Transcript mediastinal causes of chest pain

Non- Cardiac Chest pain
Prof.Dr Yaşar Küçükardalı
İç Hastalıkları ve Yoğun Bakım Uzmanı
Acute aortic syndrome is the modern
term that includes aortic dissection,
intramural hematoma (IMH), and
symptomatic aortic ulcer.
Tietze syndrome is an inflammatory
condition characterized by chest pain
and swelling of the cartilage that joins
the upper ribs to the breastbone
(costochondral junction).
On physical examination, a
patient with sternalis
syndrome exhibits myofascial
trigger points at the midline
over the sternum .
Pain is reproduced with
palpation of these trigger
points, rather than movement
of the chest wall and
shoulders.
In Münchausen syndrome, the affected person exaggerates or creates symptoms of
illnesses in themselves to gain investigation, treatment, attention, sympathy, and
comfort from medical personnel.
SAPHO syndrome
synovitis,
acne,
pustulosis,
hyperostosis,
osteitis
Skin and sensory nerves
 Chest pain may be the presenting
symptom of herpes zoster
(shingles)
 it may precede the characteristic
rash and, rarely, zoster may occur
without a rash
 Dysesthesia is usually present in
the affected dermatome.
 Postherpetic and postradiation
neuralgia are other unusual causes
of chest pain.
Stress-induced
cardiomyopathy —
Emotional stress can precipitate
severe, reversible left ventricular
dysfunction in patients without
coronary heart disease, related
to exaggerated sympathetic
stimulation.
Patients most commonly present
with acute substernal chest pain
typically triggered by an acute
medical illness or by intense
emotional or physical stress,
Postulated pathogenic
mechanisms include
•catecholamine excess,
•multivessel coronary artery
spasm,
•microvascular dysfunction.
Gastroesophageal reflux disease
 *GERD, can mimic angina pectoris and
may be described as squeezing or
burning, located substernally and
radiating to the back, neck, jaw or arms,
lasting anywhere from minutes to hours,
and resolving either spontaneously or
with antacids.
 It may occur after meals, awaken
patients from sleep, and be exacerbated
by emotional stress.
 Diagnosis is usually made via endoscopic
biopsy after treatment with protonpump inhibitors fail to improve
symptoms, or esophageal pH monitoring
excludes GERD as the diagnosis
Esophageal hypersensitivity
 There are considerable experimental data to
indicate that some patients with chest pain
have a lower threshold for esophageal pain
than normal subjects.
 Studies utilizing intraesophageal balloon
distension have shown that many patients
with unexplained chest pain experience their
pain at a lower volume of balloon inflation
than that found in appropriate control
subjects
Abnormal motility patterns and
achalasia
 The relatively uncommon diagnosis
of a motility disorder or esophageal
spasm
 chest pain is associated with
dysphagia,
 barium swallow study does not
reveal an anatomic abnormality of
the esophagus
Esophageal rupture, perforation, and foreign bodies
 * Spontaneous perforation of the esophagus most commonly results from a sudden
increase in intraesophageal pressure combined with negative intrathoracic pressure
caused by straining or vomiting (effort rupture of the esophagus or Boerhaave's
syndrome) .
 Odynophagia, tachypnea, dyspnea, cyanosis, fever, and shock develop rapidly thereafter .
 Other causes of perforation include caustic ingestion, pill esophagitis, Barrett's ulcer ,
infectious ulcers in patients with AIDS, and iatrogenic injury .
 A patient with a foreign body impacted in the esophagus may present with chest pain.
Other causes of esophagitis
 The types of medication causing direct esophageal injury
can be roughly divided into antibiotics (most commonly
tetracyclines and clindamycin), antiinflammatory agents
(especially aspirin), bisphosphonates potassium
chloride, quinidine preparations, and iron compounds
 Esophagitis may also be due to infectious causes, including
esophageal candidiasis or CMV esophagitis, particularly in
immunocompromised hosts due to AIDS or stem-cell
transplant patients.
 Radiation injury may also induce esophagitis.
Other gastrointestinal causes of
chest pain
 hiatus hernia, paraesophageal
hiatus hernia can lead to symptoms
due to life-threatening gastric
volvulus.
 The possibility of radiating or
referred visceral pain due to
cholecystitis or biliary colic , peptic
ulcer disease, pancreatitis, kidney
stones, and even appendicitis
should be considered in any patient
with unexplained chest pain.
Acute pulmonary embolism
 It should be considered in any patient who presents with
chest pain Individual symptoms and signs are not helpful
diagnostically
 The most common symptoms of pulmonary embolism were
dyspnea (73 percent), pleuritic chest pain (66 percent),
cough (37 percent), and hemoptysis (13 percent) .
 90 percent had dyspnea, tachypnea, or signs of deep
venous thrombosis;
 84 percent had a chest x-ray abnormality;
 50 percent had nonspecific electrocardiographic
abnormalities.
Pulmonary hypertension (PH) and
cor pulmonale
 Patients with secondary PH often have symptoms that
reflect the underlying etiology (eg, chronic obstructive
pulmonary disease, pulmonary embolic disease, collagen
vascular disease).
 There are, however, symptoms directly attributable to
secondary PH including dyspnea on exertion, fatigue,
lethargy, chest pain, and syncope with exertion.
 Idiopathic PH is a rare disease. Most patients present with
exertional dyspnea, which is indicative of an inability to
increase cardiac output with exercise.
 Exertional chest pain, syncope, and edema are indications of
more severe PH and impaired right heart function
Pneumonia
 The patient with community acquired
pneumonia (CAP) caused by pyogenic
organisms classically presents with the
sudden onset of rigors followed by
fever, pleuritic chest pain, and cough
productive of purulent sputum.
 Chest pain occurs in 30 percent of
cases, chills in 40 to 50 percent, and
rigors in 15 percent.
 Because of the rapid onset of
symptoms, most individuals seek
medical care within six days
Cancer
 Isolated chest pain is a relatively
rare presentation of lung cancer .
 The chest pain experienced by 25
to 50 percent of lung cancer
patients is usually in association
with cough, dyspnea, weight loss,
or hemoptysis.
 Some patients have a dull,
intermittent pain on the side of
the tumor; severe or persistent
pain often indicates chest wall or
mediastinal invasion.
Sarcoidosis
 Chest pain is a common manifestation
of pulmonary sarcoidosis, most
commonly it is accompanied by cough
and dyspnea.
 Granulomatous involvement of the
ventricular septum and conduction
system of the heart can lead to a
variety of arrhythmias (including heart
block) and sudden death; such
involvement may be heralded by chest
pain, palpitations, syncope, or
dizziness.
Asthma and COPD
 Diseases of the bronchial airways such as asthma and COPD
may present with chest pain.
 both characterized by airway inflammation and
bronchospasm.
 Chest pain is common in asthma exacerbations, 76 percent
 asthma and COPD exacerbations often have triggers (such
as pneumonia or pulmonary embolism) that may actually be
the cause of chest pain.
Pleura and pleural space
 Pleuritic chest pain is caused by irritation
of nerve endings of pain fibers in the costal
pleura.
 It often worsens with inspiration.
 Pain referred from the pleura may be felt in
the thoracic wall in the areas of skin
innervated by the intercostal nerves .
 Clinicians should note that other etiologies
of chest pain may worsen with deep
breathing, such as pericarditis or
musculoskeletal chest pain syndromes
Pneumothorax
 A spontaneous pneumothorax should be
considered in any patient who complains of
the sudden onset of pleuritic chest pain and
respiratory distress .
 A secondary spontaneous pneumothorax
occurs as a complication of underlying lung
disease such as chronic obstructive pulmonary
disease, pneumocystic pneumonia, or as an
iatrogenic complication of certain procedures.
 A tension pneumothorax is rare, but
potentially life-threatening unless treated
emergently. It occurs when a tissue flap from
the injured lung creates a one-way valve,
progressively trapping air in the intrapleural
space during inspiration. Respiratory failure
occurs as the healthy lung is compressed.
Physical findings include unilateral loss of
breath sounds with hypertympany, shift of the
trachea away from the injured side, and
jugular venous distension.
Pleuritis
 Pleuritis is an inflammation of the
parietal and serous pleura of the
lung.
 Viral pleurisy is a common cause of
pleuritic chest pain in young adults
.
 Other causes include autoimmune
diseases such as systemic lupus
erythematosus or rheumatoid
arthritis, and drugs that can cause a
lupus-like syndrome
including procainamide, hydralazin
isoniazid,
MEDIASTINAL CAUSES OF CHEST
PAIN
 Disease originating in the mediastinum is a rare
cause of chest pain in primary care practice, but
may be seen in other settings.

 Mediastinitis may result from esophageal rupture
such as in effort rupture of the esophagus or
postoperatively as a complication of cardiac
surgery. Spontaneous pneumomediastinum is a
rare entity that commonly presents with chest
pain
PSYCHOGENIC/PSYCHOSOMATIC
CAUSES OF CHEST PAIN
 Chest pain may be a presenting symptom of panic disorder, depression,
and hypochondriasis, as well as cardiac, cancer, or other phobias
 Reviews of the literature have estimated that approximately one-third
of patients presenting to the emergency department for chest pain have
a psychiatric disorder, while approximately one-half of patients with
noncardiac chest pain have various psychiatric diagnoses .
 Among patients with chest pain due to coronary artery disease (CAD),
20 to 30 percent also have a coexisting psychiatric disorder.
 Hyperventilation, which is associated with panic attacks, can also result
in nonanginal chest pain and occasionally electrocardiographic changes,
particularly nonspecific ST and T wave abnormalities .
Panic disorder
 Panic disorder is a particularly common cause of chest pain.
 chest pain found that 20 percent had panic disorder as the
etiology.
 Vigilance is necessary since patients with psychiatric
disorders may develop organic disease
 In addition, ischemia may occur during a panic attack in a
patient with CAD . Thus organic disease must be reasonably
excluded before ascribing chest pain to a nonorganic origin.
Munchausen syndrome
 In one literature review, 58 patients with cardiac Munchausen
syndrome were identified . Of these, 54 (95 percent) were male;
the mean age was 44 years (range, 23 to 71). The most common
presenting symptom was retrosternal chest pain (50 patients);
other presenting complaints were syncope, dyspnea, and back
pain.
 Patients typically gave a history of prior cardiac disease and often
reported having "white collar" jobs;
 Acute myocardial infarction was the most common admitting
diagnosis.
 All subjects had had numerous admissions and extensive cardiac
testing, which were negative for cardiac disease but which the
patients reported were positive. When confronted, most patients
changed their history, became uncooperative, and refused
psychiatric examination.
PAIN REFERRED TO THE CHEST
 Referred pain may occur when the same spinal cord
segments supplying dermatomal areas of the chest wall
also innervate the very sensitive parietal pleura or
peritoneum.
 As an example, irritation of the mediastinal pleura or of the
central diaphragm due to gallbladder or liver disease may
result in neck and shoulder pain, while more peripheral
diaphragmatic irritation may result in inferior chest pain .
 A herniated thoracic disc may cause "band-like" anterior
chest pain
Diagnostic algorithm Step 1
 The initial step : a focused history and physical examination,
and consider performing an ECG and/or chest x-ray. Once a lifethreatening etiology has been excluded, attempts should be
made to identify the specific cause of symptoms and begin
treatment.
 (Evaluate need for emergent care) — Consider potentially lifethreatening causes of chest pain. Patients in whom an acute
coronary syndrome (acute myocardial infarction or unstable
angina) is suspected should receive emergent care (this
generally includes chewing an aspirin while awaiting transport to
an emergency department, ideally via an ambulance equipped
with a defibrillator).
Emergent care should also be provided to patients who appear
to be seriously ill and to patients in whom there is a suspicion of
a critical noncoronary diagnosis such as pulmonary embolus,
pneumothorax, aortic dissection, esophageal rupture, or acute
abdomen.
Step 2
 Evaluate the patient for gastrointestinal disease. This
evaluation may initially involve a trial of acid
suppression.
Step 3 (Symptoms not suggestive of
angina)
 Step 3a— For patients who are felt not to have an
ischemic etiology for chest pain but who have
significant risk factors for CHD, consider arranging for
an evaluation for CHD
 Step 3b— If symptoms suggest
a musculoskeletal etiology, a trial of an NSAID is
appropriate; If pain persists, consider rib films, a bone
scan, and plain or CT chest radiography.
 Step 3c— If symptoms suggest
a gastrointestinal etiology, evaluate the patient for
gastrointestinal disease; otherwise, proceed to step
3d. This evaluation may initially involve a trial of acid
suppression.
 Step 3d— If symptoms suggest
a psychogenic etiology, evaluate the patient for a
psychosocial source of chest pain
 Step 3e— Consider chest anatomy as a guide
to other less common causes of non-life-threatening
chest pain including: chest wall pain (eg, zoster,
breast disease); other cardiac pain such as
pericarditis; pathology of the lung parenchyma,
vasculature, or pleura; and pain referred to the chest
from the gallbladder, diaphragm, or from a disc
herniation.
 Step 4 (Persistent chest pain) — If chest pain persists
and evaluations for CHD , musculoskeletal pain,
gastrointestinal pain , psychogenic pain, and other
causes have not all been performed, those
evaluations should now be undertaken.
 Step5 (Diagnostic evaluations negative) — Patient
likely has chronic idiopathic chest pain. Since this is
known to cause significant disability, consider referral
to a pain management center or medical symptom
reduction program. No further evaluation is required
unless the patient has a change in symptoms or the
symptoms are disabling.