Post-Prandial Thoracic Pain and Pre-Syncopal Symptoms: Watch Out for Roemheld Syndrome

Clinical History

A 26-year-old woman with common variable immunodeficiency (CVID), asthma, chronic lung disease, and dorsal spondyloarthrosis presented with a one-year history of heartburn, chest pain, and palpitations. She also reported nocturnal regurgitation, marked abdominal distension, abdominal pain, and occasional constipation.

Electrocardiogram and echocardiography were negative; palpitations were not captured on ambulatory monitoring. Upper endoscopy showed a large hiatal hernia. Esophageal manometry demonstrated ineffective esophageal motility. A 24-hour pH study confirmed pathologic reflux, with a positive DeMeester score, 7.3% acid exposure, and a 99.3% symptom association probability (SAP; threshold >95%).

She was treated with a potassium-competitive acid blocker (P-CAB) for three months, with clear clinical improvement. Symptoms recurred when the medication was stopped, and P-CAB was restarted. Despite acid suppression she still had occasional postprandial abdominal pain, weight loss, nausea, diaphoresis, and dizziness. The attacks began with bloating and distension, then thoracic pain, then autonomic features including presyncope and dizziness.

Endoscopic and Physiologic Findings

1. Upper endoscopy showed a large hiatal hernia.
2. The distal esophagus showed reflux esophagitis.
3. High-resolution esophageal manometry demonstrated ineffective esophageal motility.
4. A 24-hour pH study confirmed pathologic reflux, with a positive DeMeester score, 7.3% acid exposure, and a 99.3% symptom association probability.

Endoscopic Technique

Diagnostic EGD was performed to evaluate heartburn, regurgitation, and chest pain. Complementary high-resolution esophageal manometry and 24-hour pH monitoring completed the esophageal workup. No therapeutic endoscopic intervention is described in this case.

Discussion

Roemheld syndrome, also called gastro-cardiac syndrome, is a 1912 eponym for postprandial thoracic pain and autonomic dysfunction driven by gastrointestinal factors. It is not a Rome IV or ICD entity. Common cardiac-like features include palpitations, irregular heartbeat, tachycardia, chest tightness, shortness of breath, dizziness, anxiety, and fatigue. Gastrointestinal features include bloating, regurgitation, heartburn, and belching.

The proposed mechanism is trapped gas that distends the stomach. A hiatal hernia lets gastric contents slide into the thorax and press on the diaphragm, which can trigger the autonomic cascade. In this patient, a large hiatal hernia plus pathologic GERD and ineffective esophageal motility sit in that pathway. Symptoms followed a repeatable sequence: abdominal bloating and distension, then thoracic pain, then presyncope and dizziness.

Diagnosis is one of exclusion. Cardiac testing here was limited to electrocardiogram and echocardiography. P-CAB therapy improved reflux symptoms for three months, with recurrence after discontinuation. After restarting P-CAB she still had occasional postprandial pain, weight loss, nausea, diaphoresis, and dizziness. Gastric emptying was not reported.

Management targets the GI drivers: smaller, more frequent meals, fewer gas-producing foods, remaining upright for several hours after eating, and treating reflux with a PPI or P-CAB. In a patient with CVID and excess gas, a breath test for SIBO is a reasonable add. If symptoms persist, refer for surgical evaluation of the hiatal hernia. A multidisciplinary path is needed when the same patient presents with both gastrointestinal and cardiac-like symptoms.

References

1. Roemheld L. Der gastrokardiale Symptomenkomplex. Z Phys Diät Ther. 1912;16:339-349.
2. Pimentel M, Saad RJ, Long MD, Rao SSC. ACG Clinical Guideline: Small Intestinal Bacterial Overgrowth. Am J Gastroenterol. 2020;115(2):165-178.
3. Yadlapati R, Kahrilas PJ, Fox MR, et al. The Chicago Classification of esophageal motility disorders, v4.0. Neurogastroenterol Motil. 2021;33(1):e14058.