First AD

Second AD

A 28-year-old woman is evaluated for chest pain, which is considered to be esophageal in nature. Her workup has included a normal upper endoscopy, a normal barium swallow, and a normal 24-hour pH/impedance study. She has tried a twice-daily PPI for several weeks without improvement in her symptoms.

This patient has functional chest pain. Her workup has been thorough and she does not have any evidence of reflux as a cause of her symptoms. Therefore, switching to another acid suppressant is not likely to help in this case. Baclofen is a reflux inhibitor and can reduce the number of transient lower esophageal sphincter relaxations. This drug can be used to manage non-acid reflux. Metoclopromide is a promotility agent and be used in the management of GERD and gastroparesis. Several studies have demonstrated efficacy of pain modulators in functional esophageal symptoms. These studies have used several antidepressants and the best evidence to date is with venlafaxine, a selective serotonin norepinephrine inhibitor. Typically, these antidepressants are prescribed in lower doses when managing functional esophageal pain.

What Treatment for Functional Chest Pain?