Roemheld syndrome

Roemheld syndrome (RS), also known as Roemheld-Techlenburg-Ceconi-Syndrome or gastric-cardia, is a complex of gastrocardiac symptoms first described by Ludwig Roemheld (1871–1938). It is a syndrome where maladies in the gastrointestinal tract or abdomen trigger/cause cardiac symptoms. There is rarely a traceable cardiac source to the symptoms which may lead to a lengthy period of misdiagnosis.

Epidemology

Roemheld syndrome is characterized strictly by abdominal maladies triggering reflexes in the heart. There are a number of pathways through which cardiac reflexes can occur: hormones, mechanical, neurological and immunological.

Mechanical

Mechanically induced RS is characterized by pressure in the epigastric and left hypochondriac region. Often the pressure is in the fundus of the stomach, esophagus or distention of the bowel. It is believed this leads to elevation of the diaphragm, and secondary displacement of the heart. This reduces the heart's ability to fill and increases the contractility of the heart to maintain homeostasis.

Neurological

The mechanical changes in the gut can compress the vagus nerve at any number of locations along the vagus, slowing the heart. As the heart slows, autonomic reflexes are triggered to increase blood pressure and heart rate.

This is complemented by gastro-coronary reflexes whereby the coronary arteries constrict with "functional cardiovascular symptoms" similar to chest-pain on the left side and radiation to the left shoulder, dyspnea, sweating, up to angina pectoris -like attacks with extrasystoles, drop of blood pressure, and tachycardia (high heart beat) or sinus bradycardia (heart beat below 60). Typically, there are no changes / abnormalities related in the EKG detected. This can actually trigger a heart attack for persons with cardiac structural abnormalities i.e. coronary bridge, missing coronary, and atherosclerosis.

If the heart rate drops too low for too long, catecholamines are released to counteract any lowering of blood pressure. Catecholamines bind to alpha receptors and beta receptors, decreasing vasodilation and increasing contractility of the heart. Sustaining this state causes heart fatigue which results in fatigue and chest pain.

History

Ludwig Roemheld characterized this particular syndrome shortly before his death; one of his research topics around this time was the effects of calorie intake on the heart. In Elsevier, there is no current research or publishing under the name Roemheld syndrome, and as a result many cases go undiagnosed. German publishing on the subject remains untranslated as of 2009.

Symptoms

Symptoms are periodic, and occur only during an "episode", usually after eating.

• Sinus bradycardia
• Difficulty inhaling
• Angina pectoris
• Left ventricular discomfort
• Fatigue
• Anxiety
• Uncomfortable breathing
• Poor perfusion
• Muscle pain (crampiness)
• Burst or sustained vertigo or dizziness
• Sleep disturbance (particularly when sleeping within a few hours of eating, or lying on the left side)
• Extrasystoles
• Hot flashes

Common causes

As gas is the usual trigger, eating foods that a person is intolerant to can make symptoms more severe.

• Excessive gas in the transverse colon caused by:
  • Lactose intolerance
• abnormal gall bladder function and/or blood flow
• Gall stones
• Sphincter of Oddi dysfunction
• Hiatal hernia
• Cardiac bridge (Coronary occluding reflexes triggered by coronary reflexes)
• Enteric disease
• Aneructonia, the loss of the ability to belch (continuous or intermittent)
• Bowel obstruction (Less common, this usually leads to intense pain in short time)
• Acute pancreatic necrosis^[1]

Diagnosis

Diagnosis of RS usually starts with a cardiac workup, as the gastric symptoms may go unnoticed, the cardiac symptoms are scary and can be quite severe. After an EKG, Holter monitor, tilt test, cardiac MRI, cardiac CT, heart catheterization, EP study, echo-cardiogram, and extensive blood work, and possible a sleep study, a cardiologist may rule out a heart condition.

Often a psych workup may ensue as a conversion disorder may be suspected in the absence of heart disease, or structural heart abnormalities.

Diagnosis is often made based on symptoms in the absence of heart abnormalities. A gastroenterologist will perform a colonoscopy, endoscopy, and ultrasound to locate or eliminate problems in the abdomen.

Determining the cause of Roemheld syndrome is still not an exact science. If you have an ultrasound or sleep study, ensure that you know how to reproduce the symptoms, as it is difficult to detect any abnormalities when symptoms have subsided.

Therapy

Treatment of the primary gastroenterological distress is the first concern, mitigation of gastric symptoms will also alleviate cardiac distress.

• Anticholinergics, magnesium, or sodium (to raise blood pressure) supplements
• Anticonvulsants Has eliminated all symptoms in some RS sufferers Lorazepam, Oxcarbazepine Increase GI motility, reduce vagus "noise" (sodium channel blocking believed to contribute to positive effects)
• Alpha blockers may increase gi motility if that is an issue, also 5 mg to 10 mg amitriptyline if motility is an issue that can't be solved by other methods
• antigas - simethicone, beano, omnimax reduces epigastric pressure
• Antacids - nexium, tums, Pepcid AC, rolaids, etc. reduces acid reflux in the case of hiatal hernia or other esophageal type RS.
• Vagusectomy
• Beta blockers - reduces contractility and automaticity of the heart which reduces irregular rhythms but also lowers blood pressure when symptoms occur, and further reduces perfusion ex: [Atenolol], this will control disarrhythmia, but can precipitate Prinzmetal Angina and [Heart Block] substantially.

See also

Swallowing syncope

References

1. Pancreatic Necrosis associated with auricular fibrillation and flutter : report of a case simulating coronary thrombosis (autopsy findings). Edgar Leon Dittler, M.D. and Thomas H. McGavack, M.D. New York, N.Y. viewable from elsivier science direct