Gastrocardiac syndrome: A forgotten entity
a b s t r a c t
Symptomatic bradycardia due to gastric distension is a rarely reported entity in the field of medicine. The mech- anism of gastrointestinal distention that contributes to bradycardia is complex. A 75-year-old female with recur- rent episodes of dizziness in the setting of gastric distension was found to have severe Sinus bradycardia which resolved upon resolution of gastric distension. No structural or functional abnormality of heart was found. The patient was treated with permanent pacemaker implantation due to Recurrent episodes of dizziness in the setting of sinus bradycardia.
The gastrocardiac symptom complex was recognized as a nosographic entity in the early 20th century after observing the frequent occurrence of cardiac symptoms in patients with Digestive disorders . Since then, multiple studies reported the association of cardiac arrhythmias with gastrointestinal disorders. Most of these stud- ies looked at the correlation of atrial fibrillation with gastroesophageal reflux disease (GERD)  but there is no literature on association of severe bradycardia with gastric symptoms.
- case presentation“>Case presentation
A 75-year-old-woman presented with recurrent episodes of diz- ziness for the past couple of weeks. She denied any episode of loss of consciousness, fall, chest pain, palpitations, nausea, vomiting or blurriness of vision. Initial electrocardiogram showed sinus brady- cardia with a heart rate of 35/min (Fig. 1). Her past medical history was significant for hypertension, COPD, dementia, and chronic con- stipation. She was taking aspirin, Lisinopril, fluticasone-salmeterol, albuterol, and tiotropium at home. Pertinent findings on physical examination were bradycardia and mildly distended tympanic abdo- men, with normal bowel sounds. Laboratory workup revealed nor- mal electrolytes and cardiac enzymes. Echocardiogram showed normal ejection fraction without any valve abnormality. On further evaluation, there was no evidence of ischemia, medications or toxins
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that can contribute to bradycardia. The initial chest X-ray showed air filled left upper quadrant large bowel loops. Abdominal X-ray confirmed the findings (Fig. 2). Abdomen CT revealed small bowel and gastric distention along with a hiatal hernia and left hemi-diaphragm elevation (Fig. 3). Gastric distension improved after placement of nasogastric tube (NG) and symptomatic bradycar- dia also resolved. No mechanical obstruction was found on further evaluation of gastrointestinal tract and gastric distension was assumed to be from aerophagia. All the follow-up electrocardio- grams and Telemetry monitoring showed normal sinus rhythm (Fig. 4). After resolution of gastric distention, NG tube was removed. She was again found to have symptomatic bradycardia in the next couple of days. Repeated abdominal x-rays revealed the same gastric and colonic distension. The patient was diagnosed with gastrocardiac syndrome presenting as severe sinus bradycardia which got reversed by gastric decompression. Along with behavioral modification for aerophagia, Surgical repair of a hiatal hernia was offered which she declined. As an alternative, she received perma- nent pacemaker implantation resulting in complete resolution of symptoms.
The occurrence of cardiac symptoms associated with digestive disorders was initially described by Roemheld in 1912, 1922 . He pointed out that mechanical elevation of left diaphragm secondary to accumulation of gas in the stomach or large intestine is the main etiology for cardiac symptoms although there was suspicion of reflex mechanism at role, such as chemotoxic and hormonal factors. Similar
Fig. 1. Initial EKG showing severe sinus bradycardia (Heart rate 35/min).
findings were observed by Lurje and Stern in 1931 who suggested the term phrenicocardiac symptom complex . Salvesan in 1939 proposed the term gastrocardiac syndrome for the same clinical entity . As per Maddock et al. , the accumulation of air in the stomach and large intestine is likely secondary to aerophagia mainly seen in a patient with Lower esophageal sphincter dysfunction . A
nervous predisposition also plays a role in developing gastrocardiac syndrome as some individuals swallow more air compared to others .
Patients can present with variable cardiac symptoms, the com- mon ones being palpitation, extrasystole, paroxysmal tachycardia or angina . Dalsgaard-Nielsen (1945) stated that the symptoms might depend on whether the person is predominantly vagotonic or symphathicotonic . Reomheld also indicated that the cardiac symptoms in patient with hyperacidity were mainly of vagotonic na- ture as compared to patients with an acidity who exhibited mainly sympathicotonic features .
Multiple recent studies showed that GERD may play a role in initia- tion and perpetuation of Atrial fibrillation but evidence for true causal relationship is still lacking. Treatment with proton pump inhibi- tors may improve symptoms related to AF and facilitate conversion to normal sinus rhythm. The proposed mechanisms mainly include Autonomic dysfunction, inflammation and mechanical compression in case of hiatal hernia. 
Our patient, who had baseline dementia and hiatal hernia was predisposed to aerophagia and accumulation of gas in the stomach and large intestine. She presented with symptomatic severe sinus bradycardia which got reversed with gastric decompression. To our knowledge, this is the first reported case of gastrocardiac syndrome presenting as severe bradycardia. The definitive therapy would be elim- inating the underlying cause of aerophagia such as hiatal hernia repair in this case.
Severe symptomatic sinus bradycardia is Class I indication for per- manent pacemaker implantation but Reversible causes of bradycardia should be evaluated thoroughly. This is the first reported case of revers- ible symptomatic bradycardia due to gastrocardiac syndrome. In these patients, behavioral modification with surgical intervention should be offered wherever possible to correct the underlying cause of abdominal distension related to aerophagia. If the underlying cause cannot be corrected permanent pacemaker implantation can be considered for symptomatic bradycardia.
Fig. 3. CT abdomen A. Axial film showing colonic and gastric distention along with a hiatal hernia and B. Coronal film showing the elevation of left hemi-diaphragm secondary to air accumulation.
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