What are the potential causes of mid-back pain that worsens with eating?

Etiology of Mid Back Pain Worse with Eating

The most likely cause of mid-back pain that worsens with eating is a gastrointestinal disorder, particularly gastroesophageal reflux disease (GERD), esophageal motility disorders, or mesenteric ischemia. 1

Gastrointestinal Causes

Gastroesophageal Reflux Disease (GERD)

• Most common gastrointestinal cause of chest/mid-back pain (10-20% of outpatients with chest pain) 1
• Characteristics:
  • Pain described as squeezing or burning
  • Duration can range from minutes to hours
  • Often occurs after meals or at night
  • May worsen with stress
  • May or may not resolve spontaneously or with antacids
  • Can mimic myocardial ischemia

Esophageal Motility Disorders

• Less common but significant causes of mid-back pain worsening with eating 1
• Include:
  • Achalasia
  • Distal esophageal spasm
  • Nutcracker esophagus
• Present as squeezing retrosternal pain or spasm
• Often accompanied by dysphagia (difficulty swallowing)

Mesenteric Ischemia

• Characterized by insufficient vascular supply to the bowel 1
• Chronic mesenteric ischemia typically presents with:
  • Post-prandial pain (worse after eating)
  • Fear of eating
  • More indolent clinical presentation compared to acute ischemia
• Pain is often colicky and worse after oral intake 1
• May be associated with weight loss due to fear of eating

Other Potential Causes

Pancreatic Disorders

• Pancreatitis or pancreatic tumors can cause mid-back pain that worsens with eating
• Often accompanied by other symptoms like nausea, vomiting, or jaundice

Biliary Disease

• Gallstones or biliary tract disorders can cause pain that radiates to the mid-back
• Typically worsens after fatty meals

Peptic Ulcer Disease

• Can cause pain that radiates to the back
• Often worsens with eating or when stomach is empty

Evaluation Approach

1. Rule out cardiac causes first

   • Especially important in patients with risk factors for cardiovascular disease
   • Cardiac pain can sometimes mimic or coexist with gastrointestinal causes 1

2. Gastrointestinal evaluation 1

   • Upper endoscopy is recommended when esophageal cause is suspected
   • Early evaluation (within 2 weeks) is warranted if any of these are present:
     • Dysphagia
     • Odynophagia (painful swallowing)
     • GI bleeding
     • Unexplained iron deficiency anemia
     • Weight loss
     • Recurrent vomiting

3. For suspected mesenteric ischemia 1

   • CT angiography (CTA) of the abdomen and pelvis in non-contrast, arterial, and portal venous phases
   • Evaluates for:
     • Underlying cause of ischemia
     • Possible bowel complications
     • Vascular abnormalities

Red Flags Requiring Urgent Evaluation

• Severe, unremitting pain
• Significant weight loss
• Anemia
• Blood in stool
• Fever
• Persistent vomiting
• Pain that awakens patient from sleep

Management Considerations

• For GERD and esophageal causes:

  • Trial of empiric acid suppression therapy is reasonable in patients without concerning symptoms 1
  • If symptoms persist despite acid suppression and normal endoscopy, consider esophageal function testing and pH monitoring 1

• For mesenteric ischemia:

  • Rapid revascularization may be necessary
  • Treatment depends on chronicity, etiology, and degree of concern for bowel infarction 1

• For functional disorders:

  • Cognitive behavioral therapy may be beneficial for patients with recurrent symptoms and negative workups 1

Remember that mid-back pain worsening with eating is a symptom that should not be dismissed, as it could indicate serious underlying conditions requiring prompt evaluation and management.