Chest Discomfort: Possible Causes and Solutions - Gastroenterology and Hepatology

Does the xiphoid process contract?

Hello, Dr.
Lin.
I have a stent in my heart, and I experienced the following symptoms once two years before the procedure, which were quite severe.
I was scared and went to the emergency room where multiple tests were conducted, but no cause was found.
This incident occurred in 2011, and between then and March 2014, five months after the stent was placed, I did not have a recurrence.

The symptoms I described are located in the mid to lower part of the sternum.
Occasionally, I feel a sudden squeezing sensation (imagine the feeling of squeezing a water pipe).
When this happens, I struggle to catch my breath, and in severe cases, it is accompanied by nausea and dry heaving.
If there is no accompanying nausea, the squeezing sensation will persist until the nausea and dry heaving occur, at which point the squeezing sensation gradually diminishes.
(During the dry heaving, there is no burning sensation or gastric acid reflux.) It is quite frightening.

My cardiologist has indicated that numerous routine examinations over the years have shown no abnormalities, no new blockages, and no signs of hypoxia, only very mild arrhythmia.
The post-operative condition looks good.
I have also seen a pulmonologist who reviewed the imaging and found no abnormalities compared to previous cardiology images, and they advised me to return to cardiology.
I also consulted a gastroenterologist for an endoscopy, which showed no issues, and they also suggested I return to cardiology.

However, the aforementioned symptoms still occur intermittently, especially when eating, climbing stairs (I get a bit breathless), feeling anxious, squatting for too long (due to my body type), or during long-distance biking.
Currently, my family medicine physician believes it may be caused by gastroesophageal reflux disease (GERD) because I occasionally report experiencing regurgitation, burping, a sensation of a foreign body in my throat, and coughing.
Additionally, since I only experienced the symptoms once but now take aspirin after the stent placement, it is possible that this has led to more frequent occurrences.

Because the endoscopy did not reveal any abnormalities, I was prescribed gastric motility medication to take as needed.
It has provided some improvement, but it does not work every time.
Note: The squeezing sensation is not just a single squeeze; it occurs in a series of squeezes, pausing in between.

I would like to ask Dr.
Lin what possible issues my symptoms could indicate.
It is quite concerning that I have not been able to find a specific or potential direction for this problem.
Thank you, Dr.
Lin, for your clarification.

Li Yuan, 50~59 year old female. Ask Date: 2016/11/10

Dr. Lin Minghui reply Gastroenterology and Hepatology

The pain at the xiphoid process may occur suddenly and be cramp-like.
If there are no abnormalities found in cardiology and endoscopy, there is no need for excessive concern.
Some cases may involve gastroesophageal reflux, where the endoscopy appears normal but there is a reaction to medication.
Additionally, functional dyspepsia could also present symptoms such as abdominal pain, postprandial bloating, and discomfort, which can sometimes be related to emotional factors and eating habits.
It is advisable to follow up for treatment.

Reply Date: 2016/11/10

More Info

Understanding chest discomfort, especially in someone with a history of heart disease and stent placement, is crucial for both the patient and healthcare providers. Your symptoms, which include a squeezing sensation in the chest, shortness of breath, nausea, and a feeling of being "squeezed" or "pinched," can be distressing and may arise from various causes.
Given your medical history, including the placement of a stent and the subsequent monitoring for heart-related issues, it’s essential to consider both cardiac and non-cardiac causes for your symptoms. Here are some potential explanations and considerations:
1. Cardiac Causes: Although your cardiologist has indicated that there are no new blockages or significant arrhythmias, it’s important to remember that heart-related issues can sometimes manifest in atypical ways. Conditions such as angina (chest pain due to reduced blood flow to the heart) can occur even with a stent in place, particularly if there are changes in blood flow or if the stent is not functioning optimally. Additionally, microvascular angina, which involves the small blood vessels of the heart, can also cause similar symptoms without significant blockages being present.

2. Gastroesophageal Reflux Disease (GERD): Your family medicine physician's suggestion that your symptoms may be related to GERD is plausible. The sensation of chest tightness, along with nausea and a feeling of something stuck in the throat, can often be attributed to acid reflux. The fact that your symptoms sometimes improve with the use of medications like proton pump inhibitors or antacids supports this theory. GERD can also cause referred pain to the chest, mimicking cardiac symptoms.

3. Anxiety and Stress: Emotional factors can significantly impact physical health. Anxiety can lead to chest discomfort, shortness of breath, and gastrointestinal symptoms. If you notice that your symptoms worsen during times of stress or anxiety, this could be a contributing factor. Techniques such as mindfulness, cognitive behavioral therapy, or relaxation exercises may help alleviate these symptoms.

4. Musculoskeletal Issues: Sometimes, chest discomfort can arise from musculoskeletal problems, such as costochondritis or muscle strain. If you experience tenderness in the chest wall or if the pain changes with movement or palpation, this could indicate a musculoskeletal origin.

5. Functional Dyspepsia: This condition can cause symptoms similar to GERD but is more related to the stomach's ability to process food. Symptoms can include nausea, bloating, and discomfort after eating, which may overlap with your experiences.

Given the complexity of your symptoms and the various potential causes, it is essential to maintain open communication with your healthcare providers. Here are some steps you might consider:
- Follow-Up with Specialists: Since your symptoms persist, it may be beneficial to revisit your cardiologist for further evaluation, including possibly a stress test or advanced imaging if not already done. Additionally, consulting a gastroenterologist for a thorough evaluation of GERD or functional dyspepsia may provide further insights.

- Symptom Diary: Keeping a detailed diary of your symptoms, including when they occur, their duration, associated activities, and any relieving factors, can help your doctors identify patterns and potential triggers.

- Lifestyle Modifications: Consider dietary changes that may alleviate GERD symptoms, such as avoiding spicy foods, caffeine, and large meals. Additionally, managing stress through relaxation techniques or therapy can be beneficial.

- Medication Review: Discuss with your doctor the medications you are currently taking, including aspirin and any gastrointestinal medications, to ensure they are not contributing to your symptoms.

In conclusion, while your symptoms are understandably concerning, they can arise from various causes, both cardiac and non-cardiac. A comprehensive approach involving follow-up with specialists, lifestyle modifications, and possibly further diagnostic testing will be essential in identifying the underlying issue and providing relief. Always prioritize your health and seek immediate care if you experience severe symptoms or changes in your condition.

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