ANSWER 47
A number of features in the history make oesophageal refluxa likely diagnosis. The char-
acter and position of the pain and the relation to lying flat and to bending mean reflux is
more likely. She is overweight, increasing the likelihood of reflux. The improvement with
glyceryl trinitrate and with proprietary antacids is inconclusive. The ECG shows one ven-
tricular ectopic and some T-wave changes in leads I, aVl, V5 and V6 which would be com-
patible with myocardial ischaemia but are not specific. The exercise ECG was negative which
reduces the likelihood of ischaemic heart disease although it certainly does not rule it out.
Other causes of chest pain are less likely with the length of history.
In view of the long history and the features suggesting oesophageal reflux, it would be rea-
sonable to initiate a trial of therapy for oesophageal reflux with regular antacid therapy,
H 2 -receptor blockers or a proton pump inhibitor (omeprazole or lansoprazole). If the pain
responds to this form of therapy, then additional actions such as weight loss (she is well above
ideal body weight) and raising the head of the bed at night should be added. If doubt remains,
a barium swallow should show the tendency to reflux and a gastroscopy would show evi-
dence of oesophagitis. There is a broad association between the presence of oesophageal
reflux, evidence of oesophagitis at endoscopy and biopsy, and the symptoms of heart burn.
However, each can occur independently of the others.
Recording of pH in the oesophagus over 24 h can provide additional useful information.
It is achieved by passing a small pH-sensitive electrode into the oesophagus through the
nose. This provides an objective measure of the amount of acid reaching the oesophagus
and the times when this occurs.
This woman had an endoscopy which showed oesophagitis, and treatment with omepra-
zole and an alginate relieved her symptoms. Attempts at weight loss were not successful.
- In non-specific chest pain with a normal ECG, the oesophagus is a common source of
the pain. - 24-h pH recording in the oesophagus provides further information on acid reflux.