Gastr Del Sol Blogspot

[Robinette Ith]

BMJOpen Gastroenterology publishes high-quality medical research from all disciplines and therapeutic areas of gastroenterology and hepatology. The monthly blog distils some key messages and topics from recent gastroenterology research

Coastal Gastroenterology Associates is excited to bring you a variety of articles highlighting common GI diseases and conditions, as well as relief tips while deepening your understanding of important gastroenterology topics.

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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.

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.

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.

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,.

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Piriformis syndrome and herniated discs are painful conditions of the back. Both can cause sciatica. Sciatica is a type of pain that affects your lower back and legs. It occurs due to irritated or compressed sciatic nerve. The sciatic nerve travels down the back to the legs.

Severe cases of brain injury or damage can lead to states of impaired consciousness. Disorders of consciousness (DoC), such as a vegetative or minimally conscious state, are classified based on extensive testing, including behavioral factors, such as purposeful behaviors or merely reflexes. Electrophysiological and neuroimaging data are also utilized in diagnosing DoC. Consciousness disorders have several possible causes. One of the primary causes of disability and fatalities worldwide is traumatic brain injury (TBI). Each year, over 5 million people suffer from severe TBI.

The main aim of treatment is to replace the fluid lost through vomiting and diarrhoea. This will not stop the vomiting and diarrhoea but it will prevent your child from becoming dehydrated.7,11 Fortunately, most cases of gastro can be managed at home and only a small number of children require treatment in hospital.5,7

Most cases of gastro (about 70%) are caused by viruses, the most common being Rotavirus.4,11 Less commonly, it may also be caused by bacteria and parasites, which can occur from undercooked meats, unwashed fruits and salads, and contaminated water.3

Most children with mild dehydration are appropriate for treatment at home. If your child has any features of moderate to severe dehydration, you should seek urgent review by a doctor.

Most children with mild dehydration can be treated with oral fluid. The best fluids to give are Oral Rehydration Solutions (such as HYDRAlyte or Gastrolyte), as these contain the glucose and salts which are lost through vomiting and diarrhoea.4 If you do not have these, plain water or diluted apple juice (1 cup of unsweetened apple juice per 4 cups of water) may be given.5,10,11

Do not give undiluted juice, soft drinks or sports drinks, as they contain too much sugar, which can make diarrhoea and dehydration worse. For similar reasons, do not give salty liquids such as chicken broth.3,4

It is best to give small amounts of fluid frequently (every 15 minutes), as it is better tolerated than giving large volumes at a time. You can use a rehydration chart such as the Night Doctor Oral Rehydration Chart to ensure your child is getting an adequate amount of fluid for their size. Even if your child continues to vomit, still continue to offer sips of fluid, as some will still be retained and provide some hydration.11 If your child is refusing to drink, you can try offering an iceblock (e.g. Gastrolyte / HYDRAlyte Ice Blocks) .4,7

Breastfed infants should continue to be given breast milk, however they will likely need to be fed more frequently, and may also require supplementation with Oral Rehydration Solution or boiled water (subsequently cooled to room temperature before giving).4,11

There is differing opinion about what fluid to give formula fed infants. Some experts will recommend Oral Rehydration Solutions while there is significant vomiting, whereas others recommend continuing formula if your child is tolerating it.

It is no longer recommended to restrict food intake while your child has gastro, although it is normal for them to have a reduced appetite, particularly in the first 24 hours of the illness.4 You can continue to offer their normal foods and allow them to eat once they feel hungry again.3 Restarting a normal diet with balanced nutrients as soon as possible will help your child get better quicker.11

Temporary lactose intolerance may occur after an episode of gastro. It may be suspected if the diarrhoea becomes worse, or is frothy and explosive after consuming lactose-containing food/drinks such as milk or formula.11 It is important you see a doctor before restricting lactose intake in your child.

Medicines to stop vomiting may occasionally be given by doctors to children with persistent vomiting and dehydration, to help them with tolerating oral fluids. A commonly used medication to stop vomiting called Ondansetron is available in wafer form and has shown to be safe in children older than 6 months of age.5,9

Medicines to reduce diarrhoea are often not required. Routine use is not recommended. They do not improve dehydration significantly, and, like all medicines, they have potential side effects that can cause harm to your child.3

There is some evidence that probiotics can decrease the duration of viral gastro, however there is a lack of research about the optimal type of probiotic, dosage and frequency. For this reason, their use is not currently recommended routinely.1

Gastro is usually a short-lived illness and most children recover quickly. Vomiting is often the first symptom to appear and can last for 2-3 days. The diarrhoea may persist longer, up to 10 days in some children.4, 5, 11, 12

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