Roemheld syndrome
Encyclopedia
Roemheld syndrome 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.
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 hearts ability to fill and increases the contractility of the heart to maintain homeostasis.
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 irradiation 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.
Oftentimes 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.
vagusectomy
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 pressurePressure
Pressure is the force per unit area applied in a direction perpendicular to the surface of an object. Gauge pressure is the pressure relative to the local atmospheric or ambient pressure.- Definition :...
in the epigastric and left hypochondriac
Hypochondrium
The hypochondrium is the upper part of the abdomen dorsal to the lowest ribs of the thorax. The word derives from the Greek term ὑποχονδρος hupochondros, meaning abdomen, or literally under cartilage.The liver is found in the right hypochondrium....
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
Thoracic diaphragm
In the anatomy of mammals, the thoracic diaphragm, or simply the diaphragm , is a sheet of internal skeletal muscle that extends across the bottom of the rib cage. The diaphragm separates the thoracic cavity from the abdominal cavity and performs an important function in respiration...
, and secondary displacement of the heart. This reduces the hearts 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 irradiation 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
Atherosclerosis
Atherosclerosis is a condition in which an artery wall thickens as a result of the accumulation of fatty materials such as cholesterol...
.
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 bradycardiaSinus bradycardiaSinus bradycardia is a heart rhythm that originates from the sinus node and has a rate of under 60 beats per minute.-Signs and symptoms:The decreased heart rate can cause a decreased cardiac output resulting in symptoms such as lightheadedness, dizziness, hypotension, vertigo, and syncope...
- Difficulty inhaling
- Angina pectoris
- Left ventricular discomfort
- Fatigue
- AnxietyAnxietyAnxiety is a psychological and physiological state characterized by somatic, emotional, cognitive, and behavioral components. The root meaning of the word anxiety is 'to vex or trouble'; in either presence or absence of psychological stress, anxiety can create feelings of fear, worry, uneasiness,...
- Uncomfortable breathing
- Poor perfusionPerfusionIn physiology, perfusion is the process of nutritive delivery of arterial blood to a capillary bed in the biological tissue. The word is derived from the French verb "perfuser" meaning to "pour over or through."...
- Muscle pain (crampiness)
- Burst or sustained vertigoVertigoVertigo is a form of dizziness.Vertigo may also refer to:* Vertigo , a 1958 film by Alfred Hitchcock**Vertigo , its soundtrack** Vertigo effect, or Dolly zoom, a special effect in film, named after the movie...
or dizziness - Sleep disturbanceSleep disorderA sleep disorder, or somnipathy, is a medical disorder of the sleep patterns of a person or animal. Some sleep disorders are serious enough to interfere with normal physical, mental and emotional functioning...
(particularly when sleeping within a few hours of eating, or laying on the left side) - ExtrasystolesPremature ventricular contractionA premature ventricular contraction , also known as a premature ventricular complex, ventricular premature contraction , ventricular premature beat , or extrasystole, is a relatively common event where the heartbeat is initiated by the heart ventricles rather than by the sinoatrial node, the...
- 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 colonTransverse colonThe transverse colon, the longest and most movable part of the colon, passes with a downward convexity from the right hypochondrium region across the abdomen, opposite the confines of the epigastric and umbilical zones, into the left hypochondrium region, where it curves sharply on itself beneath...
caused by:- Lactose intoleranceLactose intoleranceLactose intolerance, also called lactase deficiency or hypolactasia, is the inability to digest and metabolize lactose, a sugar found in milk...
- Lactose intolerance
- abnormal gall bladder function and/or blood flow
- Gall stones
- Sphincter of Oddi dysfunctionSphincter of Oddi dysfunctionSphincter of Oddi dysfunction refers to two motility conditions affecting the Sphincter of Oddi; papillary stenosis and sphincter of Oddi dyskinesia...
- 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 obstructionBowel obstructionBowel obstruction is a mechanical or functional obstruction of the intestines, preventing the normal transit of the products of digestion. It can occur at any level distal to the duodenum of the small intestine and is a medical emergency...
(Less common, this usually leads to intense pain in short time) - Acute pancreatic necrosis
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 a 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.Oftentimes 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 gastro interlogical distress is the first concern, mitigation of gastric symptoms will also alleviate cardiac distress.- Anticholinergics, magnesiumMagnesiumMagnesium is a chemical element with the symbol Mg, atomic number 12, and common oxidation number +2. It is an alkaline earth metal and the eighth most abundant element in the Earth's crust and ninth in the known universe as a whole...
, or sodiumSodiumSodium is a chemical element with the symbol Na and atomic number 11. It is a soft, silvery-white, highly reactive metal and is a member of the alkali metals; its only stable isotope is 23Na. It is an abundant element that exists in numerous minerals, most commonly as sodium chloride...
(to raise blood pressure) supplements - Anticonvulsants Has eliminated all symptoms in some RS sufferers LorazepamLorazepamLorazepam is a high-potency short-to-intermediate-acting 3-hydroxy benzodiazepine drug that has all five intrinsic benzodiazepine effects: anxiolytic, amnesic, sedative/hypnotic, anticonvulsant, antiemetic and muscle relaxant...
, Oxcarbazapine 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 amitriptylineAmitriptylineAmitriptyline is a tricyclic antidepressant . It is the most widely used TCA and has at least equal efficacy against depression as the newer class of SSRIs...
if motility is an issue that can't be solved by other methods - antigas - simethiconeSimethiconeSimethicone is an oral anti-foaming agent used to reduce bloating, discomfort and pain caused by excess gas in the stomach or intestinal tract. It is a mixture of polydimethylsiloxane and silica gel.-Chemical action and pharmaceutical effects:...
, beanoBeanoBeano can refer to:* The Beano, a British children's comic* Blues Breakers with Eric Clapton, a 1966 John Mayall & the Bluesbreakers album nicknamed The Beano Album as the cover shows Clapton reading a Beano comic...
, omnimaxOmnimaxOmnimax may refer to:* A variation of the IMAX film format that is projected on an angled dome* A shorthand expression for a deity that is omnipotent, omniscient, omnipresent, and/or omnibenevolent...
reduces epigastric pressure - Antacids - nexium, tumsTumsTUMS is an antacid made of sucrose and calcium carbonate manufactured by GlaxoSmithKline in St.Louis, Missouri, USA. It is a non-prescription drug and available at many retail stores, including drug stores, grocery stores and mass merchandisers. It provides relief from acid indigestion, heartburn,...
, Pepcid AC, rolaidsRolaidsRolaids is a brand of antacid produced by McNeil Consumer Healthcare, a subsidiary of Johnson & Johnson. The brand was acquired from Pfizer Consumer Healthcare as part of a merger in 2006. It was invented by American chemist Irvine W. Grote in the late 1920s...
, 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 perfusionPerfusionIn physiology, perfusion is the process of nutritive delivery of arterial blood to a capillary bed in the biological tissue. The word is derived from the French verb "perfuser" meaning to "pour over or through."...
ex: [Atenolol], this will control disarrhythmia, but can precipitate Prinzmetal Angina and [Heart Block] substantially. - CabbageCabbageCabbage is a popular cultivar of the species Brassica oleracea Linne of the Family Brassicaceae and is a leafy green vegetable...
- WebMD indicates cabbage has been used to treat Roemheld syndrome