Pediatric emergency medicine trisk 1077 1077
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motility testing after persistent chest pain. Intra-abdominal processes such as
cholecystitis can present with postprandial pain and pain in the right upper
quadrant.
Musculoskeletal causes of chest pain are common accounting for 15% to 56%
of cases and are typically overuse injuries (muscle strain and inflamed tissue).
Chest pain often occurs after physical activity and is reproducible by palpation
and contraction of the muscle group on physical examination. Direct trauma may
produce a contusion or rib fracture. Costochondritis is an inflammatory condition
of the costochondral junctions which may be preceded by a respiratory illness and
characteristically has reproducible pain on examination. The pain is described as
sharp and exaggerated by physical activity or deep inspiration. Tietze syndrome is
a benign inflammatory condition of unknown cause which results in isolated
swelling of a costochondral junction. The inflamed area appears as a mass on the
chest wall and results in chest pain that typically radiates to the shoulder or arm.
This syndrome usually occurs in adults but has been reported in children and
infants. When evaluating a chest wall mass the differential diagnosis should
include osteomyelitis and tumors.
Slipping rib syndrome is a pain syndrome caused by hypermobility of the
anterior aspect of the 8th to 10th ribs which do not directly attach to the sternum
but instead are held together by fibrous tissue. It is thought that weakening of the
fibrous tissue in the area allows the ribs to rub against the other irritating the
intercostal nerve and referring pain to the chest wall and abdomen. Patients
describe a popping or clicking sensation followed by pain which lasts several
minutes. Pain is reproduced by hooking the lower ribs with the hand and pulling
anteriorly.
A large group of children with chest pain will have no evidence of organic
disease and no history of underlying cardiorespiratory disease or trauma. They
may have a family history of chest pain and are able to identify a stressful
situation that has precipitated the episode. Others have chest pain as a
manifestation of anxiety or depression. Such children have psychogenic chest
pain which represent approximately 5% to 17% of pediatric chest pain cases.
Complaints of chest pain and other somatic aches often are chronic and other
symptoms of psychiatric illness or hyperventilation may be present. Nonorganic
chest pain may appear to cause respiratory distress in the hyperventilating
teenager but close examination should distinguish this syndrome from serious
problems (see Chapter 126 Behavioral and Psychiatric Emergencies ).
Finally, idiopathic chest pain is a very common diagnosis of chest pain in
pediatrics representing 23% to 45% of cases. The term is used to describe chest
