Using more pillows is generally ineffective.
- Chew your food thoroughly, eat smaller meal portions and lose weight.
- Stop smoking.
- There may also be an improvement in symptoms by reducing stress.
- Medications, both over the counter and prescribed, are sometimes used, however this should be done in consultation with your doctor.
- Medical review is needed is there has been any recent change in symptoms, and in particular for the following ‘alarm’ symptoms: difficulty or painful swallowing, weight loss, persistent vomiting, rectal bleeding including passing black tarry stools or severe abdominal pain.
NONCARDIAC CHEST PAIN
- There are many causes of chest pain, with cardiac causes being the most serious. Noncardiac chest pain is the term for chest pain where cardiac causes have been excluded. The most common cause of noncardiac chest pain is oesophageal disorders, in particular GORD. Oesophageal spasm is another cause although it is a relatively rare.
APPROACH TO PATIENT WITH NONCARDIAC CHEST PAIN
1. Make sure that cardiac causes have been excluded.
Oesophageal chest pain can be difficult to distinguish from cardiac chest pain. The features which favour an oesophageal cause of pain over a cardiac cause include pain not being related to exertion, longer lasting pain, meal related pain and sleep disturbance.
2. Empirical trial of proton pump inhibitor (PPI).
Oesophageal chest pain commonly is associated with GORD and a trial of PPI is generally recommended. Adding a low dose tricyclic antidepressant can help by reducing visceral hypersensitivity.
3. Further investigations in PPI non-responders.
Patients with noncardiac chest pain who don’t respond to empirical treatment of PPI should be considered for further testing with ambulatory 24 pH probe +/- oesophageal manometry.