Roemheld syndrome (RS), also known as Roemheld-Techlenburg-Ceconi-Syndrome or gastric-cardia, is a complex of gastrocardiac symptoms first described by Ludwig von 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.
Contents
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.
Common causes
As gas is the usual trigger, eating foods that a person is intolerant to can make symptoms more severe.
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.