What is Causing My Chest Pain?

Many referrals to gastroenterologists like me originate from emergency rooms.  Patients seen there with all manners of abdominal pain, nausea and vomiting, bowel disturbances and rectal bleeding are typical examples of this.  Chest pain is another common issue that emergency rooms and primary care specialists send to gastroenterologists, which we often find to be vexing to explain.  I have been through this exercise for a few decades now.  Here’s how it goes down.

A patient experiences chest pain and seeks care in an emergency room fearful that his heart is the culprit.  Emergency room personnel take a careful medical history, examine him and do all of the necessary testing and confidently conclude that the heart is well.  No explanation for the pain is determined. 

Here’s what this patient should be told.

‘Your heart is fine.  We’re not sure what’s causing your chest pain.  Please arrange to follow up with your primary care physician (PCP) to consider other causes.’

Here’s what the patient is often told.

Well, your heart is normal.  We think the pain might be coming from your esophagus.  It might be esophageal spasm or even reflux.  Please arrange to see a gastroenterologist to discuss this further’.

Patients tossed down rabbit holes!

These patients hardly ever have an esophageal abnormality.  Esophageal spasm is a very rare disease although the diagnosis is often invoked for unexplained chest pain.  When a patient is told of a suspected esophageal origin of the pain, he leaves the emergency room erroneously believing he has an esophageal condition.  When the gastroenterologist, however, exculpates the esophagus or expresses skepticism, the patient becomes understandably confused and frustrated.  If any esophageal testing is undertaken, it is likely that the results will be normal.  What happens then?  The patient is referred on to his PCP which should have happened at the outset.

I'm not stating that chest pain is ever causes by an esophageal condition, but that such a connection is invoked much more often than is truly the case

We doctors can’t always explain your symptoms.  This happens to me every day.  Patients accept this even if they find our ignorance to be frustrating.   If we can’t crack the code of your issue, we should say so.  If there is a clear referral that makes sense, then we should advise this.  But if not, there’s no reason to casually throw out a diagnosis or two and send the patient down a rabbit hole.

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