The Way to a Man’s Heart Is Through His Stomach

Abstract

A 64-year-old man with hypertension was eating fast food while driving home when he suddenly experienced nausea and tunnel vision. He lost consciousness and awoke to find his truck in a cornfield. He called his family who brought him to the ED. Computed tomography scan of the chest and abdomen demonstrated an intrathoracic stomach due to a large hiatal hernia (Fig. 1). Surgical repair was scheduled, and he was started on a liquid diet. Immediately after ingesting ∼20 cc of broth, he developed bradycardia, followed by sinus arrest with junctional escape beats (Fig. 2), at which time he lost consciousness. His rhythm spontaneously reverted back to sinus, and he regained consciousness. He was kept NPO until repair of his hernia with resolution of his symptoms. Figure 1. CT chest and abdomen demonstrating an intrathoracic stomach. Figure 2. ECG demonstrating sinus bradycardia, followed by sinus arrest with junctional escape beats. Deglutition syncope is a neurally mediated reflex syndrome. The common innervation of the esophagus, stomach, and heart by the vagus nerve is important in the pathogenesis, whereby deglutition causes inhibition of the cardiac conduction system.1 Several disorders of the esophagus are associated with deglutition syncope, caused by a number of bradyarrhythmias.2 The intrathoracic stomach caused intense vagal stimulation in our patient when he ate, leading to sinus node slowing, followed by arrest, resulting in transient syncopal episodes.