What could be causing pain under the right breast after swallowing in an adult with a possible history of gastrointestinal or musculoskeletal issues?

Pain Under Right Breast After Swallowing

This symptom most likely represents extramammary pain from a gastrointestinal source (such as esophageal spasm, gastroesophageal reflux, or hiatal hernia) rather than true breast pathology, given the direct temporal relationship with swallowing. 1, 2

Understanding the Pain Pattern

The key distinguishing feature here is the direct association with swallowing, which strongly points away from breast tissue itself and toward structures in the mediastinum or upper gastrointestinal tract that share nerve pathways with the chest wall. 2

• The breast's nerve supply comes from intercostal nerves T3-T5, meaning irritation anywhere along their course—including from the esophagus, stomach, or diaphragm—can cause perceived "breast pain." 2
• Extramammary causes account for 10-15% of all breast pain presentations, and these are frequently overlooked when clinicians focus solely on breast pathology. 1, 2

Most Likely Differential Diagnoses

Gastrointestinal Causes (Most Probable)

• Esophageal spasm or dysmotility: Pain triggered specifically by swallowing suggests esophageal origin, particularly if the pain is sharp or cramping in nature. 2
• Gastroesophageal reflux disease (GERD): Can cause substernal or right-sided chest pain that worsens with swallowing, especially if there's associated heartburn or regurgitation. 2
• Hiatal hernia: May cause pain in the lower chest/upper abdomen that correlates with eating or swallowing. 2

Musculoskeletal Causes (Secondary Consideration)

• Costochondritis (Tietze syndrome): A common chest wall condition that can mimic breast pain, though it typically worsens with palpation or movement rather than swallowing specifically. 1, 2
• Intercostal muscle strain: Could be aggravated by the mechanical act of swallowing if there's concurrent chest wall inflammation. 1

Cardiac Causes (Must Exclude)

• While less likely given the swallowing trigger, cardiac ischemia can occasionally present with atypical chest pain and should be considered in patients with cardiac risk factors. 2

Critical Evaluation Steps

History Taking Focus

• Characterize the pain: Sharp, burning, cramping, or pressure-like? Duration and frequency? 2
• Swallowing specifics: Does it occur with all foods, liquids only, or solids only? Any dysphagia or odynophagia? 2
• Associated GI symptoms: Heartburn, regurgitation, nausea, early satiety, or epigastric discomfort? 2
• Cardiac risk factors: Age, hypertension, diabetes, smoking, family history, exertional component? 2
• Musculoskeletal factors: Recent trauma, heavy lifting, new exercise regimen, or positional changes in pain? 1, 2

Physical Examination Priorities

• Chest wall palpation: Reproduce pain by pressing on costochondral junctions or intercostal spaces (positive in costochondritis). 1, 2
• Breast examination: Assess for masses, skin changes, or focal tenderness to exclude primary breast pathology. 2
• Cardiac auscultation: Listen for murmurs or irregular rhythms. 3
• Epigastric tenderness: May suggest gastric or lower esophageal pathology. 2

Imaging and Diagnostic Workup

For this specific presentation, breast imaging is NOT the first priority unless there are concurrent breast-specific findings on examination. 1, 2

When Breast Imaging Is Indicated

• Only pursue if there's focal breast tenderness, a palpable mass, or skin changes on examination. 2, 4
• For women ≥30 years: diagnostic mammography with ultrasound. 2, 4
• For women <30 years: ultrasound alone. 2, 4

Appropriate Initial Workup for Swallowing-Related Pain

• Upper GI evaluation: Consider esophagogastroduodenoscopy (EGD) or barium swallow if dysphagia or significant reflux symptoms are present. 2
• ECG: To exclude cardiac etiology, especially if pain is severe, prolonged, or associated with exertion. 2
• Trial of proton pump inhibitor (PPI): Therapeutic trial for suspected GERD can be both diagnostic and therapeutic. 2

Management Algorithm

Step 1: Exclude Serious Pathology

• Obtain ECG if any concern for cardiac origin (atypical presentation, risk factors, or severe pain). 2
• Refer for urgent GI evaluation if there's dysphagia, weight loss, or progressive symptoms suggesting esophageal obstruction. 2

Step 2: Empiric Treatment for Likely GI Cause

• PPI therapy: Start once-daily PPI (e.g., omeprazole 20mg) for 4-8 weeks if GERD is suspected. 2
• Dietary modifications: Avoid trigger foods, eat smaller meals, avoid lying down within 3 hours of eating. 2
• NSAIDs for musculoskeletal component: If chest wall tenderness is present, ibuprofen or naproxen can provide relief. 1, 4

Step 3: Reassurance and Monitoring

• Reassure that pain triggered specifically by swallowing is rarely indicative of breast cancer (cancer risk with pain alone is 1.2-6.7%, and even lower when pain is clearly extramammary). 1, 2
• Follow up in 2-4 weeks to assess response to treatment. 1

Step 4: Specialist Referral if Symptoms Persist

• Gastroenterology: For persistent symptoms despite PPI therapy or if alarm features develop. 2
• Cardiology: If cardiac workup shows abnormalities or symptoms suggest angina. 2

Critical Pitfalls to Avoid

• Don't order unnecessary breast imaging for pain that clearly correlates with swallowing and has no focal breast findings on examination—this wastes resources and increases patient anxiety. 1, 2
• Don't dismiss the symptom without considering cardiac causes, especially in patients over 50 or with multiple cardiac risk factors. 2
• Don't fail to recognize extramammary causes when breast examination is normal—this is where the diagnosis lies in 10-15% of "breast pain" cases. 1, 2
• Don't assume all chest pain is musculoskeletal just because it's reproducible with palpation—GI and cardiac causes can coexist with chest wall tenderness. 2