Pain Originating from the Oesophagus

Introduction

Oesophageal pain is usually burning in quality and tends to be localised behind the sternum.
Oesophageal pain may be associated with difficulty in swallowing (dysphagia).
Dysphagia to water suggests achalasia, while that to solids and not water suggests mechanical obstruction by tumour or stricture.
It may sometimes be confused with other causes of chest pain.

Causes of Oesophageal pain

  • Irritation of the oesophageal mucosa by reflux of the acidic contents of the stomach (Gastro-oesophageal Reflux Disease (GORD)
  • Oesophageal candidiasis
  • Hiatus hernia
  • Achalasia
  • Spasm of the oesophageal muscle in response to obstruction.
  • Oesophageal tumours

Symptoms of Oesophageal pain

  • Retrosternal chest pain worsened by swallowing (pain worse on lying flat may suggest GORD)
  • Regurgitation of ingested material
  • Difficulty in swallowing

Signs of Oesophageal pain

Usually none

  • Patient may be obese or severely underweight in the case of GERD
  • Severe weight loss may suggest tumour or candidiasis from immune suppression
  • There may be oral candidiasis in the case of oesophageal candidiasis

Investigations

  • Barium swallow
  • Oesophago-gastroduodenoscopy (upper Gl endoscopy)
  • Oesophageal manometry when achalasia is suspected

Treatment for Oesophageal pain

Objectives

  • To relieve pain
  • To treat identified cause

Pharmacological treatment

A. For GERD

1st Line Treatment
Evidence Rating: [B]
Omeprazole, oral,
Adults: 20 mg 12 hourly for 14 days

Or

Esomeprazole
Adults: 20-40 mg daily for 14 days

B. For patients not responding to monotherapy with PPI

Evidence Rating: [B]
Omeprazole, oral, 20 mg 12 hourly for 14 days

Or

Esomeprazole, oral, 20-40 mg daily for 14 days

And

Magnesium trisilicate, oral, 10 ml 8 hourly for 10 days

C. For oesophageal candidiasis

Evidence Rating: [A]
Nystatin, oral,

  • (Swish in mouth for several minutes and then swallow)

Adults 400,000-600,000 units 6 hourly for 7 days

Or

Fluconazole,
Adults: 200 mg stat.

Then

100 mg daily for 14 days

Referral Criteria

Refer to a specialist for confirmation of diagnosis and management.