1/13. Tachyarrhythmias triggered by swallowing and belching. Three cases with supraventricular tachyarrhythmias related to oesophageal transit are reported. A 61 year old man had episodes of atrial tachycardia on each swallow of food but not liquid; this has been reported only rarely. A 55 year old man had atrial fibrillation initiated by drinking ice cold beverages; this has not been described previously although atrial tachycardia triggered by drinking ice cold beverages has been described once. A 68 year old man had supraventricular tachycardia initiated by belching; this has not been described previously. These cases illustrate the diversity of atrial tachyarrhythmias that can be precipitated by oesophageal stimulation and suggest that what is regarded as a very rare phenomenon may be found more commonly when sought. ( info) |
2/13. A case of inability to belch. A 22-year-old man was unable to belch. He could sense intraesophageal gas, but had no chest pain. An upper gastrointestinal X-ray series and endoscopic examination showed no abnormalities. Esophageal manometry showed normal relaxation of both the upper and lower esophageal sphincters with primary peristalsis during deglutition. However, bolus injection of air into the middle esophagus failed to initiate the belch reflex. ( info) |
3/13. High-frequency diaphragmatic flutter: symptoms and treatment by carbamazepine. Classic diaphragmatic flutter, a rare disorder associated with dyspnoea, thoracic or abdominal wall pain, and epigastric pulsations, is caused by involuntary contractions of the diaphragm with a frequency of 0.5-8.0 Hz. We have seen three patients with diaphragmatic flutter of higher frequency not associated with respiratory disease. The patients presented with longstanding oesophageal belching, hiccups, and retching, respectively. The diagnosis was established by the presence on electromyography of the diaphragm and scalene and parasternal intercostal muscles of repetitive discharges of 9-15 Hz. Spirographic tracings, especially those of volume or flow vs time, showed similar high-frequency oscillations superimposed on tidal respiratory movements. Treatment with carbamazepine 200-400 mg three times daily led to disappearance or great improvement of flutter and clinical symptoms in all three patients. The phenomenon was not seen in other patients with chronic hiccups or oesophageal belching or in patients without these symptoms who had undergone electromyography or spirography for other reasons. Thus, high-frequency diaphragmatic flutter seems to be a new disease entity. The response to carbamazepine, which suggests that the flutter causes the symptoms, requires further study. ( info) |
4/13. Hiccups, eructation, and other uncommon prodromal manifestations of herpes zoster. Although the most frequent presentation of herpes zoster involves sensory neurons, motor and autonomic symptomatology is also known to occur in this disease. An unusual symptom of hiccups is described here. Other infrequent manifestations of this common illness, including the Ramsay Hunt syndrome, herpes zoster ophthalmicus, urinary and fecal retention, sexual dysfunction, and zoster sine herpete, are reviewed. Greater awareness of unusual presentations of herpes zoster is necessary for proper diagnosis and timely management of complications that may otherwise lead to disability and serious long-term sequelae. ( info) |
| We report on an uncommon manifestation of molecularly proven neuroacanthocytosis in a 32-year-old man in whom dyspnea with desaturation while awake accompanied by continuous involuntary belching were the major consequences of the disease. ( info) |
6/13. Situational syncope induced by belching. We describe a case of situational syncope induced by belching. The patient showed severe syncope with a high-degree atrioventricular block just after belching, but has not experienced syncope or dizziness over a 3-month follow-up after permanent pacemaker implantation. ( info) |
7/13. Symptomatic differentiation of duodenal from gastric fistulas in Crohn's disease. Fistulization to the duodenum or stomach from a diseased segment of bowel in Crohn's disease is rare, with only 63 cases reported. We report an additional two cases of Crohn's disease with recurrent fistulization to the duodenum. Although one or both patients complained of pain, diarrhea, and/or weight loss at presentation, neither of them experienced vomiting or feculent eructation. A review of 46 of the 63 reported cases of gastric and duodenal fistulization indicated that patients with gastric fistulas commonly present with vomiting (39%), and with histories of feculent eructations or frank feculent vomiting (44%), but that patients with duodenal fistulas rarely present with vomiting (3.6%), and never have feculent vomiting or eructations. This difference is an important clue to the diagnosis and localization of upper gastrointestinal fistulas in Crohn's disease. ( info) |
8/13. Acute airway obstruction in achalasia. Possible role of defective belch reflex. Achalasia presenting as an acute airway obstruction is a rarely reported phenomenon. The pathophysiology of this dramatic complication of achalasia remains an enigma. Our patient with achalasia presented with an acute airway compromise necessitating emergent endotracheal intubation. We review the available literature on this interesting yet rare complication of achalasia. We also add some information to help elucidate the possible pathophysiologic mechanism of this emergency, proposing that specific upper esophageal sphincter manometry may indicate abnormality of the "belch reflex." ( info) |
9/13. Off-period belching due to a reversible disturbance of oesophageal motility in Parkinson's disease and its treatment with apomorphine. Two L-dopa-treated patients with Parkinson's disease who developed distressing belching during "off" periods are reported. In each case, contrast cine radiography revealed disturbed oesophageal motility which disappeared after injection of the dopamine receptor agonist apomorphine. It is suggested that central dopaminergic abnormalities may be important in the aetiology of "off period belching." ( info) |
10/13. Dysfunction of the belch reflex. A cause of incapacitating chest pain. We report a 25-yr-old woman who suffered incapacitating chest pain caused by upper esophageal sphincter (UES) dysfunction. She presented with a long history of severe episodic chest pain associated with gurgling noises in her chest and was unable to belch despite feeling a need to do so during pain episodes. Fluoroscopic and manometric studies confirmed that the patient's chest pain and gurgling noise were associated with dysfunction of the belch reflex. Although reflux of gas from the stomach into the esophageal body occurred normally, the extreme esophageal distention resulting from the gas reflux failed to trigger UES relaxation. Consequently, there was no venting of gas across the UES. The gurgling noise was caused by the gastroesophageal reflux of gas and the pain was associated with profound esophageal distention. A manometric study of the UES revealed absent or incomplete UES relaxation in response to abrupt esophageal distention by gastroesophageal gas reflux, so that the nadir of UES pressure always exceeded esophageal body pressure. The distended esophagus was repeatedly cleared by secondary peristalsis. To our knowledge this is the first description of chest pain caused by dysfunction of the belch reflex. We speculate that the mechanism described in this patient may account for a subgroup of patients with "chest pain of esophageal origin." ( info) |