An unusual cause of syncope.

An 86-year-old lady with a past medical history of hypertension, chronic kidney disease stage 3 and osteoarthritis presented to our institution with a 6-year history of syncopal episodes. These episodes of transient loss of consciousness occurred most frequently while sitting for a meal and were occasionally related to choking. On one occasion she had a secondary partial seizure related to one of these collapse episodes with no residual neuro-logical deficit. Her physical examination was unremarkable. Previous investigation with an electrocardiogram (ECG), a carotid sinus massage, magnetic resonance imaging (MRI) brain, electro-encephalograph and 24-h blood pressure monitoring were normal. She was referred to the gastroenterologists with a history of choking and dysphagia. Careful history taken with her daughters present revealed that these episodes of dysphagia were occasionally related to dizzy episodes and rarely would lead to a collapse. A barium swallow (Figure 1) showed a small hiatus hernia and tertiary contractions in the lower oesopha-gus with mild gastro-oesophageal reflux. An oeso-phagogastroduodenoscopy with biopsies confirmed the hiatus hernia and mild chronic reflux oesopha-gitis. Her ECG showed normal sinus rhythm with a rate of 72 beats/min. A 24-h ECG monitor revealed sinus rhythm with first degree and an episode of second-degree atrioventricular (AV) block. The longest r-r interval was 3.75 s (Figure 2). This pause was related to eating a meal. The patient was given the diagnosis of swallow syncope and she subsequently had a permanent pacemaker inserted. Swallow or deglutination syncope is a rare neur-ally mediated syncope. It is more common in men and the majority of cases exhibit oesophageal abnormalities. 1 The syncope is due to a vasovagal reflex triggered by stimulation of the oesophagus causing bradycardia. 2 The proposed mechanism of Figure 1. Barium swallow demonstrating lower oesopha-geal tertiary contractions.