WHAT IS ROEMHELD SYNDROME?
Medically Reviewed and Updated by Dr. Sony Sherpa (MBBS) - July 22, 2024
Between the decades of 1910 and 1920, Dr. Ludwig Roemheld studied the phenomenon in which patients suffering from digestive problems and no detectable heart issues would experience cardiac symptoms. By the 40's, his research received more attention and the medical community would eventually accept the existence of a gastro-cardiac symptom complex, also known as the Roemheld Syndrome (RS). Gastrocardiac syndrome, another term for Roemheld Syndrome, underscores the connection between gastrointestinal disturbances and cardiac symptoms. The most common model known for Roemheld Syndrome involves some gastrointestinal problem or disease that leads to arrhythmia or other types of abnormal heart rate issues. Although the precise interactions involved in Roemheld Syndrome are not well-described, anatomical proximity, the vagus nerve (VN) and electrolyte deficiencies are still considered as equally valid candidates for the key element in Roemheld Syndrome, with VN being a well-supported option.
Roemheld Syndrome is not a disease, is just a particular combination of symptoms appearing together being caused by one or more pathologies. Although in the first publications discussing this phenomenon several authors (including Roemheld himself) mention how “frequent“ was to see patients with gastrointestinal diseases presenting RS, very little information about this syndrome’s epidemiology is available today. In fact, observing Roemheld Syndrome, personally seems to be so rare that a big portion of all modern publications on this topic tend to be case studies about individual patients. Overall, even patients with the exact conditions to be diagnosed with Roemheld Syndrome, usually aren’t, the connection between the guts and heart symptoms is made, but the syndrome is rarely mentioned.
In this article we’ll examine the available information for Roemheld Syndrome and provide hard facts about its causes, specific symptoms, people at risk, diagnosis, treatment and prevention.
Causes
Since the 1920’s, is well-known that the primary cause of Roemheld Syndrome, is the accumulation of gas in the gastrointestinal (GI) tract. Initially, physicians assumed that those who experienced RS were producing more gas than usual though fermentation (part of the normal processes of digestion), however, as time went on, it became clear that for a great majority of cases, the problem wasn’t the gas produced, but the gas ingested.
A phenomenon called aerophagia (the excessive swallowing of air) seemed to be more pronounced in individuals with Roemheld Syndrome. It’s considered that any condition that promotes aerophagia will also increase the risk for Roemheld Syndrome.
The gas is “the problem” that leads to RS, however, for someone to develop this condition, the vagus nerve is key. If this nerve can be easily overstimulated by the stress in the GI tract then is much more likely for the heart’s rate of pulsations per minute to become affected (normally decreasing to then increase rapidly). Considering this, a pre-existing or easily producible vagotonic condition could also be considered as a cause (or at least a main contributing factor) for Roemheld Syndrome.
What Causes Roemheld Syndrome Symptoms?
When Ludwig von Roemheld first described the syndrome, he observed that the symptoms were not rooted in cardiac issues but rather in the gastrointestinal tract. The primary cause of the symptoms was identified as the excessive accumulation of gas in the stomach and intestines.
Additionally, anatomical conditions, such as a hiatal hernia (where the stomach slides through the diaphragmatic opening towards the esophagus), also contribute to the development of symptoms associated with Roemheld syndrome.
The increased volume in the gastrointestinal tract results in the diaphragm being pushed towards the chest cavity. Under normal conditions, the diaphragm, located below the lungs, acts as a crucial respiratory muscle and serves as a partition between the chest and abdominal cavities.
When displaced into the chest cavity, the available space for the lungs and heart is reduced, leading to compression and a variety of symptoms. The heart's ability to beat regularly is compromised, causing typical cardiac symptoms. Similarly, the lungs cannot expand fully, resulting in breathing difficulties and shortness of breath.
- Heart problems arise because the pressure on the diaphragm constricts the heart within its chest cavity (mediastinum), preventing it from developing its full pumping power.
- Shortness of breath occurs due to the elevated position of the diaphragm, which exerts pressure on the lungs. This makes it difficult for the diaphragm to contract fully, resulting in breathing challenges.
- Hot flashes are a consequence of impaired cardiac function, which triggers the activation of the autonomic nervous system, specifically the sympathetic nervous system responsible for the "fight or flight" response. This activation can lead to the sensation of hot flashes.
- Anxiety is often triggered by the activation of the autonomic nervous system and the sensation of pain in the heart area, leading to acute anxiety episodes.
Pathologies known to promote Roemheld Syndrome, include:
- Lactose intolerance
- Abnormal gallbladder function
- Hiatal hernia
- Enteric disease
- Loss of the ability to burp (Aneructonia)
- Bowel obstruction
- Acute pancreatic necrosis
Symptoms
Roemheld Syndrome, can manifest in several different ways, these are the most common symptoms reported by patients.
- Sinus Bradycardia (slow heart rate)
- Shortness of Breath
- Chest tightness
- Muscle cramping
- Dizziness
- Palpitations
- Belching, nausea
- Arrhythmia (irregular heart beat)
- Tachycardia (rapid heart rate)
- Panic attacks
- Confusion
- Anxiety
- Depression
- Blood pressure fluctuations
- Lightheadedness
- Vasovagal syncope (fainting)
- Tinnitus (ringing in the ears)
- Fatigue
- Heartburn behind the breastbone
- Hot flashes
It is also noted that sleeping on the right side may aggravate symptoms.
People at risk
As we mentioned before, aerophagia is an important element in Roemheld Syndrome, and those with this condition will be at a higher risk of developing the syndrome.
Aerophagia is common in people who have the habits of:
- Eating too quickly
- Talking while they eat
- Drinking through straws
- Smoking
- Breathing through their mouths
- Exercising vigorously
- Drinking carbonated beverages
- Wearing loose-fitting dentures
People with respiratory problems who use medical equipment to alleviate their condition are also at risk. Sleep apnea is a good example, usually this condition requires the patient to use a Continuous Positive Airway Pressure Machine (CPAPM) in the form of a mask. If the air pressure being generated by the machine is not properly calibrated or there’re some congestion problems, a lot of air will be swallowed. In general, any need for long-term assisted breathing will increase the risk of aerophagia and Roemheld Syndrome.
In the 1920’s researchers also noticed that those of “nervous predisposition” were more likely to develop symptoms. By today's standards, this means that those struggling with anxiety are also at risk.
People with an overstimulated vagus nerve like those with vasotonic angina will have the right conditions to manifest the syndrome, however, very little is known about the precise vagotonic conditions that could be related to higher or lower risk. People with symphathicotonic conditions will also be vulnerable.
Pathologies that lead to weakness of the superior esophageal sphincter (like cricopharyngeal fibrosis) can also increase the risk for Roemheld Syndrome, since they allow more air to enter the GI tract. A good example of this is the link that seems to be between gastroesophageal reflux disease (GERD) and atrial fibrillation (AF). Up to 14% of people who suffer from GERD also experience AF.
Diagnosis
Diagnosing Roemheld Syndrome is not easy and due to its nature, many will be misdiagnosed with either a non-existent heart condition or mental issue. Patient’s experiences will vary considerably depending on which doctor they visit first.
Since the most obvious symptoms of Roemheld Syndrome are very similar to those belonging to many different cardiac diseases, most patients will visit a cardiologist first. Most doctors will focus on finding a heart problem that is not really there. With that purpose, they’ll use diagnostic tools like EKG’s, Holter monitors, slope tests, cardiac MRIs, cardiac CTs, cardiac catheterizations, EP studies, Echocardiograms and many blood tests. Sleep studies may even be included. If everything goes well, no heart condition will be found.
Some patients are put under psychological examination to detect any signs of anxiety, depression or a conversion disorder. Mainly because their symptoms will appear to have no physical cause.
Gastroenterologists have the best chance of diagnosing RS in symptomatic patients by performing colonoscopies, endoscopies and ultrasounds. This way, a doctor will be able to detect the presence of a gastrointestinal problem (leading to a distended GI tract).
Linking the cardiac symptoms to the GI issues is more difficult. Roemheld Syndrome, diagnosis at this point is not an exact science and only recently the medical community has started to consider this type of association between the digestive and circulatory systems in the context of treating arrhythmias.
If Roemheld Syndrome is suspected by a doctor, a combination of X-rays and EKGs to detect simultaneous air-filled bowels and arrhythmia has been used for effective diagnosis; However, improvement of cardiac symptoms after treatment of the gastric conditions is the strongest confirmation for Roemheld Syndrome,.
Treatment
Roemheld Syndrome has no definitive cure but it can be managed by treating its symptoms. The following medications are very helpful for this purpose:
- Anticholinergics or magnesium/ sodium supplements to raise blood pressure
- Anticonvulsants like Lorazepam and Oxcarbazepine help regulate motility in the GI tract and the vagus nerve
- Alpha and beta blockers to increase motility and regulate heart rate respectively
- Antigas to reduce gastric pressure. In this category Simethicone is very popular
- Antacids help against acid reflux
Some sources mention Vagusectomy as another type of treatment, but we’ve not found information to support this option.
Diet for Roemheld Syndrome
Managing Roemheld Syndrome involves addressing dietary habits to reduce the symptoms caused by gastrointestinal issues.
Foods to Avoid
- Carbonated Drinks: These can increase gas accumulation in the stomach and intestines, exacerbating symptoms.
- Fried and Fatty Foods: These are harder to digest and can slow down gastric emptying, leading to increased gas production.
- Certain Vegetables: Vegetables such as beans, cabbage, onions, and broccoli are known to cause gas and should be avoided.
- Large Meals: Overeating or consuming large portions can increase the pressure on the diaphragm, leading to more pronounced symptoms.
Foods to Eat
- Smaller, Frequent Meals: Opting for smaller, more frequent meals may help lessen pressure on your digestive system and diaphragm, promoting smoother digestion.
- Easily Digestible Foods: For smoother digestion and less gas, opt for easily digestible foods like rice, bananas, and applesauce.
- Probiotics: Incorporating probiotics into the diet can improve gut health and reduce symptoms associated with Roemheld Syndrome. Fermented foods like yogurt and kefir are powerhouses of probiotics.
Additional Dietary Tips
- Chewing Food Thoroughly: Ensuring that food is well-chewed before swallowing can aid digestion and reduce the amount of air swallowed.
- Avoiding Straws: Drinking directly from a glass instead of using straws can reduce the intake of excess air.
- Hydration: Staying well-hydrated with water can aid digestion and reduce gastrointestinal discomfort.
Prevention
A healthier lifestyle and reducing some of the behaviors that lead to gas accumulation in the intestines will help prevent RS.
- Eat slowly and with your mouth closed
- Don't smoke
- If you need assisted breathing, check with your doctor to determine if your equipment is properly calibrated.
- Follow a reduced FODMAP diet. It will help prevent gas accumulation
- Use magnesium supplements and regular exercise to make your heart stronger
Latest Research on Roemheld Syndrome Treatment
Recent advancements in the understanding and treatment of Roemheld Syndrome focus on several innovative approaches:
- LINX Magnetic Sphincter Augmentation: LINX magnetic sphincter augmentation is a minimally invasive surgery that involves strengthening the lower esophageal sphincter by implanting a ring of magnetic beads. This device helps to enhance sphincter function and prevent reflux. By reducing gastroesophageal reflux, the procedure can alleviate symptoms related to Roemheld Syndrome. LINX augmentation has been shown to significantly improve quality of life and reduce reflux symptoms in GERD patients.
- Fundoplication Surgery: Fundoplication is another surgical intervention aimed at treating GERD, which often coexists with Roemheld Syndrome. This surgery reinforces the sphincter between the esophagus and stomach by wrapping the upper stomach around the esophagus, preventing acid reflux. Fundoplication has been found to be effective in reducing symptoms of acid reflux and improving esophageal function, which can help alleviate the cardiac symptoms associated with Roemheld Syndrome.
- Vagus Nerve Stimulation (VNS): VNS is a treatment that involves stimulating the vagus nerve to manage symptoms. Excessive gas can overstimulate the vagus nerve, which regulates heart rate and digestion, potentially causing cardiac symptoms. VNS treatments aim to normalize nerve function and reduce the impact on the heart, offering promise in alleviating symptoms of Roemheld Syndrome.
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