Mechanisms of Chest Pain in Eosinophilic Esophagitis
Chest pain in eosinophilic esophagitis results from transmural inflammation causing esophageal smooth muscle hypertrophy and dysmotility, along with reduced esophageal wall compliance from chronic remodeling. 1
Primary Pathophysiologic Mechanisms
Transmural Inflammation and Muscle Dysfunction
- Untreated transmural inflammation in EoE leads to remodeling of the esophageal wall and smooth muscle hypertrophy, which reduces esophageal wall compliance and contractility. 1
- The inflammatory process extends beyond the mucosa to involve all layers of the esophagus, triggering widespread tissue changes. 2
- This deep tissue involvement directly affects the muscular function of the esophagus, producing pain sensations similar to cardiac angina. 3
Esophageal Dysmotility
- Manometric studies demonstrate that eosinophilic infiltration causes tertiary contractions and other dysmotility patterns that generate chest pain. 4
- The dysmotility resolves when the eosinophilic inflammation is treated with corticosteroids, proving a direct causal relationship between tissue eosinophilia and abnormal esophageal motor function. 4
- These abnormal contractions can occur spontaneously or be triggered by swallowing, eating, or even exercise. 5
Structural Changes from Chronic Disease
- Chronic inflammation causes esophageal remodeling with stricture formation, edema, and reduced wall compliance—all of which contribute to chest discomfort. 2, 6
- The remodeling process involves fibrosis in the lamina propria and changes in the esophageal architecture that persist even after acute inflammation subsides. 1
Clinical Presentation Patterns
Spontaneous vs. Provoked Chest Pain
- Approximately 50% of EoE patients experience spontaneous chest pain separate from dysphagia episodes. 5
- Some patients present exclusively with exercise-induced chest pain as their only manifestation of EoE, particularly younger males. 5
- The chest pain can mimic cardiac angina with squeezing or burning retrosternal discomfort, making cardiac evaluation necessary before attributing symptoms to esophageal origin. 7, 8
Associated Symptoms
- Chest pain in EoE frequently occurs alongside dysphagia, food impaction, and heartburn, though it can present in isolation. 1, 2
- The pain may worsen with eating or occur at night, overlapping with GERD-like symptoms. 8
Important Clinical Considerations
Persistence Despite Mucosal Healing
- Continued esophageal symptoms including chest pain can persist despite resolution of mucosal disease, requiring investigation for subtle strictures or motility disorders. 1
- This highlights that the pain mechanism involves deeper structural and functional changes beyond surface inflammation alone.
Diagnostic Pitfall
- Physicians must consider EoE when unexplained chest pain persists after cardiac evaluation and reflux therapy, as the condition can present identically to angina pectoris. 3
- Up to 58% of adults with EoE present with chest pain, yet the diagnosis is frequently missed without esophageal biopsies. 7
- Normal-appearing esophageal mucosa does not exclude EoE; multiple biopsies from proximal and distal esophagus are mandatory. 7, 8