Angina Pectoris
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Epigastric pain
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In the last few years the non cardiac angina-like chest pain has encompassed more and more agitation not only in many patients but also in cardiologists, gastroenterologists and psychologists, as it involves socio-economic, pathophysiologic and therapeutic problems. The socio-economic aspect is well explained by the fact that in the USA at least 200,000 patients a year suffering from non cardiac angina-like chest pain, even when coronary arteriography has demonstrated normal coronary vessels, nevertheless continue to require cardiologic examinations and, if no one has clearly demonstrated the origin of their pain, they continue to live as invalids in constant fear of myocardial infarction. The discovery that the esophagus may be one of the causes of chest pain in these patients presenting with a previous diagnosis of "atypical" angina pectoris, unfortunately cannot resolve definitively the problem. An association of esophageal angina in patients with angina pectoris treated for long periods of time with Ca-antagonists and nitroderivatives has been described. In addition, the provocative or spontaneous tests to demonstrate the esophageal origin of chest pain give only a "likely" and not a "definite" diagnosis of esophageal angina. This also means to no "gold standard" text exist. Lastly, the "likely" diagnosis of esophageal angina is made in only about 50% of patients leaving the problem of the remaining 50% unanswered. These uncertainties induce some psychologists to assert that the cause of non cardiac angina-like chest pain is in the head ("panic disorder") and not in the esophagus, where the observed motor disorders should be an epiphenomenon.(ABSTRACT TRUNCATED AT 250 WORDS)
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ABSTRACT. Effort‐related chest pain and chest pain fulfilling the criteria of the Rose questionnaire for angina pectoris are often used as evidence for coronary heart disease. In patients with different kinds of oesophageal dysfunction (OD) the frequency of chest pain of angina‐like type was studied and compared to that in the general population. Eighty per cent of patients with hiatal hernia at oesophageal manometry had chest pain, 63% of which was effort‐related. In 217 patients with a positive acid perfusion test, i.e. the provoked heart burn or pain is the same as that experienced in daily life, 82% had a history of chest pain. The chest pain was effort‐related in 70% and in almost half of the cases their chest pain was classified as angina pectoris according to the Rose questionnaire. Since angina‐like chest pain is a predominant symptom in patients with OD and OD is far more common than angina pectoris due to myocardial ischemia in the general population, it is reasonable to assume that the oesophagus and not the heart is the most common source of angina‐like chest pain.
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In a series of 18 patients with angina pectoris, in whom treatment over at least 3 years with nitroderivatives and Ca-antagonists had become partially ineffective on chest pain, and in 18 patients with angina-like non-cardiac chest pain, the following examinations were carried out: upper gut x-ray and endoscopy, acid perfusion test, esophageal manometry, 24-hour esophageal pH monitoring associated with Holter recording. The presence or absence of coronary insufficiency was established by means of scintigraphic and ECG tests, Holter monitoring and coronary arteriography. In both groups the majority of patients had abnormal esophageal function, but in patients with angina pectoris treated for a long period of time the motility changes were prevalently reflux-related. With respect to the origin of chest pain, the esophagus was found to be the likely cause in 4 patients with angina pectoris, and the probable cause in another 10 of the same group; it was the likely cause in 7 patients without angina pectoris, and the probable cause in another 7 of the same group. As nitroderivatives and Ca-antagonists decrease the LES tone and the amplitude of esophageal pressure waves, long-term treatment with these drugs may be taken into account in the genesis of gastro-esophageal reflux and related changes, including esophageal pain.
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Epigastric pain is a very common symptom which can be caused by a wide range of clinical conditions. A 28 year old male presented to our clinic with new onset severe epigastric pain. As part of the routine work up for pain of this nature, we proceeded to upper gastrointestinal endoscopy. A toothpick was found lodged in the antral gastric wall with a resulting inflammatory mass abutting the free edge. It was removed successfully with full resolution of symptoms, however a review of the literature shows that ingested toothpicks can cause major morbidity.
Epigastric pain
Upper gastrointestinal endoscopy
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Pancreatic heterotopia or aberrant pancreas is a rare birth defect, usually asymptomatic. Its preoperative diagnosis is difficult; the therapeutic attitude remains debated. The clinical implications and embryological description of these rare abnormalities are discussed. We report a case of gastric aberrant pancreas revealed by recurrent epigastric pain. The patient was 57-year-old and had no specific pathological history. She reported several recurrent epigastric pains and presented epigastric pain at admission. Endoscopic examination was performed showing an umbilicated polypoid lesion at the antrum in the stomach. Endoscopic ultrasonography showed a hypoechoic image in favor of an aberrant pancreas. Therefore, we should be aware that a gastric aberrant pancreas can cause recurrent epigastric pain.
Epigastric pain
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Variability of angina symptoms over a 5-year period was examined in a prospective study, in which 7,109 British middle-aged men completed two chest pain questionnaires, Q1 (1978–1980) and Q5 (1983–1985), and were classified as having no chest pain, nonexertional chest pain, or angina (Q) (exertional chest pain) on each occasion. Within persons, there was considerable variability in response to the chest pain questions at Q1 and Q5. Angina (Q) persistence showed marked associations with previous myocardial infarction, diagnosed angina, electrocardiogram ischemia, and subsequent major ischemic heart disease events from Q5 onward. Compared with men without angina (Q), the age-adjusted hazard ratios were 1.5 (95% confidence interval (CI): 1.1, 2.2) for angina (Q) at Q1 only, 2.6 (95% CI: 2.1, 3.2) for angina (Q) at Q5 only, and 3.4 (95% CI: 2.8, 4.3) for angina (Q) on both occasions. For men without diagnosed ischemic heart disease, for whom apparent remission of angina (Q) was particularly frequent, a similar pattern of association was found between angina (Q) persistence and subsequent major events. In middle-aged men, exertional chest pain is a strong indicator of major coronary risk but frequently appears transient in the longer term. Persistently reported symptoms are associated with severe disease and a poor prognosis.
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Epigastric pain involves the inflammation, ulcer,spasm and tumor in the stomach, esophagus,diaphragm and the like. The heart, liver, gallbladder and spleen are near to the epigastrium, so the pain associated with these organs is mistakenly taken as epigastric pain. Consequently, some of these organs' disorders are inevitably included in this study. With the help of computer, we have statistically analyzed the information concerning the treatment of epigastric pain by acupuncture in 93 ancient medical books. Results show that 66 pieces of information and 60 acupoints (139 times in frequency) are involved in the treatment of epigastric pain.
Epigastric pain
Diaphragm (acoustics)
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A 54-year-old female patient was referred to our outpatient clinic in December 2017 due to unresolved epigastric pain. She underwent cholecystectomyin in October 2012 due to epigastric pain, without evidence of lithiasis or biliary sludge. Subsequently, the patient continued to present epigastric discomfort with episodes of epigastralgia and was admitted in August 2016. There was evidence of elevated transaminases AST 125, ALT 97 and GGT 47, with normal amylase and no specific diagnosis was made on discharge from hospital.
Epigastric pain
Endoscopic Ultrasound
Biliary sludge
Outpatient clinic
Elevated transaminases
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