Most esophageal causes of chest pain are not immediate threats to life; however, differentiating esophageal pain from ischemic chest pain can be impossible in the ED. Patients with esophageal pain can report spontaneous onset of pain or pain at night, regurgitation, odynophagia, dysphagia or meal-induced heartburn; however, these symptoms are also found in patients with coronary artery disease (CAD), and there is no historical feature that is sensitive or specific enough to routinely make a differentiation between the two.
To minimize missing active ischemic heart disease, clinicians often appropriately set into motion a patient evaluation that proceeds beyond what a traditional ED visit can accomplish, including a provocative test to rule out CAD. The high rate of admission for chest pain of noncardiac etiology is well publicized: ultimately, esophageal disease is frequently determined to be the responsible pathology. The incidence of esophageal disease as the cause of chest pain in patients with normal coronary arteries has been reported as ranging from 20 to 60 percent.7 The use of ED observation units can help to sort through this process by providing time for a protocol-driven, rapid rule-out of acute myocardial infarction, followed by risk stratification for underlying CAD through the use of some form of stress or radionuclide testing. (See Chap.45 for further discussion.) At a minimum, an electrocardiogram (ECG) and chest radiographs should be obtained in all patients with ambiguous presentations.
If chest pain is determined to be noncardiac in nature, treatment aimed at esophageal disease is often initiated empirically, without further diagnostic workup. There are no good data on which to base a therapeutic plan for these patients.13 Outpatient workup options in addition to 6 to 8 weeks of empiric treatment for GERD include an acid infusion test, esophagoscopy, and/or manometry to help clarify pain of esophageal origin.
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Gastroesophageal reflux disease is the medical term for what we know as acid reflux. Acid reflux occurs when the stomach releases its liquid back into the esophagus, causing inflammation and damage to the esophageal lining. The regurgitated acid most often consists of a few compoundsbr acid, bile, and pepsin.