1772 Novel Use of Low Dose Amitriptyline in the Prevention of Deglutition Syncope: A Case Report

Abstract

INTRODUCTION: Deglutition syncope is a rare entity with approximately 100 reported cases. It is a subtype of neurocardiogenic syncope triggered by deglutition secondary to organic and functional esophageal pathology. There are limited treatment options, and here we report a case of using low-dose amitriptyline (10 mg) for deglutition syncope. CASE DESCRIPTION/METHODS: A 58 year old male with hypertension, diabetes mellitus, and peripheral neuropathy presented to gastroenterology clinic with a diagnosis of deglutition syncope. Over the preceding year, he experienced four syncopal episodes while eating, described as lightheadedness before losing consciousness for a minute. Electroencephalogram, electrocardiogram, and echocardiography were unremarkable. Tile-table test showed reflex vasovagal syncope with systolic vasodepression (63 mm Hg) without cardioinhibition. Continuous telemetry showed sinus bradycardia (50 bpm) followed by three sinus pauses up to 4 seconds and return to normal sinus rhythm during episodes of dysphagia and lightheadedness. Evaluation for dysphagia with esophagogastroduodenoscopy (EGD) was unremarkable. Esophagram showed tertiary contractions in the mid-distal esophagus. Esophageal manometry was unremarkable for dry swallows with premature contractions possibly suggestive of distal esophageal spasm (Figure 1). Patient refused repeat EGD. A diagnosis of deglutition syncope with combined cardioinhibition and vasodepression secondary to esophageal spasm was made. Pacemaker implantation was recommended for syncopal symptoms from cardioinhibition; however, the patient declined due to potential persistence of symptoms from vasodepression. Initial recommendations of dietary changes and avoidance of triggering medications were made. Calcium channel blockers and nitrates were limited by bradycardia and hypotension. Hyoscyamine provided partial relief, but pre-syncopal symptoms persisted. Low-dose amitriptyline was initiated for the potential underling etiology of esophageal spasm. After a year, the patient reported resolution syncopal symptoms and dysphagia. DISCUSSION: Deglutition syncope due to cardioinhibition and vasodepression secondary to underlying esophageal spasm was diagnosed with tilt-table testing, continuous telemetry, and esophageal manometry. Amitriptyline was chosen for its anticholinergic effects and esophageal neuromodulator properties. Low-dose amitriptyline may be considered as a preventative treatment for resistant deglutition syncope.