What diagnostic tests would you order for right-sided chest pain postprandially (after eating)?

From the Guidelines

For right-sided chest pain after eating, I would order an electrocardiogram (ECG), chest X-ray, upper gastrointestinal endoscopy, esophageal pH monitoring test, esophageal manometry, abdominal ultrasound or CT scan with contrast, and laboratory tests including complete blood count, liver function tests, lipase, and amylase to evaluate potential gastrointestinal and cardiopulmonary causes. The diagnostic approach should prioritize ruling out life-threatening conditions such as acute coronary syndrome (ACS) and pulmonary embolism, as well as identifying potential gastrointestinal causes like gastroesophageal reflux disease (GERD), peptic ulcer disease (PUD), and gallbladder disease 1.

Initial Evaluation

• An ECG and chest X-ray should be performed initially to rule out cardiac and pulmonary conditions, as recommended by the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain 1.
• Upper gastrointestinal endoscopy would be valuable to directly visualize the esophagus and stomach for conditions like esophagitis, gastritis, or peptic ulcer disease, as suggested by the ACR Appropriateness Criteria for epigastric pain 1.

Additional Testing

• An esophageal pH monitoring test and esophageal manometry would help identify acid reflux and motility disorders, which are common causes of chest pain after eating 1.
• Abdominal ultrasound or CT scan with contrast would be appropriate to evaluate the gallbladder, liver, and pancreas, as gallstones or biliary disease can present with right-sided pain after meals 1.
• Laboratory tests should include complete blood count, liver function tests, lipase, and amylase to assess for inflammation, infection, or pancreatic issues, as recommended by the ACR Appropriateness Criteria for chest pain-possible acute coronary syndrome 1.

Cardiac Evaluation

• If cardiac concerns exist, cardiac enzymes like troponin should be checked, and a stress test or coronary angiography may be necessary to evaluate for ACS, as recommended by the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain 1.

Gallbladder Evaluation

• A hepatobiliary iminodiacetic acid (HIDA) scan might be ordered if gallbladder dysfunction is suspected, as recommended by the ACR Appropriateness Criteria for chest pain-possible acute coronary syndrome 1. These tests are recommended because right-sided chest pain after eating could indicate various conditions ranging from gastroesophageal reflux disease and gallbladder disease to less common but serious conditions like pulmonary embolism or cardiac issues, particularly when the pain occurs consistently with food intake 1.

From the Research

Diagnostic Tests for Right-Sided Chest Pain Postprandially

To diagnose right-sided chest pain postprandially, the following diagnostic tests may be ordered:

• Electrocardiogram (ECG) to rule out acute coronary syndrome, as a normal or nonspecific ECG does not exclude acute myocardial infarction 2
• Echocardiography to detect wall motion abnormalities, diagnose aortic dissection by pointing out the intimal flap, and prove the existence of pulmonary hypertension and right ventricular overloading 3
• Cardiac stress test to rule out possible cardiac causes of chest pain, especially if the patient has a history of coronary artery disease 4
• Laboratory tests, such as troponin levels, to diagnose acute coronary syndrome
• Imaging studies, such as chest X-ray or computed tomography (CT) scan, to rule out pulmonary embolism or other non-cardiac causes of chest pain

Considerations for Diagnostic Testing

When evaluating a patient with right-sided chest pain postprandially, it is essential to consider the following:

• The patient's medical history, including any history of coronary artery disease, gastroesophageal reflux disease (GERD), or other conditions that may cause chest pain
• The patient's symptoms, including the characteristics of the chest pain, any triggers or relieving factors, and any associated symptoms such as shortness of breath or nausea
• The results of the physical examination, including any signs of cardiac or pulmonary disease
• The need for prompt diagnosis and treatment of life-threatening conditions, such as acute coronary syndrome, aortic dissection, or pulmonary embolism 5, 3