What are the next steps for an adult patient with a history of gastrointestinal complaints, experiencing chest pain, back pain, and jaw pain after consuming unhealthy food, despite a negative Esophagogastroduodenoscopy (EGD) result?

Cardiac Evaluation Must Be Completed First

Given chest pain, back pain, and jaw pain after eating—especially with a negative EGD—you must immediately rule out cardiac ischemia before pursuing further gastrointestinal workup, as the mortality risk of missing acute coronary syndrome far exceeds that of any esophageal pathology. 1

Immediate Next Steps

1. Cardiac Assessment

• Obtain ECG, cardiac biomarkers (troponin), and cardiology consultation to exclude myocardial ischemia, as chest pain radiating to the jaw and back represents a classic presentation of cardiac disease that takes priority over GI causes 1
• The pattern of symptoms triggered by eating can occur with both cardiac ischemia (increased metabolic demand) and esophageal disorders, making differentiation critical 1

2. Once Cardiac Causes Are Excluded

After definitively ruling out cardiac etiology, proceed with the following algorithmic approach:

A. Empiric PPI Trial (First-Line)

• Initiate high-dose PPI therapy (twice-daily dosing) for 4-8 weeks as GERD is the most common esophageal cause of chest pain and may not show erosive changes on EGD 2, 1, 3
• The American College of Gastroenterology recommends this as Grade A evidence for suspected reflux chest pain syndrome 1
• Up to 58% of adults with eosinophilic esophagitis present with chest pain, and a subset may respond to PPIs 2

B. Obtain Esophageal Biopsies If Not Already Done

• If EGD was performed without esophageal biopsies, repeat endoscopy with multiple biopsies from proximal and distal esophagus to evaluate for eosinophilic esophagitis (EoE), which can present with normal-appearing mucosa 2, 1
• EoE affects 1-58% of adults presenting with chest pain and is frequently missed without biopsy 2
• British Society of Gastroenterology guidelines emphasize that chest pain occurs in adults with EoE even without dysphagia 2

C. Consider pH or Impedance-pH Monitoring

• If symptoms persist despite 4-8 weeks of twice-daily PPI therapy, perform ambulatory pH monitoring off medications to objectively document reflux episodes and correlate with symptoms 2, 1
• This distinguishes true refractory GERD from functional chest pain 1

D. Dietary Modification

• Implement elimination of specific trigger foods identified by the patient, as this approach shows effectiveness in reducing GERD symptoms in up to 85% of patients 4
• Common triggers include spicy foods, chocolate, tomatoes, fried foods, and carbonated beverages—particularly relevant given the patient's report of symptoms after "unhealthy food" 5, 4

E. Psychological Evaluation

• If all objective testing remains negative and symptoms persist, refer for cognitive-behavioral therapy as anxiety, panic disorder, and somatoform disorders contribute to functional chest pain (Class 2a, Level B-R recommendation) 1

Critical Pitfalls to Avoid

• Never assume chest pain with jaw/back radiation is esophageal without cardiac clearance—the morbidity and mortality of missed ischemic heart disease vastly exceeds that of GERD 1
• Do not rely on EGD appearance alone—up to 46% of patients with food bolus obstruction have EoE with normal or subtle endoscopic findings, requiring systematic biopsy protocols 2
• Avoid single-dose PPI trials—chest pain from GERD requires twice-daily dosing for adequate acid suppression, unlike typical heartburn 1, 3
• Do not dismiss the temporal relationship with eating as purely GI—this pattern occurs in both cardiac demand ischemia and esophageal disorders 1

Special Consideration for "Unhealthy Food"

The specific mention of symptoms after unhealthy food suggests dietary triggers for GERD, which are modifiable risk factors including fatty, fried, and spicy foods 5, 4. However, this same pattern can occur with cardiac disease due to increased metabolic demands of digestion, reinforcing the absolute necessity of cardiac evaluation first 1.