The Korean Journal of Internal Medicine: 20:68-71, 2005

Cases of Swallow Syncope Induced by the Activation

of Mechanorecepters in the Lower Esophagus
Ki Hoon Kang, M.D., Wook Hyun Cho2, M.D., Myung Chan Kim, M.D.,
Hee Jong Chang, M.D., Jae Il Chung, M.D. and Dong Jun Won, M.D.
Division of Cardiology, Department of Internal Medicine, Seoul Adventist Hospital, Seoul, Korea;
Division of Cardiology, Department of Internal Medicine, Seoul Paik Hospital, Inje University2, Seoul, Korea

Swallowing is a rare cause of neurally mediated syncope. The mechanism of swallow syncope that contributes to
hypotension, bradycardia, or to both is complex. A 59-year-old man had experienced a recurrent loss of
consciousness during swallowing of carbonated beverages or sticky foods. Another 59-year-old man had complained
of intermittent syncope just after eating foods. These two patients had no significant structural or functional
abnormalities in the esophagus or heart. Both cases showed bradycardia when the lower esophagus was stretched
by balloon inflation. The activation of mechanoreceptors in the lower esophagus can be regarded as an initiating factor
of these cardioinhibitions. The patients were treated with permanent pacemaker implantation and instructed to change
eating habits, respectively.
Key Words : Swallow syncope, Mechanoreceptors, Esophagus

INTRODUCTION
Swallow syncope is a dysautonomic syndrome associated
with intense vagal afferent activation due to esophageal
1)
stimulation . It causes the loss of consciousness during or
shortly after swallowing, due to the reduction of blood flow to
the brain through vasodepression and/or arrhythmia. The first
2)
report of swallow syncope dates back to 1793 by Spens ; yet,
to date there have been only about 50 cases of swallow
syncope reported in the literature worldwide. Because of its
rarity, the mechanism of swallow syncope could not be
understood completely. We report two patients who had
swallow syncope without any significant structural or functional
abnormalities in the esophagus or heart. We also describe the
role of the mechanoreceptors in the lower esophagus that
initiate this syncope.

CASE REPORT
Case 1.
A 59-year-old man was admitted to hospital for the
evaluation of syncope. The patient had been in good health
except for when hypertension was detected 20 years earlier,
and he had subsequently been treated for 3 years. Since he
was about 30 years old, he had experienced many episodes of
syncope when drinking a carbonated beverage (eg., a soda
pop) and beer. About 4 years ago, syncope occurred while
drinking cold water when he was taking a bath. Eating sticky
foods such as a sweet potato, or even fast running caused
syncope. The physical examination and routine laboratory
results were normal except for a slightly increased serum
creatinine level (132.6 mol/L). Electrocardiography and chest
X-ray findings were not specific. The left ventricular ejection

Received : April 26, 2004

Accepted : June 12, 2004
Correspondence to : Wook Hyun Cho, M.D., Division of Cardiology, Department of Internal Medicine, Seoul Paik Hospital, Inje University, 85, 2
ga, Jeo dong, Jung gu, Seoul, 100-032, Korea Tel : 82-2-2270-0001, Fax : 82-2-2279-4021, E-mail : whcho@inje.ac.kr

Ki Hoon Kang, et al: Swallow Syncope Associated with Mechanoreceptors in the Esophagus

fraction in the echocardiogram was 55% and concentric left

69

result showed that he had Graves' disease (TSH: 0.003 mU/L,

Figure 2. (A) A basal electrocardiography shows normal sinus

rhythm (75 beats per minutes) in case 1. B. Esophageal balloon
inflation at the lower esophagus initiated marked sinus bradycardia
(33 beats per minutes) that could not be induced at the middle and
upper esophagus.
Figure 1. (A) Holter monitoring immediately following the ingestion
of a cup of beer (Case 1). The patient had a 7.2-second sinus
pause. (B) Electrocardiogram monitoring of the challenge test with a
carbonated beverage (a soda pop). The sinus bradycardia caused
by the first sip of a soda pop turned into a sinus arrest for 5.4
seconds after the second sip.

ventricular hypertrophy was detected. A brain CT was normal.

A carotid massage did not evoke any abnormal rhythms. Holter
monitoring showed a sinus arrest with a maximum 7.2 seconds
pause while drinking beer and a carbonated beverage (Figure
1A, 1B). An esophagogastroscopy, performed to search for an
abnormality in the esophagus and stomach, showed only
superficial gastritis at the fundus. Gastric distension by air could
not induce syncope or an abnormal rhythm. An esophageal
manometry showed no specific esophageal motility disorder
except for transient low pressure in the lower portion of the
esophagus. The patient was treated with a permanent
pacemaker. After backing up the permanent pacemaker,
esophageal balloon inflation by a Sengstaken- Blakemore tube
with the pressure of 40 mmHg at the lower esophagus induced
marked sinus bradycardia (Figure 2). However, no response
was observed at the middle and upper esophagus.
Case 2
A 59-year-old male was referred to hospital for the
evaluation of about four episodes of syncope which he had
experienced for 1 year. The first episode occurred with a loss
of consciousness for 5 minutes following eating foods with
feeling obstruction in the esophagus. No specific kinds or forms
of foods had been associated with the symptom. He had
experienced syncopal episodes usually right after eating, but
sometimes while eating foods. The patient had been in good
health except for having about ten episodes of an obstructive
feeling while eating for 3 years. The result of an esophagogastroscopy conducted 1 year ago had been normal. Physical
examination results showed no abnormality. The laboratory

Figure 3. (A) Esophageal balloon inflation at the T7 level of the

esophagus made a sinus pause (3.08 seconds) and marked
bradycardia. (Case 2) B. Esophageal balloon inflation at the T9
level of the esophagus initiated a junctional rhythm. C. Esophageal
balloon inflation at the T9 level of the esophagus after atropine 1mg IV
blocked the reflex.
T: thoracic vertebra

Figure 4. Esophageal balloon inflation done under fluoroscopy.

White hollow arrows indicate an esophageal balloon inflated at the
lower esophagus (9th thoracic vertebra level in case 2). Black
arrows indicate the margin of air shadow in the stomach.

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The Korean Journal of Internal Medicine: Vol. 20, No. 1, March, 2005

FT4: 26.445 pmol/L, TSH receptor antibody 30.5%). The blood

count and liver function tests were normal. An electrocardiography
showed sinus bradycardia (57 beats per minutes). A chest
X-ray showed a compression fracture at the lower thoracic
spine. A thyroid scan showed no demonstrable abnormal
finding. The Holter monitoring test could not be done for refusal
of patient and rarity of the symptoms. Inflation of the balloon in
the lower esophagus and gastroesophageal junction that was at
the 9th thoracic spine level resulted in junctional rhythm (3236
beats per minutes) with lightheadedness (Figure 3, Figure 4).
However, an atropine pretreatment blocked this response
(Figure 3C). A syncopal episode was considered to occur with
eating a bolus of food in a hurry; thus, he was treated by
changing his eating habits for syncope and given propylthiouracil for Graves' disease.

DISCUSSION
According to the analysis of 1,002 syncopal patients, included
from 1984 to 1990, the causes of syncope can be classified into
three groups: 18% of cardiogenic, 48% of non-cardiogenic, and
34% of unknown causes. Swallow syncope is included in 5% of
the syncopal causes, and the situational syncope syndromes
include defecation syncope, micturition syncope, and cough
syncope3). People who are middle aged or older have been
associated with swallow syncope, yet it may occur in all age
groups including children. A 5-year-old girl was reported with a
4)
syncopal history during eating since age 2 .
Related diseases of swallow syncope
In Palmer's review, achalasia, diverticulum, esophageal
stricture, hiatal hernia, esophageal spasm and cancer are
1)
reported as related esophageal diseases . Swallow syncope
has occurred also in the setting of cardiac conditions such as
an inferior wall myocardial infarction, rhematic myocarditis, and
an aortic valve calcification extending into the crest of the
1, 4, 7)
.
intraventricular septum and interrupting the His bundle
Various drugs such as digoxin, -blockers (eg., propranolol),
calcium channel blockers (eg., verapamil) and ACE inhibitors
6)
(eg., enalarpril) have been regarded as aggravating factors .
Rarely have illuminating gas inhalation, a diphtheria infection in
childhood, metastatic cancer of the bronchus, and surgery of
an aortic aneurysm been the causes. Pathologically aberrant
communication between vagal afferent and efferent fibers after
a trauma, demyelination, mechanical irritation and inappropriate
connections of esophageal afferents to medullary cardiovascular
7)
interneurons have been reported as causes .
Triggering factors

Syncope may occur by swallowing solid foods, only liquids,

or both solids and liquids. The temperature, eating habits and
stickiness of foods are associated as the triggering factors.
Type of liquids (eg., carbonated beverage) and the presence
of belching have been involved with the triggering in some
cases4, 7, 8).
Mechanism
The mechanism of swallow syncope involves the autonomic
nervous system of the esophagus and heart via the vagus
7)
nerve . Cardioinhibition caused by inflation of the balloon in the
lower esophagus was blocked by the atropine pretreatment in
case 2, which implies the involvement of the vagus nerve in the
mechanism. The afferent impulses from the esophageal plexus
via the vagus nerve travel to the nucleus solitarius tract (NST)
at the bran stem. Signals from the NST travel to an adjacent
motor nucleus that gives rise to efferent fibers through the
vagus nerve to the heart. Thereby, impulses from the
9)
esophagus through the reflex arc influence heart rhythm . A
variety of arrhythmia has been observed in swallowing syncope.
The atrioventricular block has been most often reported; less
frequently, sinus bradycardia, a sinoatrial block and a complete
atrial and ventricular asystole have been reported. Rarely have
sinus tachycardia, supraventricular tachycardia, ectopic atrial
tachycardia, paroxismal atrial fibrillation and ventricular arrhythmia
been reported1, 4, 7). Less commonly reported, is when the
afferent arm involved in swallow syncope arises from the
7)
glossopharyngeal nerve secondary to pharyngeal irritation .
It has been suggested that vasodepression, in various
degrees (mainly or partially), contributes to hypotension in
8, 10)
swallow syncope . An 86-year-old female patient who
required a Heller's cardiomyotomy for postural hypotension and
long- standing achalasia showed a reduction of blood flow to
10)
the brain without a change in heart rate after swallowing food .
It has been postulated that impulses conveyed to the NST
travel to sympathetic preganglionic nuclei in the spinal cord and
other nuclei of the brain stem and higher central nervous
system. Thus, abnormal depression of sympathetic tone results
9)
in hypotension .
Though structural and functional disorders of the esophagus
or heart are likely associated with each afferent or efferent
system, some cases of swallow syncope with no underlying
10, 11)
. In such a case, an
disorders have also been reported
abnormal chemorecepter or mechanorecepter of the esophagus
has been suggested10). In our two cases, the cardioinhibition by
balloon inflation was induced only in the lower portion of the
esophagus. This means that the mechanoreceptors in the lower
esophagus may play an important role in swallow syncope.
Some humoral factors such as epinephrine and nitric oxide
have been recognized as important factors in the mechanism

Ki Hoon Kang, et al: Swallow Syncope Associated with Mechanoreceptors in the Esophagus

of vagally mediated syncope7). Yet, the relationship of swallow

syncope with a thyroid hormone excess has not been clarified
in the literature. Thus, more study would be necessary in order
to say that the thyroid hormone excess seen in case 2 might
have influenced the syncopal attacks.
Diagnosis
In order to diagnose swallow syncope, careful history
recording is important to recognize the relationship of
4)
swallowing and syncopal or presyncopal symptoms . The
Holter monitoring and provocation tests may reveal a definite
correlation between swallowing and syncope11, 12). In the case in
which vasodepression acts as a dominant contributor, blood
6)
pressure monitoring is important for excluding a cardiac effect .
An esophagogastroscopy or barium study can be adopted to
detect an underlying disease of the esophagus. An electrocardiography and echocardiogram might help to exclude a
cardiac origin. An electroencephalography, brain magnetic
resonance imaging or computed tomography can been used for
differential diagnosis.
Treatment
In treating patients with swallow syncope, surgical correction
of esophageal pathology has been successful in some cases
12)
such as esophageal carcinoma and esophageal stricture . Of
the current medical options, the discontinuation or reduction of
aggravating drugs (eg., digoxin, ACE inhibitors etc.) should be
6, 12)
first considered . Medications to block vagal conduction such
as atropine or propantheline may be another choice. Other
medications such as adrenaline, epinephrine or isoprenaline
5, 12)
have been used for increasing the ventricular rate directly .
However, no medications have been uniformly successful and
most of the drugs have unpleasant side effects that have been
poorly tolerated. Avoidance of carbonated fluids or other agents
associated with symptoms and the correction of eating habits
4)
may be all that is required . Permanent pacemaker insertion
has been increasingly employed in recent years for patients
with no correctable esophageal pathology, especially for those
12)
showing cardioinhibiton upon swallowing .

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CONCLUSION
Swallow syncope with no significant structural or functional
abnormality of the esophagus and heart showed a cardioinhibitory
response with balloon inflation in the lower esophagus only.
Abnormality of the mechanorecepters of the lower esophagus
or its abnormal reaction to stimuli may be involved in the
mechanism of swallow syncope. The problem can be treated
with changing eating habits, or if uncontrolled, with permanent
pacemaker implantation.

REFERENCES
1) Palmer ED. The abnormal upper gastrointestinal vagovagal reflexes
that affect the heart. Am J Gastroenterol 66:513-522, 1976
2) Spens T. Medical commentaries. In: Major RH, eds. Classic descriptions
of disease. 3rd ed. p. 331, Springfield Illinois, Charles C. Thomas,
1978
3) Linzer M, Yang EH, Estes NA 3rd, Wang P, Vorperian VR, Kapoor
WN. Diagnosing syncope: pt 1. value of history, physical examination,
and electrocardiography. Ann Intern Med 126:989-996, 1997
4) Farb A, Valenti SA. Swallow syncope. Md Med J 48:151-154, 1999
5) Armstrong PW, McMillan DG, Simon JB. Swallow syncope. Can
Med Asso J 132:1281-1284, 1985
6) Deguchi K, Mathias CJ. Continuous haemodynemic monitoring in an
unusual case of swallow induced syncope. J Neurol Neurosurg
Psychiatry 67:220-222, 1999
7) Levin B, Posner JB. Swallow syncope: report of a case and review
of the literature. Neurology 22:1086-1093, 1972
8) Olshansky B. A pepsi challenge. N Engl J Med 340:2006, 1999
9) Benditt DG. Neurally medicated syncopal syndrome: pathophysiological
concepts and clinical evaluation. Pacing Clin Electrophysiol 20:572584, 1997
10) Carey BJ, de Caestecker J, Panerai RB. More on deglutition
syncope. N Engl J Med 341:1316-1317, 1999
11) Ausubel K, Gitler B. Swallow syncope in an otherwise healthy young
man. Am Heart J 113:831-832, 1987
12) Basker MR, Cooper DK. Oesophageal syncope. Ann R Coll Surg
Engl 82:249-253, 2000