The patient arrived in the emergency room with tie askew, forehead clammy, fist pressed into his breastbone. He was a 50-year-old Wall Street banker and looked like the picture of a heart attack. Margaret, the EKG technician, quickly got a tracing, while Josie, our head nurse, started an IV.
“When did it start?” I asked him.
“About 35 minutes ago. I was just eating lunch.”
“Where did you first feel pain?”
“Right here.” He indicated the lower half of his sternum.
“Ever smoke? Any history of diabetes or high blood pressure? Anyone in your family ever have a heart attack?”
“No. No. No.”
Margaret’s machine whirred. The bump-spike-bump of a normal EKG— crisply black against the salmon-pink graph paper—marched across the page.
“This looks fine,” I told him.
Josie glanced at the EKG. “This isn’t cardiac,” she pooh-poohed. “Look at him. It was the lunch. It got stuck, right?”
“I’m not having a heart attack?”
Josie shook her head. “You’re going to be fine, sweetie.”
Color filled his face. But I was still worried: Partially clogged coronary arteries can twitch shut and cause transient chest pain. “Let’s check cardiac enzymes anyway,” I told Josie. That would help detect any damage to the heart muscle.
“Already sent,” she said.
I moved on to other possibilities. If he didn’t have heart problems, the esophagus—the other organ beneath the sternum—might provide some clues. It is a strong, muscular tube that can spasm when stomach acid backs up into it. Contractions are so painful that they can mimic a heart attack.
“You were eating. Ever had trouble swallowing? Any history of ulcers?”
“Never had ulcers. Two weeks ago something got caught while I was eating lunch. But it went away.”
The patient’s wife dashed in. She satisfied herself that her husband was still breathing, then turned to me.
“How is he?”
“Good. We’ll take a good look at his heart. But this could also be gastrointestinal. Very hard to tell the difference sometimes.”
She pursed her lips, then said, “Well, he gets very short of breath when we fly.”
“Every time?” I asked.
“Well, we’ve flown twice in the past year, and each time it really bothered him. Remember?”
“But no other times? How about climbing stairs, doing yard work?” I prompted.
“No. Only on airplanes,” she answered.
A clear diagnostic clue, but not very gastrointestinal. Other possibilities included blood clots caused by prolonged sitting that travel from leg to lung and intrinsic lung disease unmasked by a low-oxygen aircraft cabin. But why no symptoms at other times?
We still had to rule out heart disease. The surest way to do that was to thread a catheter into the blood vessels of the heart and look for blockages. The next best strategy—far less invasive—would be to find a solid alternate diagnosis.
“We need to wait for the cardiac enzymes anyway,” I told the couple. “In the meantime, my friend Dr. Forrest Manheimer can look down your esophagus.”
Starting at the throat, the esophagus extends down into the chest and pokes through the diaphragm into the stomach. It is designed to move food, not digest it. A one-inch band of muscle called the lower esophageal sphincter lies ready to constrict like a mini-anaconda and keep stomach acid in its place. And the diaphragm’s muscular fibers mesh with the outer layer of the esophagus to fashion an external sphincter. If you’re a hunter-gatherer eating frequent small meals, it’s a marvelous one-way arrangement. But if you’re a 21st-century American, tucking into the big, high-fat meals (fat delays stomach emptying) we consider “normal,” odds are good that someday you’ll have trouble keeping your food down.
When overeating stuffs the stomach, the expansion spreads the esophageal valve like the neck of an overfilled balloon. A vicious cycle kicks in: The fuller the stomach, the less effective the valve. Acid backs up and sears the esophageal lining, causing heartburn. But the problem goes beyond discomfort: Chronic acid exposure can transform the cells of the esophagus into stomachlike cells, greatly increasing their chances of turning cancerous (the risk is about 1 percent per year in patients with acid reflux). Moreover, the constant irritation, distension, and spasms weaken not only the lower esophageal sphincter but also the external muscular ring, or hiatus, of the diaphragm. The stomach, often nudged by an obese belly, shoves upward until part of it comes to reside permanently in the chest. This adds a mechanical problem to the chemical irritation by creating a conduit between the esophagus and the acid factories beyond.
“Tony, come take a look.” Forrest beckoned me into the endoscopy suite. The patient, well sedated, lay with the thin black endoscopy tube still down his throat. On the overhead screen, the far end of the pink esophagus ballooned into dark stomach folds.
“Wow. That’s big, isn’t it?” I asked.
“Huge,” came the answer.
“His wife says he gets short of breath when he flies. Any connection?”
He gave me a look, as if I’d just asked who was buried in Grant’s tomb.
“People with big hiatal hernias have lots of trouble on planes,” he explained patiently. “When you’re sitting at a 90-degree angle for hours, everything gets pushed up.”
I headed out of the room to explain the diagnosis to the patient’s wife.
“So you’re sure it’s not his heart?”
“Yes. Best of all, it explains the plane trouble too.”
Josie was at the patient’s bed, fussing with the monitors. She winked, as if to say, I told you, not cardiac.
Hiatal hernias are extremely common. In some emergency departments where I’ve worked, it seems everyone over 50 with good health insurance (meaning access to a gastroenterologist and an endoscope) carries the diagnosis. Medical studies report that about 20 percent of older Americans live with part of their stomach where it doesn’t belong, which, among other things, can greatly confound the assessment of chest pain.
I witnessed this firsthand when another patient came in a few weeks after the banker. She was in her mid-forties, curled up on a gurney, wailing in Spanish that she couldn’t stand the pain. “Vomiting and vomiting. Nothing stays down. For weeks. My head. Oh my God, it is a pain that wants to kill me.”
Brain tumor? I wondered.
“Vomiting for two weeks,” Susan, my resident, told me.
“That’s a long time,” I replied. “She’s either very sick or very pregnant.”
I turned to the patient. “Can you tell me where it hurts?”
“Oh, my head!”
“What time of day do you vomit?” (Brain tumors hurt more after a night’s sleep because pressure in the brain increases while the patient is lying down.)
“All the time! I can’t keep food down.”
“Ever have hepatitis?”
“They operated on my tubes.”
“They took it out. Years ago.”
“Oh, I hurt everywhere.”
The patient’s neurological exam was normal. Her belly was tender all over. She wasn’t jaundiced. Stumped, I turned to Susan. “It would be nice to know which organ system is malfunctioning.”
I stared at the patient, thinking, Pick an organ, any organ. “Let’s scope her,” I finally said. “Check for tumors blocking stomach emptying. Or scarred-down ulcers. In the meantime, how about some intravenous fluids and an antiemetic?”
Her endoscopy looked just like what I’d seen in the man with the puzzling chest pain. I explained to her what we’d found.
“You mean all my pain and vomiting and headaches,” she said, “it’s from my stomach pushing up?”
“The symptoms of hiatal hernia and acid reflux are often severe. The chest pain can squeeze like a heart attack; the lungs can wheeze when acid backs up through the esophagus into them, often during sleep. You can experience vomiting, choking, even pneumonia.”
“From the stomach?” she interrupted, still incredulous.
“I’m afraid so. For a relatively benign condition, it can cause an astonishing amount of aggravation.” Then I told her what I had told the couple: “The solution is to eat small meals and take the acid-suppressing pills I will prescribe for you.”
I didn’t tell her that surgical procedures, called fundoplications, can reinforce the sphincter between the esophagus and the stomach, reducing acid reflux. That bridge did not need to be crossed for a while.
A week later, the patient who’d come in because of chest pain showed up in the emergency room. He was carrying chocolates and a bouquet but bustled right past me.
“How nice,” I thought, “one clever diagnosis, another grateful patient. I wonder what he brought me.”
A few minutes later, waving farewell, he called out, “You have a great staff.”
I walked into a side room and found Josie admiring her flowers and bonbons.
“What a nice patient,” she said.
“Yes,” I said, a tiny bit deflated. “I guess he knows talent when he sees it.”
Tony Dajer, a frequent contributor to Vital Signs, is the assistant director of the emergency medicine department at New York University Downtown Hospital in Manhattan. The cases described in Vital Signs are true stories, but the authors have changed some details about the patients to protect their privacy.