|LETTER TO THE EDITOR
|Year : 2022 | Volume
| Issue : 3 | Page : 196-197
Successful management of Roemheld syndrome: A diagnosis of exclusion
Sarin P John, Vijay Adabala, Mridul Dhar
Department of Anesthesiology, All India Institute of Medical Sciences (AIIMS), Rishikesh, Uttarakhand, India
|Date of Submission||30-Apr-2022|
|Date of Decision||08-Jun-2022|
|Date of Acceptance||23-Jun-2022|
|Date of Web Publication||27-Jul-2022|
Department of Anesthesiology, 6th Floor, Academic Block, All India Institute of Medical Sciences (AIIMS), Rishikesh 249203, Uttrakhand
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
John SP, Adabala V, Dhar M. Successful management of Roemheld syndrome: A diagnosis of exclusion. Bali J Anaesthesiol 2022;6:196-7
A 65-year-old male patient laborer by profession with no comorbidities presented to the emergency room (ER) with chief complaints of pain in the abdomen for 4 days and shortness of breath for 1 day. His vitals showed a heart rate of 160/min with a blood pressure of 116/76 mm Hg and SpO2 of 97% on room air. Electrocardiogram was recorded immediately, which showed fibrillary waves. Screening echo was performed, which revealed normal right and left atrial chambers, normal right and left ventricular sizes, no valvular/wall defects, no cardiomegaly, and have average ejection fraction of 60%–65%. Chest X-ray was performed, which showed air under the diaphragm pointing toward likelihood diagnosis of hollow viscus perforation for which exploratory laparotomy was planned. Arterial blood gas (ABG) and serum electrolytes were within normal limits.
On arrival to the operation theater, vitals showed a heart rate of 180/min with blood pressure of 108/72 mm Hg and SpO2 of 97% on room air. Electrocardiography (ECG) showed fibrillary waves with no p waves. In view of emergency, the patient was induced with injection fentanyl, injection etomidate and succinylcholine, and intubated with an 8 mm cuffed endotracheal tube using rapid sequence induction. Antiarrhythmic drugs and a biphasic defibrillator for cardioversion were kept on standby. The surgeon proceeded with decompression of the stomach after which 1 L of bilious fluid was drained. Immediately after decompression of the stomach heart rate dropped to 76 bpm. ECG reverted to sinus rhythm with no fibrillary waves. Vitals were maintained after decompression of stomach till end of surgery without any episodes of atrial fibrillation (AF). Patient was extubated and shifted to the ward. Postoperative period was uneventful.
Gastrocardiac syndrome is a clinical syndrome, which describes the clusters of cardiovascular symptoms such as shortness of breath, chest pain, palpitations, and arrhythmias stimulated by changes associated with the gastrointestinal system. Although the exact mechanism was not known, it can be secondary to mechanical, hormonal, chemo toxic and structural defects (e.g., hiatus hernia) in gastrointestinal tract. Esophageal cardiac stimulation can be due to hypersensitivity to gastric distension and esophageal acid stimulation. When the stomach is full, it can add pressure to the diaphragm and consequently move the heart position, triggering the palpitations seen in gastro cardiac syndrome. Bloated stomach may stimulate heart muscles that also activate the vagus nerve, which slows down heart rate leading to arrhythmia. Hiatus hernia may also initiate gastro cardiac syndrome by stimulating the left atrium. The decompression of the stomach relieves cardiac stimulation and symptoms.
Both gastroesophageal reflux disease (GERD) and cardiac arrhythmia have common risk factors such as obesity, binge eating, and sleep apnea. A meta-analysis study showed that GERD was independently a trigger for AF. Inflammation followed by GERD in the lower esophagus leading to esophagitis was thought to be the reason for AF. In these patients, it is shown that acid suppression resulted in the improvement of GERD and cardiac symptoms.
These data showed that there is an interrelationship between cardiac and gastrointestinal systems. Probability of having undiagnosed gastrointestinal factors in patients with arrhythmic disorders should not be neglected. It might alter the management approach of dysrhythmic patients. In our case, we have excluded the causes of arrhythmia such as structural and chemical disorders and came to a conclusion that the above case could be gastro cardiac syndrome.
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