8changes, and even left ventricular segmental wallmotion abnormalities.
In this case, several unusual features of thispatient's history and presentation as well as the recur-rent nature of her symptoms after ischemia had beenruled out suggested an alternative diagnosis than acardiac etiology. With a five-day history of pain at rest,one would expect to have found electrocardiographicchanges consistent with ischemia or infarction. Inaddition, the nature of her pain, with radiation to theback is somewhat atypical for myocardial ischemia.
The patient's description of her pain as similar to thatwhich had brought her to the emergency room severaltimes prior to this admission suggest that the patient'ssymptoms at that time were most likely caused bycholecystitis rather than ongoing intermittentischemia. In addition, the patient was confirmed tohave had normal coronaries by catheterization lessthan five years prior to this admission with multipleadmissions in the recent past for similar symptoms.This should have signaled that there was a possiblenon-cardiac source of her pain. The associationbetween gastrointestinal symptoms, including nauseaand vomiting, and acute coronary syndromes is wellestablished.
This is particularly true for inferiormyocardial events and among diabetics and women.Thus, these presenting symptoms could not be used tosway the diagnosis towards a non-cardiac event.However, the persistence of the patient's symptomsdespite heparin and large quantities of nitroglycerinand morphine suggested as alternative diagnosis thancardiac ischemia.The normal liver function tests and white bloodcell count were surprising in light of the etiology of her symptoms and contributed to the delay in diag-nosis. It is also unclear whether her coagulopathy wassecondary to underlying infection and possible sepsisor from her medication. This laboratory data didpersuade the decision to continue with medicalmanagement rather than surgical intervention.The clinical approach to patient with chest pain of unclear origin includes the systematic exclusion of different diagnostic possibilities. These include painfrom the chest wall, pleura or mediastinum, as well asdiseases of the gastrointestinal tract. Musculoskeletaletiologies of chest pain are common accounting forapproximately 15% of all cases of non-cardiac chestpain.
After the exclusion of coronary syndromes,musculoskeletal etiologies can usually be diagnosedby history and physical examination, with pointtenderness the major physical finding and a history of pain of insidious onset related to unaccustomedphysical activity. Pulmonary etiologies of non-cardiacchest pain, including pneumonia, pneumothorax andpneumomediastinum, are less common and canusually be identified by exam and chest radiograph.
Gastroenterologic causes of chest pain are themost common causes of non-cardiac chest pain andcan be difficult to separate from a cardiac etiology.Peptic ulcer disease, incarcerated hiatal hernia, chole-cystitis and pancreatitis may all present with chestpain instead of classic epigastric and right upperquadrant discomfort. Esophageal disease has longbeen considered a common source of non-cardiacchest pain produced by motility disorders such asachalasia, diffuse esophageal spasm and nutcrackeresophagus or high amplitude esophageal contrac-tions.
Gastroesophageal reflux disease is the othermajor esophageal cause of non-cardiac chest pain. Astudy of patients with non-cardiac esophageal chestpain found GERD to be the cause in 40%, motilitydisorders in 20% and a combination of both, eithersimultaneously or separately, in 40%.
If there is astrong suspicion for peptic ulcer disease or refluxesophagitis, esophagogastroduodenoscopy may behelpful in the diagnosis. In addition, an abdominalultrasound to rule out hepatobiliary disease may alsobe warranted as seen in this case. Once these etiolo-gies have been excluded, prolonged ambulatoryesophageal pH monitoring has become a widely avail-able technique to rule out reflux.
Approximately 40%of patients with non cardiac chest pain have anabnormal degree of acid reflux on 24 hour pH moni-toring or a correlation between their symptoms andreflux events.
It should be noted that refluxconfirmed by pH monitoring does not necessarilymean that it is the etiology of the patient's symptoms.However, a normal study may help exclude reflux asa cause of non-cardiac chest pain while a positivestudy may be used to support reflux disease as theetiology of their pain.The management of chest pain of unclear etiologyis more complicated in patients with diabetes becauseof their higher incidence of heart disease, theirtendency to present with atypical symptoms, as wellas there predisposition to infection. As has beenemphasized earlier, acute coronary syndromes shouldbe ruled out in all diabetic patients presenting withchest pain and its associated symptoms. However,particularly in elderly patients with diabetes, non-cardiac causes of chest pain can also cause seriousmorbidity and often require early diagnosis and treat-