From the Guidelines
**For a 28-year-old presenting with recurrent chest spasms followed by burping in the Emergency Department, initial management should focus on ruling out serious cardiac conditions while considering gastrointestinal causes, with the most likely diagnosis being gastroesophageal reflux disease (GERD) or esophageal spasm, and thus, immediate symptomatic relief with an antacid or a proton pump inhibitor is recommended. Begin with a thorough history and physical examination, including vital signs, cardiac and respiratory assessment, as emphasized by the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain 1. Order an ECG, basic laboratory tests (CBC, electrolytes, cardiac enzymes), and chest X-ray to exclude cardiac pathology, as these tests are essential in the initial evaluation of chest pain, according to the guideline 1. Provide immediate symptomatic relief with an antacid such as aluminum/magnesium hydroxide suspension (10-20 mL) or a proton pump inhibitor like omeprazole 40 mg IV or oral. If anxiety is contributing to symptoms, consider lorazepam 0.5-1 mg orally. For persistent pain, acetaminophen 650 mg is appropriate. Avoid NSAIDs which may worsen reflux. If symptoms improve and serious conditions are ruled out, discharge with oral omeprazole 20 mg daily for 2-4 weeks, lifestyle modifications (avoiding trigger foods, not lying down after meals), and follow-up with primary care. These interventions target the likely underlying cause of acid reflux triggering esophageal spasms, which commonly manifest as chest discomfort followed by burping as the esophagus attempts to clear refluxed acid. It is also important to note that while cardiac conditions such as non-ST-elevation acute coronary syndromes (NSTE-ACS) are a concern, the 2014 AHA/ACC guideline for the management of patients with NSTE-ACS suggests that patients with symptoms consistent with ACS without objective evidence of myocardial ischemia can be observed in a chest pain unit or telemetry unit with serial ECGs and cardiac troponin at 3- to 6-hour intervals 1. However, in this case, the presentation of recurrent chest spasms followed by burping is more suggestive of a gastrointestinal cause, and thus, the management should prioritize the diagnosis and treatment of GERD or esophageal spasm.
From the Research
Management of Recurrent Chest Spasms
The management of a 28-year-old patient experiencing recurrent chest spasms followed by burping in the Emergency Department (ED) involves several steps:
- Initial assessment to rule out cardiac causes of chest pain, as recommended by 2
- Consideration of noncardiac causes of chest pain, such as gastroesophageal reflux disease (GERD), esophageal dysmotility, or functional chest pain, as discussed in 3
- Use of diagnostic tests, including high-sensitivity troponin, electrocardiogram (ECG), and imaging studies, to evaluate the cause of chest pain, as mentioned in 4
- Referral for expedited outpatient testing or admission for inpatient evaluation, depending on the patient's risk factors and test results, as suggested by 2
Diagnostic Considerations
- The patient's symptoms of recurrent chest spasms followed by burping may be indicative of GERD or esophageal dysmotility, as discussed in 3
- Other potential causes of chest pain, such as coronary artery spasm or thyrotoxicosis, should also be considered, as highlighted in 5
- A thorough medical history and physical examination are essential to guide the diagnostic evaluation, as illustrated in 6
Treatment Options
- Treatment for noncardiac chest pain depends on the underlying cause, as discussed in 3
- Potent antireflux treatment may be offered to patients with GERD-related chest pain, while medical, endoscopic, or surgical interventions may be considered for esophageal dysmotility, as mentioned in 3
- Neuromodulators may be prescribed for functional chest pain, as suggested by 3