GI Endoscopy · 2 min read
Post-Prandial Thoracic Pain and Pre-Syncopal Symptoms: Watch Out for Roemheld Syndrome
Postprandial chest pain and autonomic symptoms after a negative cardiac workup, with a large hiatal hernia, reflux esophagitis, and ineffective esophageal motility.
Experienced teaching points
Clinical Pearls
- Roemheld syndrome (gastro-cardiac syndrome) is postprandial thoracic pain and autonomic symptoms driven by GI factors, after cardiac disease is excluded.
- A large hiatal hernia with pathologic GERD can trap gas and press the diaphragm, producing palpitations, chest pain, and presyncope after meals.
- Watch for the meal-linked sequence: bloating and distension, then thoracic pain, then dizziness or presyncope.
- Treat the GI drivers: smaller meals, fewer gas-producing foods, stay upright after eating, and control reflux with a PPI or P-CAB.
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| Patient: | 26-year-old woman with CVID, asthma, chronic lung disease, and dorsal spondyloarthrosis |
| Indication: | Heartburn, chest pain, and palpitations with postprandial bloating after a negative cardiac workup |
| Final diagnosis: | Roemheld syndrome (gastro-cardiac syndrome) after exclusion of cardiac disease |
Endoscopic Findings
- Upper endoscopy showed a large hiatal hernia.
- The distal esophagus showed reflux esophagitis.
- High-resolution esophageal manometry demonstrated ineffective esophageal motility.
- A 24-hour pH study confirmed pathologic reflux, with a positive DeMeester score, 7.3% acid exposure, and 99.3% symptom association.
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 postprandial thoracic pain and autonomic dysfunction driven by gastrointestinal factors. 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 within the GI tract. A hiatal hernia lets stomach 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. Electrocardiogram and echocardiography were negative before the GI evaluation was treated as the driver. 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, which kept the gastro-cardiac pattern in view.
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. A multidisciplinary path is needed when the same patient presents with both gastrointestinal and cardiac-like symptoms.
References
- Roemheld L. Die Gaskardie, ein Herzleiden mit Magen-Darm-Symptomen. Dtsch Arch Klin Med. 1916;120:130-149.
- Pimentel M, et al. A new clinical consensus statement for the diagnosis and treatment of small intestinal bacterial overgrowth. Am J Gastroenterol. 2020;115(8):1257-1270.
- Kahrilas PJ, et al. The Chicago Classification of esophageal motility disorders, v4.0. Neurogastroenterol Motil. 2021;33(1):e14058.
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