Abdominal pain when lying down

Chest pain when lying down - all causes simply explained:

This article is based on the current scientific status, medical literature and medical guidelines and has been checked by medical professionals. → Look at sources

Chest pain when lying down is medically referred to as chest pain (thorax is the Rib cage). In general practitioner care, they are the reason for a doctor's visit in almost one percent of cases.

In many cases the pain in the chest at night or when lying down comes from reflux disease or reflux esophagitis, we will talk about these and other complaints in our article.

If these occur in an upright position during the day, this can also have many other causes.

Chest pain while lying down

If such chest pain when lying down preferably at night after a long horizontal position occur, there is usually one Reflux disease behind, in which the stomach acid rises into the esophagus. This disease is common; according to estimates, about suffer ten percent of all people in it. In the extreme case it becomes a Inflammation of the esophagus (reflux esophatitis), which is considered a precancerous stage.


Chest pain when lying down: reasons for chest pain

If chest pain is only noticeable when lying down, in most cases it is due to stomach acid entering the esophagus.

Still can other causes behind it, whose complaints are Only reinforce when lying down and not perceived as dramatic in an upright position.

Some of them require immediate medical attention. It is therefore important to know these other possible causes so that they can be differentiated from the relatively harmless reflux disease.

Chest pain when lying down - The most important things at a glance!

  1. Chest pain is called chest pain in medicine. They're very common and can have a variety of causes.
  2. If such chest pain occurs when lying down, it is usually caused by rising stomach acid in the esophagus (reflux disease).
  3. Reflux disease can be treated relatively well with medication.
  4. Other diseases can also cause chest pain, which is only aggravated in the lying position. The heart, lungs and stomach / intestines as well as psychogenic effects come into question.
  5. Since these causes of chest pain when lying or standing can have much more dramatic consequences, a differential diagnostic differentiation from reflux disease is absolutely necessary.

Reflux disease and reflux esophagitis cause chest pain when lying down

Chest pain when lying down: How does reflux disease and reflux esophagitis come about?

Reflux esophagitis is an advanced form of reflux disease. The name already says what is responsible for the chest pain when lying down: One Inflammation of the gullet (esophagitis). How does this happen?

The chewed food enters the stomach via the esophagus. In it there is a normal, comparable to the oral cavity neutral pH. The stomach itself is a muscular tube that can stretch considerably when you eat and is then under tension. In the gastric mucosa there are cells that form protons (H.+) release into the lumen of the stomach while consuming energy. The resulting Stomach acid is extremely acidic with pH values ​​around 1 and serves to kill possible pathogens, denaturate proteins in food and break down food components through acid hydrolysis.

In contrast to the gastric outlet, the pylorus, the stomach entrance is not provided with a "real" sphincter muscle as a sphincter. Instead, fibers of smooth visceral muscles run helically between the stomach and esophagus. These muscle strands can contract and thus form one to a certain extent functional closure (functional sphincter).

In addition, like all components of the gastrointestinal tract, the esophagus moves in a wave-like manner in one direction. These peristalsis ensures that rising stomach contents and stomach acid are transported back into the stomach.

Depending on how well the functional closure and persistence work and / or the filling status of the stomach, the Stomach acids rise up into the esophagus. Also increased stomach acid production favors such an effect. You may know something like this after a long meal heartburn. This is due to the fact that the highly aggressive acid attacks the sensitive mucous membrane of the esophagus. In contrast to the gastric mucosa, it does not have any special acid protection and neutral pH conditions prevail in it.

Heartburn usually passes quickly, but it can become chronic. Then a change in diet and the use of gastric acid suppressants, so-called help Antacids. An advanced variant of reflux disease is that Reflux esophagitis. It is from frequent besides heartburn Belching (regurgitation) marked. In contrast to normal heartburn, the mucous membrane here is so damaged that it becomes a local inflammation comes and local Erosions occur.

Chest pain when lying down: why do these occur in reflux esophagitis especially when lying down?

This is because when you are lying down your stomach and esophagus are more or less on the same level. Depending on how well the stomach entrance closes, gastric acid can get into the esophagus so much more easily than when standing, where the stomach lies below the esophagus and its acidic contents move downwards. Sometimes it helps patients with reflux esophagitis if they raise their upper body with an additional pillow.

Chest pain when lying down: Risk factors that can lead to reflux esophagitis

In many cases, reflux disease is the result of Obesity and Eating habits. Being overweight ensures that the pressure on the stomach is higher so that the acid rises more easily. In addition, the mobility of the stomach is restricted. Food rich in fat and carbohydrates or spicy foods promote inflammation, as fat and carbohydrates do not bind as much stomach acid as proteins. Chilli and the like burn even more on the irritated and inflamed mucous membrane of the esophagus than on an unaffected one.

Coffee, alcohol and nicotine increase the production of stomach acid, which has an additional effect on the damaged esophagus.

Chest pain when lying down: How do I recognize reflux disease or reflux esophagitis?

In addition to belching, heartburn is the main symptom of reflux disease.In the morning immediately after getting up the symptoms are greatest, as this is where the stomach acid had the best access to the esophagus during the night. The acid may have risen so high that it even irritates the larynx, which is relatively high up. That leads to Cough and hoarseness. In addition, it can get too close at breakfast in the morning difficulties swallowing come.

Chest pain when lying down: reflux disease due to diaphragmatic hernia

If the heartburn is accompanied by a feeling of pressure in the chest, it is usually a diaphragmatic hernia to blame. Such Hiatal hernia is something similar to the more popular hernia or umbilical hernia. With hiatus is the place where the esophagus runs through the diaphragm. Structurally, this gap is somewhat looser than the rather compact muscle of the diaphragm and, like the abdominal wall at the navel and in the groin, can become a weak point. There parts of the upper part of the stomach are shifted into the chest (hence the fracture), where they actually have no place. A diaphragmatic hernia occurs primarily in men and in obese people, although the likelihood increases with age.

Diagnosis and therapy of reflux in the esophagus

A sufficient one is usually sufficient physical examination (medical history) with detailed questionnaire on Type of symptoms, the Changes in chest pain when lying down, after this eat and depending on Type of food for a first suspicion. In such a case, your doctor will prescribe a medication known as Proton pump inhibitors (Proton pump inhibitor, PPI) acts. These suppress the proton pumps in the gastric mucosa, which secrete protons into the gastric juice and thus form gastric acid. The best known are pantoprazole and omeprazole. Often the reflux and thus the pain in the chest can be prevented when lying down, so that a permanent medication is applied.

In doubtful cases there is one Gastroscopy more precise information, in which an endoscope in the esophagus and stomach allows direct visual inspection of the mucous membranes. In rare cases, the acid development is measured with a special, very thin probe that is inserted into the esophagus through the nose and measures the pH development for a day (24 h pH metry).

Operative treatments are now rare. Many patients received a vagotomy, an operative cutting through, in the 1970s Vagus nervethat controls acid formation. Since the introduction of proton pump inhibitors, this operation is practically no longer performed. Today, diaphragmatic hernias are only operated on in a few cases or the gastric entrance is converted into a new functional closure (Fundoplication).

Chest pain when lying down: Other possible causes

As already described, chest pain can also have completely different causes and become worse in a lying position. Since some of them require much more urgent treatment than reflux, one should also consider these possibilities. This is especially the case if the problem is not heartburn, proton pump inhibitors do not help, or if there are other symptoms besides chest pain when lying down. Above all, chest pain, which is movement-dependent, load-dependent and / or breathing-dependent, speaks against reflux.

The Guideline 15: Chest Pain the German Society for General Medicine and Family Medicine (DEGAM) gives six reasons for chest pain:

Chest pain when lying down: gastrointestinal causes (6%)

Gastrointestinal causes include reflux disease, as discussed earlier.

Chest pain when lying down: Psychogenic causes (10%)

Psychogenic causes can also cause chest pain when lying down or in another position. This includes Anxiety disorders with panic attacks, inexplicable palpitations, nervousness and shortness of breath, depressions and so-called somatoform disorders. These are repeated unspecific complaints for which no organic cause can be determined.

Chest pain when lying down: respiratory effects (10%)

Here, respiratory diseases cause chest pain when lying down. This includes Pneumonia (Pneumonia), bronchitis or Inflammation of the trachea (Tracheitis). Cause severe pain pleurisy (Pleurisy) or a build-up of fluid in the pleura (Pleural effusion). Usually these are Breath-dependent pain and often from Cough, hoarseness, sputum and fever accompanied.

Chest pain when lying down: chest wall syndrome (46%)

Chest wall syndrome is a summary of chest pain events that independent of load, but dependent on movement and position and therefore also occur when lying down. Local muscle tension is the cause. The stabbing pain that occurs can be reproduced by pressing (palpation). Clear against the chest wall syndrome speak shortness of breath, cough and a respiratory disease or known vascular disease.

Chest pain when lying down: Coronary artery disease stable (11%)

If you experience chest pain when lying down and you have already had hardening of the arteries and / or coronary artery disease (CHD), this option should definitely be considered. Such pains are load-dependent. Especially with Lie on your left they can become stronger because the heart is additionally compressed by the other chest organs. This is characteristic of coronary artery disease Improvement after administration of nitroglycerin from a spray bottle into the mouth.

The KHK is considered to be Risk factor for a heart attack. This often runs with less typical symptoms in women than in men. Therefore, chest pain that occurs suddenly, especially in women, should also be considered a possible "Silent" heart attack“Make you think. In such a case, the pain is not relieved by nitro spray.

Chest pain when lying down: Acute coronary syndrome (3.5%)

The acute coronary syndrome (ACS) is the rarest, but am most urgent cause in need of treatment for chest pain when lying and / or standing. The term stands for the preliminary working diagnosis of a disease which is an acute form of coronary artery disease, but which cannot yet be precisely named. These diseases are unstable Angina pectoris, one Heart attack or one sudden cardiac death. In any case, a patient with ACS needs immediate emergency medical care.

Sources, links and further reading

  1. Gerd Herold: Internal Medicine. Cologne 2019: G. Herold Verlag. ISBN-10: 3981466063
  2. Wolfgang Piper: Internal Medicine. 2nd Edition. Stuttgart 2012: Springer-Verlag. ISBN-10: 3642331076.
  3. German Society for General Medicine and Family Medicine (DEGAM): DEGAM guideline No. 15: Chest pain (valid until December 31, 2019, will be updated until 03/2019).

Doctor of medical science and natural scientist with a medical doctorate. This article conforms to current scientific standards and medical guidelines. (Authors M.Foerster / H.Stephan)