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I have completed bits of my EM training from India. Currently I am boarded with credentials from Christian Medical College, Vellore and also from the prestigious Royal College of Emergency Medicine, UK.  I am currently working in London as an A&E doctor, trying to appreciate the differences in the practise and culture of Emergency Medicine across different healthcare systems. I have always been an avid FOAMed supporter because FOAMed played an indispensable role during the days of my initial training. Through this blog, I aspire to disseminate knowledge and stay up to date with the EM literature. 

Monday, May 14, 2018

The Gastrocardiac Syndrome

Roemheld syndrome (RS) or gastric-cardiac syndrome, is a complex of gastrocardiac symptoms where issues with gut are found to be associated with cardiac symptoms like arrhythmias and benign palpitations. Despite a full workup, when the cause of symptoms is not found then this condition is one of the possible diagnosis. These are the patients who are often labeled as  "Non-Cardiac Chest Pain' or "MSK related CP" in the Emergency Department. 

Possible reasons for Gastrocardiac Syndrome
  • Anatomical close proximity between the stomach and the heart (GERD, Hiatus Hernia)
  • Same nerve supply - Vagus Nerve (Compressed by distended stomach leaading to bradycardia and occasionally arrythmias)
  • PPIs (Often used for GERD/Peptic ulcer) leading to HypoMg leading to ectopic beats

Due to pressure in the epigastric and left hypochondrium, the diaphragm is elevated and displaces the heart. This reduces the heart's ability to fill and increases the contractility of the heart causing palpitations/dizziness/anxiety. Typically, there are no changes/abnormalities related in the EKG detected. 


Symptoms can be variable and include a whole list of GI and Cardiovascular symptoms:  They are usually seen after eating a meal.
  • Sinus Bradycardia
  • Shortness of Breath
  • Chest tightness, Anxiety
  • Muscle crampiness
  • Dizziness
  • Palpitations
  • Belching, nausea

Conditions that come under the spectrum of RS:
  • GERD
  • Hiatus Hernia
  • Lactose intolerance
  • Gall Bladder disease
  • Intestinal Disorders 
RS in an ED diagnosis and our workup must include ECGs and troponins. Extensive GI and Cardiac workup are needed before calling this condition. Therefore, the diagnosis is made based on symptoms in the absence of heart abnormalities. 

Management
Ruling out another diagnosis such as peptic ulcer, bowel cancer, GB disease, ACS is the priority. Treatment is based on symptoms relief. Medications that have found to help include Anticholinergics, Antacids, Beta-Blockers, Anti-convulsants and simethicone. 

Take Home:
Gastrocardiac Syndrome is not an ED diagnosis. Always think of ACS first but beware of close proximity between stomach and heart.

References:

  1. Gastrocardiac syndrome: A forgotten entity; Saeed, Mohammad et al. The American Journal of Emergency Medicine , Volume 0 , Issue 0
  2. Jervell, O. and Lødøen, O. (1952), THE GASTROCARDIAC SYNDROME. Acta Medica Scandinavica, 142: 595-599. doi:10.1111/j.0954-6820.1952.tb13409.x
  3. The effect of the lateral decubitus position on vagal tone. Chen GY, Kuo CD. Anesthesia 1997 Jul;52(7):653-7. Department of Medicine, Provincial Tao-Yuan General Hospital, Republic of China.


Posted by:

              
     Lakshay Chanana
     
     Speciality Doctor
     Northwick Park Hospital
     Department of Emergency Medicine
     England

     @EMDidactic

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