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You may feel painful symptoms radiating from your abdominal area, but is this the only location where hiatal hernia pain can be felt? Dr. Vikki discusses the various area in which the symptoms of Hiatal Hernia Syndrome can be felt.

Transcript of the video

I’ve been asked to review where is hiatal hernia pain located… If you feel like you have a hiatal hernia, where would you feel discomfort?

Hiatal hernia is a syndrome

Something important to realize is that hiatal hernia is a syndrome. It’s not like a broken arm. There’s where the break is, and there’s where the pain is. It’s not quite that simple.

Pain in the upper abdomen

But it does start with the basic of where your stomach is located, which is right under your ribcage, on the left side. And one of the hiatal hernia pains you can definitely feel is in that area just on the upper abdomen, under the ribcage on the left. And you can feel pain from bloating. You can feel pain from the stomach being in spasm. It’s a discomfort there.

Pain in the oesophagus

That, people often talk about. One of the major symptoms associated with hiatal hernia is the stomach spasming and pushing its juices, its acid up into your oesophagus. So another area where you can feel hiatal hernia pain is in the oesophagus, in your chest, and that can be lower down… It can go all the way up into your mouth where you’re tasting acid, a burning in your chest. So anything along the whole oesophagus, you can feel pain and discomfort because of that.

Pain in the neck or ears

Another interesting thing is that the nerve that goes to your diaphragm comes out of the base of your neck, the bottom of your neck. That’s the nerve that makes the diaphragm work. So sometimes people can have neck pain associated with this. We recently had someone with ear pain because this nerve also goes up into the jaw; she was having a lot of ear pain and it was a hiatal hernia. So every time we feel as a team that we’ve seen every manifestation of hiatal hernia pain, a new one comes into play.

But it does make sense. So jaw pain, neck pain…

Tingling in the left arm

When someone is having trouble with getting enough oxygen because the diaphragm isn’t moving as freely as it should, and they’re a little short of breath or they’re getting heart palpitations, they can also get tingling into the left arm, which of course is scary because that’s a symptom of a heart attack as well.

In the emergency room, it has been very well known for a very long time that the differential diagnosis with someone coming in with shortness of breath and pain down the left arm is rule out the heart attack. And if it’s not that, it could be hiatal hernia pain, they do know that.

Panic attack is another alternative diagnosis. Those are the main symptoms.

I’m gonna look at my notes to see if there’s anything else…

Pain in the chest

Certainly because you’ve got sometimes shortness of breath and heart palpitations, you can get just pain in the chest. And as people get more panicked and more anxious, you can just get overall chest pain and you feel like, “isn’t my heart…?” or “isn’t my lungs…?” And certainly that’s a worthwhile differential diagnosis to make sure you’re not having a heart attack, not a life and death situation.

I’ve had so many patients go after the emergency room, then go to a cardiologist and go to a pulmonologist to evaluate the lungs and make sure it’s not that. Because their symptoms are predominantly the racing heart, the shortness of breath, the panicky feeling, and all these tests are done and the doctors told them “your heart is fine, your lungs are fine”. And by the time we meet them as like, “that’s great, I’m so glad to know my heart and lungs are fine, but I’m short of breath and I feel panicky and my heart’s racing and you know, I feel like I’m having a heart attack.”

So, it’s just a matter of realizing there is an underlying cause to that. And certainly number one, you rule out that life and death situation, but as soon as that’s ruled out, don’t give up: get to that root cause. That’s what we’re here for. So as far as where hiatal hernia pain can be located, there are those few areas, but they all make sense as far as the manifestation of hiatal hernia.

So I hope that was helpful. If you feel like this is something that’s been bothering you, or you know, you’ve been frustrated with not getting a proper diagnosis, please reach out. This is our area of expertise and has been for at least a decade now. I truly know of no other group of doctors working together who have seen so many patients and have such a high success rate.

So, if you think this is you, you don’t have to keep suffering and reach out for free consultation, give us a call at (408) 733-0400.

In-clinic and telehealth consultations

Root Cause Medical Clinic has its facilities near downtown Clearwater, FL, at the intersection of S Ft Harrison and Magnolia. We have ample parking space, you won’t have to go around to find a spot. However, if coming to our medical clinic is not possible because you live in another state or are just too far from our facility, we also offer telehealth consultations. We have been doing telemedicine for years in California, and we also propose this mode of consultation in Florida and several other states. Hiatal Hernia Syndrome is a pathology we can treat in the context of telehealth: if this is your diagnostic and we are your medical professionals of choice to treat your condition, we will work with you remotely if you are located in the states where we are licensed. Please call our offices to get details.

Additional Resources:
Read Dr. Vikki Petersen’s new book on Hiatal Hernia Syndrome
Video by Dr. Vikki on Hiatal Hernia Syndrome
Web MD on hiatal hernia symptoms
Image of chest pain

Hiatal Hernias | Michigan Medicine

A hernia occurs when an organ protrudes through the wall of muscle that encircles it. A hiatal hernia means that the upper part of your stomach has protruded up into your chest, pushing through the little opening (or hiatus) in your diaphragm (which separates your abdomen from your chest).

Most of the time, hiatal hernias are so small they might not be felt at all. But if the hernia is a bit larger, it could force the opening in your diaphragm to become larger, too. At that point, the entire stomach and other organs are in danger of sliding up into your chest.

A hiatal hernia can also put undue pressure on your stomach, by squeezing or twisting it. This pressure can make your stomach retain acid, which can then flow up into your esophagus. You could develop chest pain, gastroesophageal reflux disease, and/or heartburn, and have trouble swallowing or even breathing.  The acid may also cause ulcers within the stomach that can bleed and lead to acute or chronic anemia (low blood counts).

There are a few different kinds of hiatal hernias. Type I hernias, or sliding hiatal hernias, are the smallest and most common variety. These hernias cause your stomach to slide through a small opening in the diaphragm, and up into your chest. These often do not require an operation or treatment.

Much less common than these are Types II, III, and IV hernias, or paraesophageal hernias. These occur when a part of the stomach protrude into the chest adjacent to the esophagus. That part of the stomach is “trapped” above the diaphragm and can’t slide back down again. While these hernias are far less common, they can be more dangerous, since they cause more serious symptoms, and because the blood flow to your stomach can be compromised.

Risk Factors

Those over the age of 50, pregnant women, and the obese are at higher risk. A hiatal hernia can also be triggered by insistent pressure on the hiatus muscles. That pressure can be caused by coughing, vomiting, immoderate straining during bowel movements, lifting heavy objects, and/or excessive physical exertion.

Symptoms

Hiatal hernias, especially Type I hernias, do not usually cause symptoms. They may, however, be associated with the following: burping, heartburn, nausea, vomiting, and/or regurgitation into the esophagus.

A paraesophageal hernia, or Type II, III, or IV hernia, may cause more severe symptoms. These can include:

• Abdominal/chest pain
• Abdominal bleeding (which can be indicated by blood in vomit, red or black stool, anemia, blood test indicating loss of blood)
• Change in voice
• Early satiety (or becoming full after only eating a small amount of food)
• Occasional trouble swallowing (especially solid food)
• Shortness of breath or trouble breathing after eating
• Acid reflux
• Regurgitation or a sensation of food “sticking”

Diagnosis

Along with a complete exam and detailed medical history, your surgeon may use one or more diagnostic tests to determine the best course of treatment.

Barium Swallow / Upper GI study requires that you swallow a small amount of contrast material, or liquid barium, which coats the lining of your esophagus so that X-ray images may be obtained. If you have experienced trouble swallowing, this procedure can help to locate any areas in your esophagus that may have narrowed. These areas are called strictures.

Chest X-rays: Electromagnetic energy produces images of internal tissues, bones and organs.

CT-Scans: These scans make up a series of images of the inside of your body, all taken from different angles, to reveal a high level of detail. To ensure that your veins and organs show up clearly in these scans, you may need to swallow a dye used for that purpose, or have it injected into your vein.

Upper Endoscopy (EGD): A procedure in which an endoscope is threaded through your mouth and then into your esophagus. This procedure allows your surgeon to actually see your upper digestive tract, which includes your esophagus, stomach, and duodenum, or the first part of your small intestine. Your surgeon can then remove a tissue sample as well.

Treatments

Hiatal hernias don’t always require treatment beyond regular monitoring and medications. Under certain conditions, however, treatment will be necessary. Those conditions include: chronic anemia; chronic pain; complications by gastroesophageal reflux disease; complications by esophagitis; danger of strangulation; inability to vomit; recurrent pneumonia or other infections. The following treatments are available for those with hiatal hernias.

Minimally Invasive Hernia Repair

Minimally invasive surgery can effectively diminish the size of a hernia, as well as reduce the opening in the diaphragm, thereby preventing strangulation. During this procedure, surgeons will insert a tiny video camera into your abdomen. They’ll be able to view images projected onto a monitor, which will allow them to complete the procedure with greater control and finesse. The purpose of this surgery is to restore the stomach into your abdomen and close down the hole in the diaphragm. Minimally invasive surgery is associated with a quicker recovery and faster return to function than traditional open repair. Your doctor will determine if you are a candidate for this approach. (Video)

Fundoplication

Your surgeons may also perform a fundoplication, which will help to prevent acid from rising through the stomach.

Make an Appointment

To discuss a potential hernia treatment or surgery, contact the Surgery Call Center at (734) 936-5738.

Pain in the left side of the abdomen

General information

Pain in the abdomen can be a symptom of many diseases. The abdomen is not a single organ like the heart or liver. The abdomen is filled with many different organs, tissues, structures. And every organ in the stomach can get sick. First of all, you should pay attention to the sudden onset sharp pain in the abdomen . This pain may be the first symptom for immediate medical assistance. Many abdominal organs are hollow. For example, stomach, intestines, gallbladder. And if one of them fails (clogs, bursts), then your life is in danger. If a sharp sudden pain lasts more than 30 minutes, you should urgently call a doctor or go to the hospital in order to exclude an urgent surgical pathology .

Conventionally, the abdomen is divided into four quadrants (or segments) – upper right, upper left, lower right and lower left. The localization of any symptom can now be assigned to one of the four quadrants. Pain in the left side in the lower abdomen, combined with symptoms of a disease of an organ located on the same side, is the primary stage of the disease. Irradiating and reflected pains are formed in chronic forms of diseases involving large areas of the body in the pathogenesis.

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Causes of pain in the left side of the abdomen

The left upper quadrant of the abdomen contains the spleen, stomach, pancreas, intestinal loops and the left side of the diaphragm. Pain in the left upper quadrant may be associated with the spleen. Spleen lies very close to the surface of the body. The main job of the spleen is to remove red blood cells from the blood, after their normal life span of 120 days. It captures them, destroys them, after which their components pass into the bone marrow, where new blood cells are formed.

In a number of diseases, the spleen enlarges, its capsule is stretched, and this causes pain. Due to the fact that the spleen is located close to the surface of the body, it is prone to rupture. Causes of a ruptured spleen can be trauma and diseases such as infectious mononucleosis . With this disease, the spleen becomes enlarged and soft. And all this increases the likelihood of its rupture. Sometimes an enlarged spleen ruptures on its own. A signal sign of rupture of the spleen, in addition to pain and sensitivity in the corresponding area, is cyanosis of the skin around the navel (due to accumulation of blood).

Pain in the upper left abdomen (left upper quadrant (or left precostal area)) may come from the stomach. Anything that irritates the stomach lining, causes gastritis (inflammation of the stomach) or functional dyspepsia, can cause pain. More often, this pain is aching in nature, often accompanied by nausea and even vomiting. Antacids prescribed by your doctor will help. In general, only a doctor can tell you exactly what you have.

Stomach pain may be due to peptic ulcer and cancer. After completing a series of laboratory tests and examinations (including endoscopic), the doctor will finally make a diagnosis for you and prescribe the treatment. Pain in the upper left quadrant may be associated with diaphragmatic hernia. In the diaphragm, which separates the chest cavity from the abdominal cavity, there is a hole through which the esophagus passes on its way to the stomach.

When the muscles that control the size of this orifice weaken, the orifice enlarges, allowing the upper stomach to exit the abdominal cavity, where it should be, into the chest cavity, where it certainly should be. This state is called diaphragmatic hernia. More common in the elderly. Due to acidic stomach contents, you feel pain in the left upper quadrant.

We must not forget that pain in the left upper quadrant can be caused by the pancreas. After all, it is stretched through the upper abdomen and when the pancreas becomes inflamed, you can feel pain on the right, in the middle and on the left side of the abdomen. Various diseases and toxins can affect the pancreas , including cancerous tumors.

You should suspect a disease of the pancreas if the pain that occurs is very sharp, comes from the inside, has a girdle character, radiates to the back, is accompanied by the following symptoms:

• Temperature;

• nausea;

• vomiting.

Pain in the lower left abdomen (left lower quadrant) may result from all conditions that cause pain in the right lower region except appendicitis.

Pain in diseases of the spleen

In the early stages of the disease, the most likely localization of pain is in the left side. Oncological disease accompanied by damage to the hematopoietic organs – spleen, liver, regional lymph nodes . There are three clinical phases of the disease:

• Chronic;

• progressive;

• blast crisis.

Symptoms of the chronic phase: pain may be absent, they appear as the tumor grows. The earliest signs:

In some cases, the disease is accompanied by weight loss . With enlargement of the spleen there is pain after eating. Many patients note that they are too quickly satiated. At an early stage, diagnosis is carried out using ultrasound and laboratory blood tests.

Symptoms of the progressive phase are detected by physical method – deep external palpation, causing increased pain in the lower abdomen on the left. It increases as the spleen and inguinal lymph nodes increase.

During the phase of the blast crisis, aching pains in the joints and bones of the pelvic girdle or at a remote distance from the location of the lesion are characteristic. The body temperature rises . Decreased blood clotting, a rapid increase in the volume of the spleen are detected. Diagnosis of the disease is carried out with the help of instrumental, laboratory studies.

Infarction of the spleen with blockage of arterioles, small arteries of the parenchyma of the organ and the development of a focus of necrosis around the thrombus of the vessel. Spleen infarction is easily confused with diseases that are its causes: infections, oncology, heart defects, pathologies of blood vessels.

Spleen infarction is manifested by sharp pain in the left hypochondrium. As the pathogenesis develops, the pain may descend to the lower abdomen. It is aggravated by deep inspiration, coughing and movement. Body temperature rises. The disease is dangerously massive blood loss . The diagnosis is made on the basis of instrumental studies. Treatment – surgery, physiotherapy, drug correction.

Volvulus of the spleen or partial or complete twisting of the splenic artery, veins and nerve bundles around its axis. The reason is the individual characteristics of a person who, from birth, has long mesenteric ligaments that hold the organ in the abdominal cavity, or injuries to the spleen. Accompanied by symptoms acute abdomen . There is a sharp pain in the left side, then it begins to fall lower and give to the groin area on the left. The pain is associated with vomiting, constipation and bloating. There is a sharp deterioration in well-being. With incomplete twisting, the patient complains only of periodic pain in the left side, aggravated by physical exertion.

A patient with symptoms of an acute abdomen is being considered for immediate surgery. Indolent pain with partial twisting is a reason for immediate clinical examination . After clarifying the diagnosis, the issue of treatment is decided, including the conduct of a planned surgical operation.

Pain in the left side of the abdomen can also cause acute enlargement of the spleen . The two main causes of enlargement of the spleen are impaired blood flow through the portal vein and inflammation.

If the outflow of blood is disturbed, paroxysmal dull pain is characteristic on the left, in the hypochondrium, it may migrate to the lower abdomen. Acute expansion after blockage of a vein (thrombi, conglomerates of parasites) is manifested by a significant increase in the organ, smoothing of the sharp edges of the spleen on ultrasound.

Inflammation of the spleen is rarely an independent disease, more often the pathology develops as a secondary process involving the spleen in pathogenesis, for example, the liver. Accompanied by symptoms of the underlying disease. The organ is much less enlarged, the pain is combined with fever, vomiting.

The most common causes of inflammation of the spleen are diseases of neighboring organs, including the liver: Gaucher’s disease – impaired fatty metabolism of the liver; Bunty’s disease – accompanied by cirrhosis or degeneration of the liver tissue; Hodgkin’s disease – lymphogranulomatosis.

Abscess of the spleen is the result of the development of limited purulent inflammation in the capsule or parenchyma of the spleen. The pathogenesis of small abscesses usually ends with complete recovery. With the formation of large or multiple abscesses, especially those that have opened into the abdominal cavity, peritonitis may develop. Its signs are severe diffuse pain radiating to the left side and lower abdomen, high temperature, a sharp deterioration in well-being, a regression of consciousness.

Spleen cyst is a cavity filled with connective tissue capsule. Inside it is filled with watery, slimy contents. The cyst forms as a result of the completion of the abscess. It can also be the result of a rupture of the spleen in 90,003 traumatic injuries. Small cysts are painless, and large ones cause slight pain when pressed with a fist in the region of the left hypochondrium. Patients also note paroxysmal dull pain of low intensity during physical exertion. Other pathologies, including congenital disorders and atrophy of the spleen, occur without a pronounced pain syndrome.

Dyspepsia | Floris

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Dyspepsia is a subjective manifestation of diseases of the digestive system, which are associated with a violation of the digestive processes. Dyspepsia can be manifested by: loss of appetite (anorexia), a feeling of “bursting” or a feeling of fullness in the stomach, heartburn, belching, swallowing disorders (dysphagia), nausea, vomiting, excessive gas formation in the intestines (flatulence), diarrhea, constipation.

What are functional diseases of the gastrointestinal tract (GIT)?

This is a complex of persistent or intermittent gastrointestinal symptoms that cannot be explained by any structural organ changes, biochemical changes or any other organic disorders.

To accurately indicate the location of any changes or pain found during examination of the abdomen, the anterior abdominal wall is conditionally divided into separate areas and departments.

Draw two horizontal lines first. The upper one connects the lowest points of both costal arches. The inferior connects both anterior superior iliac spines. Thus, the abdomen is divided into three floors: the upper one is the epigastrium, the middle one is the mesogastrium and the lower one is the hypogastrium. Two vertical lines run along the outer edges of the right and left rectus abdominis muscles. A solid curved line runs along the edge of the costal arches. The dotted line represents the dome of the diaphragm.

The following areas are distinguished.

• right hypochondrium.
• the actual epigastric region.
• left hypochondrium.
• right side area
• umbilical region.
• left side area
• right iliac (inguinal) region.
• suprapubic area.
• left iliac (inguinal) area.

Symptoms

The most common symptom in functional diseases of the stomach, intestines and biliary tract is abdominal pain, ie. abdominal pain . The most common cause of such pain is excessive activity of the intestines and biliary tract, which leads to the development of spasm. But you should not forget about such serious diseases as peptic ulcer of the stomach and duodenum.

Heartburn. The second most common symptom is heartburn. E that feeling of discomfort or burning sensation behind the sternum, spreading upward from the epigastric (pit of the stomach) along the esophagus. Instead of the burning sensation of heartburn, some people experience a feeling of pressure, fullness, warmth, or a lump. Heartburn can be with any acidity of gastric juice, but most often it occurs with increased acidity. It is important not to confuse this feeling with chest pain. Pain behind the sternum can be caused by both functional diseases of the gastrointestinal tract, and diseases of the heart and some other organs. In all cases, chest pain requires careful evaluation for an accurate diagnosis. For this purpose, it is necessary to conduct a joint study of the cardiovascular system and the gastrointestinal tract.

Belching . In diseases of the stomach and duodenum, belching often occurs. involuntary or arbitrary entry into the oral cavity of a small amount of food or air contained in the stomach, accompanied by a characteristic sound of air escaping through the mouth. Belching can also occur with other diseases of the abdominal organs, for example, the liver, gallbladder, as well as with cardiovascular diseases (coronary heart disease, myocardial infarction, etc.).

Dysphagia – swallowing disorder, manifested by difficulty or inability to swallow, pain at the time of swallowing, ingress of food or liquid into the nose, larynx, trachea. The causes of dysphagia can be inflammatory processes of the oral cavity, pharynx, esophagus, larynx, mediastinum, foreign bodies, cicatricial narrowing and tumors, diffuse spasm of the esophagus, and some nervous diseases. The most common cause of dysphagia is gastroesophageal reflux disease. Acid from the stomach enters the mucosa of the patient’s esophagus, damage is formed on it and this causes slight narrowing of the esophagus – a stricture. Spasm of the esophagus is one of the causes of dysphagia

Nausea – an unpleasant painful sensation in the epigastric region, chest, mouth, often preceding vomiting.
Nausea, like vomiting, is one of the symptoms of stomach diseases, such as acute and chronic gastritis, peptic ulcer of the stomach and duodenum, cancer, as well as functional disorders that accompany a number of diseases (chronic pancreatitis, chronic cholecystitis, cholelithiasis, chronic hepatitis and cirrhosis of the liver, diseases of the small and large intestines), intoxications of various origins, including helminthic and parasitic invasions.

Flatulence – excessive accumulation of gases in the stomach and intestines. It is manifested by bloating, swelling, belching, hiccups, a feeling of heaviness and fullness in the abdomen, attacks of cramping pains that disappear after the passage of gases.
Flatulence is a common symptom of some diseases, such as intestinal dysbacteriosis, pancreatitis, colitis, enteritis, liver cirrhosis, acute intestinal infections, and impaired motor function.

Constipation is a bowel disorder with retention of stool for more than 48 hours. the passage of hard stools, often accompanied by a feeling of tension and discomfort.
The causes of constipation are very different, among them are peptic ulcer, chronic pancreatitis, dysbacteriosis, irritable bowel syndrome, colon tumors.

Diarrhea (diarrhea) is a stool disorder characterized by frequent or single bowel movements with the release of liquid or mushy feces in a large volume (more than 200 g per day). As a rule, diarrhea occurs against the background of diseases of the gastrointestinal tract (both infectious and non-infectious). In addition, diarrhea can be a symptom of food poisoning, nervous disorders, stress, taking certain medications, physical overload, eating after a long period of fasting, climate change and nutritional conditions (traveler’s diarrhea), etc.

Abdominal pain is one of the most common complaints of patients who come to the doctor. Indeed, every person in his life has felt pain in the abdomen more than once, and the discomfort that this pain causes is difficult to compare with other pain sensations. The causes of this symptom can be both diseases of the intestines, stomach, liver and gallbladder, as well as pancreas, inflammation of the appendix and kidneys. In some cases, heart problems can also cause abdominal pain. In a special group, diseases can be distinguished that cause pain in the lower abdomen, more characteristic of women, which indicate possible diseases of the genitourinary system.

Depression, spinal disorders, thyroid disease, anemia, urinary tract infections may masquerade as abdominal pain. Abdominal pain may be accompanied by alcohol, drugs, antibiotics, anti-inflammatory drugs, iron supplements.

It is extremely important for diagnosing to correctly determine all the characteristic features of abdominal pain:

Localization of pain – the place of the greatest pain sensations. For an accurate determination, it is necessary to lie on your back and gently feel the stomach, finding the place that causes the most pain. In classical cases, there is a correspondence between the localization of pain and the affected organ. So, in diseases of the esophagus, stomach, duodenum, pain is localized in the projection of the stomach. Pain in the right hypochondrium indicates diseases of the biliary tract of the gallbladder and liver. With pancreatitis, pain is often localized in the left hypochondrium. In diseases of the small intestine – in the umbilical region, the caecum and appendix – in the right iliac region, the sigmoid colon – in the left iliac region. Pathological processes in the bladder, uterus and appendages manifest themselves as pains in the lower abdomen.

Type of pain – pain can be sharp and dull, aching, bursting and squeezing, etc.

Accompanying symptoms – vomiting, nausea, fever, diarrhoea, increased pain with certain actions or assuming a certain body position;

What preceded the onset of pain and how pain sensations developed – after nervous tension, physical exertion, eating, drinking alcohol, etc.

Chest pain and gastrointestinal disorders

Chest pain requires careful evaluation for an accurate diagnosis. For this purpose, it is necessary to conduct a joint study of the cardiovascular system and the gastrointestinal tract.
Consider the manifestations of pain in various diseases.

In esophagitis caused by gastroesophageal reflux, patients usually complain of a burning sensation deep in the chest. Burning increases after taking aspirin, drinking alcohol and certain foods. Relief is provided by antacids, sometimes by small amounts of food or water. Concomitant symptoms – dysphagia, belching of undigested food, weight loss.

Hernia of the esophageal opening of the diaphragm is characterized by the appearance or increase of pain in the supine position. For diseases associated with an increase in the acidity of the stomach, such as gastroesophageal reflux disease, fasting pain is typical, especially in the early morning, food brings relief (food neutralizes the effect of hydrochloric acid).

Spasm of the esophagus (especially against the background of gastroesophageal reflux) is accompanied by constrictive retrosternal pain, which is difficult to distinguish from angina pectoris, since even its irradiation can be the same. Another cause of severe chest pain is damage to the esophagus – a rupture of the lining of the esophageal-gastric junction with severe, repeated vomiting, retching, or severe coughing.

Other less common causes of chest pain are stomach ulcers, cholecystitis and pancreatitis.