Esophagalgia (Esophageal Pain): Causes, Diagnosis, and Treatment

Definition

Esophagalgia = pain originating from the esophagus. Often mimics cardiac pain.

Esophageal Causes

• GERD: Acid/pepsin/bile reflux → esophagitis, hypersensitivity.
• Eosinophilic esophagitis (EoE): Allergic infiltration → dysphagia, food impaction, pain.
• Esophageal motility disorders: Achalasia, distal esophageal spasm, jackhammer esophagus, nutcracker esophagus.
• Hiatal hernia: Mechanical irritation, reflux.
• Infections: Candida, HSV, CMV (immunocompromised).
• Pill esophagitis: Doxycycline, bisphosphonates, NSAIDs, potassium chloride.
• Malignancy: Squamous cell carcinoma, adenocarcinoma.

Extra-esophageal Mimics

• Cardiac (angina, pericarditis)
• Pulmonary (pleuritis, PE)
• Musculoskeletal (costochondritis, cervical spine)
• Psychogenic (globus, somatic symptom disorder)

Diagnostic Workup

1. Empiric PPI trial (if typical GERD).
2. Upper endoscopy (biopsy for EoE, Barrett's, infection, cancer).
3. Esophageal manometry (motility disorders).
4. 24-h pH-impedance (reflux correlation).
5. CT/MRI if extrinsic compression suspected.

Treatment by Etiology

• GERD: PPI, lifestyle (head elevation, weight loss, avoid triggers).
• EoE: Topical steroids (budesonide slurry), elimination diet, dilation for strictures.
• Spasm: Calcium channel blockers, nitrates, botulinum toxin, POEM.
• Achalasia: Pneumatic dilation, Heller myotomy, POEM.
• Cancer: Multimodal (surgery, chemo, radiation).

Always rule out cardiac etiology first in new-onset chest pain.