Pectus excavatum (PE) is the most common congenital chest wall deformity, characterized by an inward depression of the sternum and ribs. While PE is primarily known for potential cardiopulmonary effects, many patients report significant digestive system issues. The sunken chest can interfere with organs within and just below the thoracic cavity. This article explores the physical connection between this chest wall anomaly and resulting gastrointestinal (GI) problems.
Anatomical Mechanism of Compression
The structural anomaly of a sunken sternum significantly reduces the space available within the anterior mediastinum. This inward pressure physically displaces organs located behind the breastbone, particularly the heart. The displaced heart is pushed backward, which exerts pressure on adjacent structures, including the esophagus and the upper portion of the stomach.
The depression of the sternum can directly alter the anatomical relationship of the lower esophageal sphincter (LES) and the gastroesophageal junction. The natural angle where the esophagus meets the stomach is a key defense mechanism against reflux, and sternal compression can distort this angle. The sunken chest wall can also press upward on the stomach, creating crowding in the upper abdomen and mechanically interfering with normal digestive function and motility.
Common Gastrointestinal Manifestations
The physical compression and displacement of the digestive tract lead to several distinct gastrointestinal symptoms. The most frequently reported issue is Gastroesophageal Reflux Disease (GERD), where stomach acid flows back up into the esophagus. Patients often experience classic GERD symptoms like persistent heartburn, acid regurgitation, and chronic cough or throat irritation.
Another common manifestation is dysphagia, or difficulty swallowing, which results directly from the mechanical narrowing or displacement of the esophagus by the compressed chest structures. Since the upper stomach is subject to crowding, patients may also experience early satiety, feeling full quickly after starting a meal. This mechanical pressure can also contribute to bloating, as the stomach has less room to expand normally during digestion.
Evaluating the GI-PE Connection
Evaluating whether GI symptoms are caused by Pectus Excavatum requires a coordinated approach between a gastroenterologist and a thoracic surgeon.
Imaging and Severity Assessment
The initial diagnostic step involves a computed tomography (CT) scan of the chest to measure the severity of the deformity. Clinicians use the Haller Index to quantify the degree of sternal indentation and the resulting compression on thoracic organs. The Haller Index is a ratio derived from the CT scan.
Endoscopic and Radiographic Studies
An upper endoscopy (EGD) may be performed to visualize the upper GI tract. An EGD can identify secondary effects of acid reflux, such as esophagitis (inflammation) or Barrett’s esophagus.
A barium swallow (esophagram) is a specialized imaging test used to visualize the esophagus as the patient swallows a contrast agent. This test demonstrates the mechanical effect of the chest wall deformity, showing the resulting narrowing, deviation, or displacement of the esophagus caused by the extrinsic pressure.
Managing Pectus-Related GI Issues
Managing Pectus-related GI issues begins with medical management, similar to standard GERD treatment. This involves lifestyle modifications, such as dietary changes and elevating the head of the bed, to reduce acid reflux. Medications, including proton pump inhibitors (PPIs) and H2 blockers, are prescribed to suppress stomach acid production.
While medical therapy provides temporary relief, it does not address the underlying structural problem. The definitive treatment is surgical repair of the chest wall deformity. Procedures like the minimally invasive Nuss procedure or the open Ravitch procedure lift the sternum and ribs outward. This corrective action immediately relieves external pressure on the esophagus and stomach, mitigating chronic GI symptoms like reflux and dysphagia.