Because of the close proximity of the heart and the esophagus, it is difficult to distinguish chest pain that is caused by problems of the esophagus from true angina pectoris. Common characteristics of esophageal pain include sensations of burning, pressing, stabbing, or gripping. The pain is usually located in the anterior chest, throat, and epigastric area, and can radiate to the neck, back, or upper arms. Bennett reviewed the mechanisms, evaluation, and treatment of esophageal pain.

Symptoms are most commonly caused by irritation resulting from stimulation of the mucosa or mechanical activity of the muscular wall. Mucosal irritation can be diagnosed when cessation of an esophageal infusion of hydrochloric acid rapidly resolves the discomfort caused by the infusion. Measurement of the level of exposure of the lower esophagus to acid can be taken with a pH probe. This step can be useful in identifying episodes of atypical chest pain associated with a drop in pH; however, the amount of acid reflux is often unrelated to the severity or frequency of pain episodes.

Mechanical sensitivity of the esophageal wall can be evaluated using distention of the esophagus achieved by swallowing a large food bolus or inflating a balloon within the esophagus and observing for chest discomfort. Because altered motility of the esophagus can also cause chest pain, contraction and pressure studies can be useful. Patients with lower pain thresholds are more likely to complain of atypical chest pain and are found to have greater anxiety, depression, and somatization.

Management of esophageal pain disorders includes eliminating medications known to cause chest pain, such as triptans; relieving reflux symptoms using diet, weight education, and avoidance of contributing medications, such as nonsteroidal anti-inflammatory drugs; identifying potential cardiac causes with appropriate testing; and further searching for esophageal diagnoses using endoscopy, barium swallow, 24-hour pH monitoring, or manometric testing.

Specific treatments are listed in (see accompanying table). Reassurance and attentiveness to the patient's concerns are important therapies. If symptoms support the diagnosis of reflux and antisecretory drug therapy is unsuccessful, pH testing while taking these drugs may be useful. Tricyclic antidepressants may be especially useful because of their ability to relieve functional somatic pain. Nitrites and calcium channel blockers can be used in episodic or continuous prophylactic dosing, but these drugs may increase latent reflux. Anticholinergic drugs and prokinetic agents, such as metoclo-pramide, are not helpful.