Correspondence

Diagnostic Dilemma of A Case of Chest Pain

Sir,

A 55 years man was admitted to a rural hospital with severe respiratory distress. He was hypertensive, smoker, non-diabetic and was suffering from chronic obstructive lung disease. The patient was treated with bronchodilator, antibiotic and steroid. His symptoms improved on initial treatment. But on 3^rd day of admission he developed chest pain which was retrosternal in location and constrictive in nature. The pain was relieved after giving sub-lingual nitroglycerine. ECG showed normal axis with sinus rhythm. Except T-wave inversion in aVL lead, no abnormality was detected. He was referred to a tertiary care centre. However the patient chose to be admitted to a nursing home where ECG was repeated and reported as normal. Chest X-ray revealed hyperinflation of lungs due to chronic obstructive lung disease. Cardiac enzymes were within normal limits. No regional wall motion abnormality was detected by Echocardiography, LVEF was 64% and all other parameters were within normal limit. He was treated with isosorbide di nitrate 5mg four times daily, aspirin and clopidogrel combination, ACE inhibitor and bronchodilator inhaler. The patient’s chest pain improved with treatment. Then he was discharged from the nursing home in stable condition and was advised to get a coronary angiography. On the very next day, patient again developed chest pain during taking meal and was admitted in our hospital. Above investigations were repeated which depicted the same picture as before. This time chest pain relieved partially with nitrate. Coronary angiography was done and it revealed no obvious abnormality. To rule out any esophageal cause, upper GI endoscopy was performed and surprisingly it discovered an impacted tooth at the lower end of esophagus (Fig. 1). The tooth was removed endoscopically and an ulcer was seen at that site. Then the patient was managed symptomatically. After one week he was discharged with antihypertensive agent and bronchodilator. No chest pain reappeared on follow-up.

It is sometimes very difficult to distinguish between chest pain due to esophageal disease and chest pain secondary to cardiac ischaemia, as there are many similarities of cardiac and esophageal chest pain. Both may be mid and lower retrosternal in location; heaviness, squeezing, tightning or burning in nature; can be associated with diaphoresis. Both can radiate to upwards or to left neck, shoulder or arm. Eating can precipitate both angina and esophageal chest pain. To further compound the difficulty in distinguishing between angina and esophageal pain, both may be relieved by nitroglycerine¹

The common esophageal disorders that may mimic angina pectoris are gastroesophageal reflux and disorders of esophageal motility, including diffuse esophageal spasm as well as “nut-cracker esophagus” characterized by high amplitude peristaltic contractions and vigorous achalasia.²

In our case, problem was that the patient was totally unaware of uprooting of his tooth. He knew it only on seeing the tooth after its removal. Chest X-ray did not give any clue probably, because of superimposition of tooth-opacity with the cardiac or vertebral shadow. The character of chest pain and its relief after taking nitrate, were all suggestive of cardiac angina. Moreover in the initial few days of treatment the patient was better as he used to take nitrate four times daily before meal. On the day of admission in our hospital, patient developed severe chest pain during taking meal. Further enquiry unveiled that he forgot to take nitrate on that day before meal. But we thought it as post prandial angina. When cardiac catheterization demonstrated angiographically absence of coronary artery disease (CAD), we reviewed our diagnostic approach and thought it prudent to exclude the possibility of an esophageal cause. It is not unusual for patients of unsuspected esophageal foreign body ingestion, to present with chest pain as the main symptom. In almost all reported cases patients have undergone extensive cardiac evaluation to exclude CAD before searching for an esophageal cause.³

So, in spite of patient presenting with typical anginal chest pain, esophageal cause of chest pain should always be kept in mind.

SK Mandal*, Lopamudra Mandal**, S Majumdar**, D Bandyopadhyay*, PP Chakraborty***

*Assistant Professor; **Post-graduate Trainee; ***Senior Resident, Department of Medicine, Medical College, Kolkata.

Received : 6.2.2007; Revised : 8.10.2007; Re-revised : 30.11.2007; Accepted : 17.12.2007

REFERENCES

1.    Brand DL, IlvesR, Pope CE. Evaluation of esophageal function in patients with central chest pain. Acta Med Scand 1981;644(Suppl):53-6.

2.    Davies HA, Jones DB, Rhodes J. Newcombe RG.Angina like esophageal pain: Differentiation from cardiac pain by history. J Clin Gastroenterol 1985;7:477-81.

3.    Koyuncu N, Yilmaz S, Soysal S. An unusual cause of chest pain: foreign body in the oesophagus. Emerg Med J 2007;24:65.