What Causes Abdominal Pain Migrating To The Chest Area?

Posted on Tue, 22 Apr 2014

Question: Hi, I have been suffering from sharp chest pains, directly above the heart, for 4 days now. I am also experiencing shortness of breath. The pain initially started in my lower abdomen. The pain is not made worse/brought on by applying pressure anywhere on the left side of my chest. I went to a clinic, where I had a work-up of a chest X-ray, blood work, and an EKG. I was called in and told to go directly to the emergency room, as they were suspicious of a possible clot or an aortic dissection. The hospital performed the same tests mentioned previously, as well as a D-Dimer test and a lung scan. They did not look into my heart or aorta besides the EKG. I continue to have these pains, and am concerned about my CXR. The doctor had mentioned a few things that worried me... that my AP window (?) was not very pronounced, and that my pulmonary valve seemed enlarged. They sent me home and told me to wait and see, mentioning that it was probably chest wall pain (even though the pain is not worsened or brought on by pressure). My blood work and EKG were normal (though the first doctor I saw said that only a CT scan could rule out the aorta issue, hence my worry). I have a copy of my chest X-Ray I can show you. Thank you,

Answered by Dr. Vinay Bhardwaj (7 hours later)

Brief Answer: Aortic dissection is rare, d-dimer is normal Detailed Answer: Hi there XXXXXXX My name is Dr. Vinay Bhardwaj. Thanks for coming to HealthCareMagic. I can understand your fear, dissections are some of the most terrifying diagnoses to encounter. But I think in your case, we can dismiss the issue without the need of a CT scan. Let me try and take you through why I think this. The initial presentation you had, abdominal pain, migrating to the chest area, is unheard of in a dissection. I pray that you never have to suffer this, but the pain of a dissection presents like the worse heart attack a patient could ever have and it doesn't wax and wane like a heart attack. Also, very typically, you will have pain between the shoulder-blades in a dissection. That fact that pressure on the chest wall doesn't affect the pain certainly makes me move away from the idea of a chest wall issue or muscular issue, but it does not move me 'tword' a diagnosis of a dissection. That having been said. Chest pain is chest pain and we should always suspect a dissection in someone with even mild nonspecific chest pain. So, i'm glad they did the EKG and D-Dimer. Now LOTS of people have had dissections with a completely normal EKG, and the EKG changes can be pretty nonspecific, so i'm not going to work it into our discussion here. It won't help us decide on the issue of a dissection. On the other hand. The few dissections I have witnessed and alot of the literature have described that fact that a patients "D-Dimer" would be pretty heavily elevated in a dissection. The fact that YOUR D-Dimer came back negative would help me relax and move my thinking away from the idea of a dissection. it would also help me move away from the idea of a clot in your lungs. Now, to your chest x-ray. Thanks for uploading it. I am very 'impressed' with a doctor who can diagnose a tiny thing like a pulmonary valve change with such a nonspecific scan. I can't do that. And saying something like AP window not clear, leaves me less confident.. not in the test.. but in the doctor. The doctor just told you 2 incredibly nonspecific things and used the worlds most nonspecific test to find them. Your chest x-ray looks normal to ME. If they are worried about your pulmonary valve, and if you are worried about your aorta, an echocardiogram ('ECHO') is one way of clearing both of these issues up. As far as pushing for a CT to be done. Yes it is the absolute BEST way to prove that a dissection is occurring, but if we look at your symptoms and other tests in their totality.. the risk of a dissection seems very very low. If you couple that with the statistical probability of a dissection suddenly showing up in a 26 year old with no genetic abnormalities (you don't have any genetic issues right?.. i sort of assumed it).. the risk becomes incredibly low. If you would like, you can certainly push for a scan to put your mind at ease. But at this point, i'd be more bothered by the fact that I was exposing you to all that radiation from the scanner rather than the chance of missing a dissection. Now, to the fact that 1) You still have pain, 2) You MIGHT have a pulmonary valve abnormality. To rule out the possibility that pain is related to the heart, an ECHO could be your last step, it would also pick up and be proof positive of any pulmonary valve issues. After that, we need to start looking into other causes of this pain. Let me ask you, did they rule out the chest pain being caused by GI (Gastro-Intestinal) issues? Abdominal pain which moves to the region of the heart could be a telling sign of Acid Peptic disorder (APD) and/or an ulcer. To rule that in or out, you need a thorough workup and you might need endoscopy where they look at your stomach in detail with a device that is like a long thin camera. The possibility would be strengthened if your pain changed when you ate (if it gets worse when you eat, makes me think ulcer, if it gets better when you eat, makes me think APD). Now that is just a possibility that I think needs to be explored. Its just that it is statistically more likely than a dissection. I hope this puts you more at ease. I'm not denying there is a problem, but i think we need to look at other avenues and systems to arrive at our diagnosis. What do you think? I look forward to your follow-up. I would be VERY interested in the radiologists interpretation of your x-ray (if there is a pulmonary valve issue, then I get to learn something too). Till then, take care and stay safe. Thanks again for coming to HCM. Vinay

Note: For further queries related to coronary artery disease and prevention, click here.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar