The relationship to meals and relative lack of response to nitroglycerine should help distinguish this pain from angina pectoris. Note that nitroglycerin promptly relieves esophageal spasm causing confusion in the diagnosis. Vigorous disordered contractions in the body of the esophagus are induced by ingestion of cold liquids or normal swallowing during a meal. Anxiety and stress are also common precipitating factors. There is usually no exertional component but increased abdominal pressure from lifting, sit-ups, or running can cause reflux.
Diagnosis rests on history and verification of esophageal spasm by manometric studies.
Pulmonary Origin Pain of pulmonary origin characteristically has a distinct pleuritic quality varying with the respiratory cycle. Intercostal nerves supply sensory afferents to the costar parietal pleura. Inflammation arising from this region is appreciated in the adjacent chest wall. Referred pain originating in the diaphragm is appreciated in the ipsilateral shoulder. Differentiating features of pulmonic from musculoskeletal pain are the more intense nature of pleuritic pain and the worsening of musculoskeletal pain by extension, abduction, or adduction of the arm and shoulder.