Noncardiac Chest Pain

A 45-year-old man is referred to the outpatient gastrointestinal clinic by his primary care physician for the evaluation of a 4-year history of unexplained, intermittent, substernal chest pain. The patient describes the pain as squeezing, pressure-like, or heaviness, which does not radiate to the back, neck, arms, or jaws. The pain is continuous and unrelated to exertion, emotion, or exposure to cold, and might occur several times a week. Furthermore, the pain might last for hours and is not relieved by rest or nitroglycerin. The patient was admitted twice during the last year to the cardiac care unit but ruled out for myocardial infarction. Before referral to the gastrointestinal clinic, the patient underwent a cardiac workup that included a stress test and a cardiac catheterization; all were within normal limits. The patient’s medical history was remarkable only for recently diagnosed hypertension, currently well controlled on an angiotensin-converting enzyme inhibitor. The patient denies dysphagia, odynophagia, anorexia, nausea, vomiting, weight loss, or history of hematemesis or anemia. His primary care physician found no specific cause for his recurrent chest pain and thus initially treated the patient with NSAIDs without symptom relief and subsequently with histamine blockers (ranitidine 300 mg twice a day for 2 months) followed recently by standard dose proton pump inhibitor (PPI, omeprazole 20 mg once a day) for 2 months without symptom relief. An upper endoscopy by another gastroenterologist showed a nondilated, normal-appearing esophagus, as well as normal gastric and duodenal mucosa.

Abbreviations used in this paper:  GERD, gastroesophageal reflux disease , LES, lower esophageal sphincter , NCCP, noncardiac chest pain , PPI, proton pump inhibitor.