Chest Pain: Is It Digestive Tract?

Chest Pain: Is It Digestive Tracts?

Pathology in the upper digestive tract which are the esophagus and stomach can give rise to chest pain, though they are most commonly felt at the lower chest or upper abdomen area (epigastrium). 

Common associated symptoms in esophagus disorders include dysphagia (difficulty in swallowing) & odynophagia (pain when swallwong), while in stomach disorders, abdominal bloating, nausea, vomiting, indigestion are common related symptoms.

Gastroesophageal Reflux Disease (GERD)

This condition is caused by back-flow of acidic stomach content back into the lower part of esophagus. There is a muscular "valve" between the lower esophagus and stomach which allows only one-way flow of food content from the esophagus towards the stomach. However, due to some condition, the "valve" does not function properly and allows the food to flow backwards.

There are many condition which can give rise to GERD, such as:

- pregnancy

- obesity

- prolonged/excessive straining over abdomen (coughing/vomiting/physical exertion)

- certain foods

- smoking

- hiatal hernia

The chest pain caused by GERD is typically referred to "heartburn", where the pain is "burning" in nature and radiate upwards towards the neck/throat. It may be accompanied by bitter taste in the mouth.

Esophagitis

Infection or inflammation of the esophagus can cause pain along the chest area. The pain may be made worse after food when the food bolus pass through the inflammed area.

Esophagus spasm

Either irregular or regular esophagus spasm can cause pain, mostly after food intake. It is not common and the cause is unknown. The pain is usually intermittent and can be severe.

Esophageal cancer

Esophageal cancer most commonly occurs at the lower part of esophagus and pain is not a usual symptom. Most sufferers will complain of dysphagia or food stuck at the lower part of the esophagus. More advanced case can give rise to poor appetite and weight loss, as in all type of cancers.

Peptic ulcer disease

This is a common disorder and is highly related to Helicobacter pylori infection, regular use of NSAIDs and blood-thinning drugs. The ulcers can be at the stomach or upper portion of the small intestines (duodenum). Besides pain over the chest (heartburn) or upper abdomen especially between meals and at night, sufferers may also complain of bloating, nausea & vomiting.

Peptic ulcers can be life-threatening if it is bleeding profusely. Thus, in case of chest discomfort accompanied by vomiting blood (hematemesis) or passing black stool (melena) or anemia (pale), the patient has to seek medical attention immediately.

Gastritis

Gastritis is a term used to described inflammation or irritation of stomach lining. It is a common diagnosis made by doctors for upper abdominal pain. The pain can be felt at chest area as heartburn with abdominal bloating, nausea & vomiting. The causes and symptoms of gastritis are similar to peptic ulcer disease. Doctors can only differentiate both of them by doing an oesophageal-gastro-duodenal-scopy (OGDS).

Click here for clues on how to differentiate chest pain.

Passing Bloody Stool: Why?

Passing bloody stool (per rectal bleeding) means that there is bleeding somewhere along the digestive tract, from the esophagus, stomach, small intestine, large intestine to anus.

There are many possible causes for passing bloody stool. the more common causes include (not a comprehensive list):

- hemorrhoids/piles (may be the most common one)

- anal fissure/fistula

- tumour/cancer in lower part of the bowel (everyone is afraid of this)

- massive bleeding from upper part of the bowel (stomach ulcer/varices/cancer)

- inflammatory bowel disease esp ulcerative colitis

- diverticulitis (in the elderly)

- angiodysplasia (in the elderly)

It's important to note that massive per rectal bleeding from any cause can be life threatening. If someone suspected or known to suffer from per rectal bleeding and is very unstable (giddy, breathless, fainted), then he/she must be sent to a hospital without delay.

     Hemorrhoids: common cause of PR bleeding

 

To find out the cause of bleeding, first we need to consider the nature of the blood. Because of gravity, bleeding occurs at any part of the digestive tract will eventually pass out through the anus. The important points about the nature of the blood are:

- the colour of the blood

- the amount of blood

- is the blood mixed with stool or seperated from stool

The shorter the time the blood in the digestive tract before being passed out, the fresher/more red the blood will be. Thus, if the bleeding point is at the lower part of digestive tract (large intestine, rectum, anus), the fresher the blood will be. The more massive the bleeding is (large volume of blood will flow faster), the fresher the blood will be. The blood will turn dark/black the longer it remains in the digestive tract due to oxidation of iron within the blood.

Example of lower digestive tract bleeding that may give you fresh blood are hemorrhoids, anorectal fistula/fissures (anus/rectum), ulcerative colitis, diverculitis, angiodysplasia, colorectal cancer (large bowel).

Example of massive/heavy bleeding from upper part of digestive tract which may give "not so fresh" bloody stool are stomach/duodenal ulcer or variceal bleeding.

For most bleeding from the upper digestive tract (esophagus, stomach, small bowel), the blood will become black & tarry when being passed out (melena).

     melena stool: black & tarry

For bleeding from the lower part of the large bowel (rectum, anus), the blood usually do not mix with the stool and we can see blood dripping onto the toilet bowl.

For bleeding from higher up from the upper part of large bowel, the blood will usually mix with the stool.

After this, it is important to know whether there are other signs & symptoms accompanying the per rectal bleeding:

- pain when passing stool (usually due to anus fissure, hemorrhoids)

- tenesmus (persistent feeling of wanting to pass stool - usually due to tumour in the rectum)

- change in bowel habit (could be due to ulcerative colitis, tumour)

- abdominal discomfort/bloatedness (could be due to ulcerative colitis, diverticulitis, tumour)

- unexplained weight loss (could be due to ulcerative colitis, diverticulitis, tumour)

- anemia/pale (indicate either chronic little blood loss or sudden massive blood loss)

     Colonoscopy: Colon cancer which is bleeding

From the information gathered above, we can have an idea of where is the bleeding and what cause the bleeding. To confirm the diagnosis, an endoscopy is neccessary. If hemorrhoids or anal fissure is suspected, a proctoscopy should be enough. For lesion in the large bowel, a sigmoidoscopy/colonoscopy will be done. For lesion in the small bowel where the scope can't reach, an X-ray or CT scan with contrast can be done. Whereas for lesion high up in the stomach, duodenum & esophagus, a gastroscopy is a must.

If you have per rectal bleeding, you are advised to seek medical attention from your doctor.

Helicobacter pylori: are you infected?

If you have frequent stomach upset, you may want to check whether you are infected with Helicobacter pylori or not. Since the discovery of this bacteria in early 1980's, it has changed the belief that bacteria cannot survive in the acidic environment of the stomach.

    Helicobacter pylori

Why is H. pylori so important and why should you be treated if you are infected with it? The reasons are:

• Almost 70-90% of all peptic ulcer diseases are related to H.pylori
  • About 90% of duodenal ulcers are related to H.pylori
  • About 60% of gastric (stomach) ulcers are related to H.pylori
• If you are infected, you have 10-20% risk to get peptic ulcer disease
• If you are infected, you have a 1-2% risk of getting stomach cancer

Yes. H.pylori has been classified as class I carcinogen (cancer-causing agent) for gastric cancer, in the same class as smoking causes lung cancer.

    Gastric & duodenal ulcer

Since the bacteria stay in the digestive tract, we can get infected by taking in food/drink contaminated with the bacteria. H.pylori infection produces no symptoms in 30-35% of patients. When it does, it can cause:

• Dyspepsia (indigestion)
• Nausea/vomiting
• Abdominal pain/discomfort
• Anemia if bleeding from ulcer

It's easy to check whether you are infected or not. The screening test is usually a blood test that check your antibody level against H.pylori. If it is positive, it means that you have current or recent infection, and should be treated.

After treatment, you should check whether the bacteria are eradicated successfully by doing a urea breath test. This should be done at least 4 weeks after finishing treatment. Blood test is not recommended to be used to confirm eradication because the antibody level may remain high up to 2 years after all the bacteria died. Besides the breath test, another test that can be done to confirm eradication is stool antigen test.

If you have severe symptoms that make a doctor suspect ulcer in your stomach/duodenum, then you can straight away go for an endoscopy in which a tube with camera is inserted through your mouth into your stomach to look for the ulcer. At the same time, tissue samples (biopsy) can be taken to check for the presence of H.pylori.

Treatment for H.pylori is called triple therapy, as it is a combination of 3 types of medication (2 antibiotics and 1 anti-acid). It should be taken accordingly for at least 7 days (up to 14 days) or failure of treatment and bacteria resistance can occur easily. If treated rightly, the success rate is up to 90-95%. It is not easy to get the infection again after it has been successfully eradicated. The re-infection rate is only about 1-2%, but it is noted to be slightly higher in children and women.