Correspondence

A Pepsi Challenge

N Engl J Med 1999; 340:2006June 24, 1999

Article

To the Editor:

A 72-year-old man with recurrent dizziness, confusion, and syncope told an internist that cold, carbonated beverages caused him to feel strange, dizzy, and confused and might have triggered several episodes over a one-year study period. A carotid Doppler study, 24-hour Holter monitor, cranial magnetic resonance imaging scan, computed tomographic scan, and echocardiogram were unremarkable. An electroencephalogram showed diffuse slowing. Phenytoin was given but provided no improvement.

Another internist evaluated the patient's condition and ordered a treadmill exercise test and another magnetic resonance imaging scan, which were negative. A cardiologist was consulted, and the results of a tilt-table test and coronary angiography were normal. After this evaluation, the patient drank a carbonated beverage while driving and wrecked his car.

The patient was referred to me for further evaluation, and he gave the same history. Because the episodes were initiated reproducibly with cold, carbonated beverages, a can of Pepsi was given to the patient to drink while he was being monitored with an electrocardiograph. Abrupt bradycardia and hypotension developed, along with the patient's usual symptoms. The test was not reproduced, but it confirmed the diagnosis of deglutition syncope.1-3 Carotid-sinus massage was negative.

Deglutition syncope is a dysautonomic syndrome associated with intense vagal afferent activation due to esophageal stimulation.4 It evokes sympathetic inhibition with vagal efferent activation, causing bradycardia, peripheral vasodilatation, and hypotension. Cold beverages frequently trigger deglutition syncope.3 The problem can be treated with avoidance of the stimulus, or, if uncontrolled, with dual-chamber pacing.

Although the best initial method to evaluate syncope is to obtain a complete history and physical examination,5 it is clear from this case that it is even more important to listen to the patient. This patient provided the necessary history for each physician. The response was to perform expensive tests, at least some of which were unnecessary.

Brian Olshansky, M.D.
Loyola University Medical Center, Maywood, IL 60153

5 References

1. 1

   James AH. Cardiac syncope after swallowing. Lancet 1958;1:771-771
   CrossRef | Web of Science | Medline

2. 2

   Levin B, Posner JB. Swallow syncope: report of a case and review of the literature. Neurology 1973;22:1086-1093
   Web of Science

3. 3

   Olshansky B, Birger S. Deglutition syncope. CARDIO 1989;137:August-August
   

4. 4

   Palmer ED. The abnormal upper gastrointestinal vagovagal reflexes that affect the heart. Am J Gastroenterol 1976;66:513-522
   Web of Science | Medline

5. 5

   Olshansky B. Syncope: overview and approach to management. In: Grubb B, Olshansky B, eds. Syncope mechanisms and management. Mt. Kisco, N.Y.: Futura Publishing, 1998:15-71.
   

Citing Articles (7)

Citing Articles

1. 1

   Wataru Omi, Yoshiharu Murata, Takanori Yaegashi, Jun-ichiro Inomata, Masahiko Fujioka, Shingo Muramoto. (2006) Swallow Syncope, a Case Report and Review of the Literature. Cardiology 105:2, 75-79
   CrossRef

2. 2

   Samer Gawrieh, Ty Carroll, Walter J. Hogan, Konrad H. Soergel, Reza Shaker. (2005) Swallow Syncope in Association with Schatzki Ring and Hypertensive Esophageal Peristalsis: Report of Three Cases and Review of the Literature. Dysphagia 20:4, 273-277
   CrossRef

3. 3

   Ilker Turan, Galip Ersoz, Serhat Bor. (2005) Swallow-Induced Syncope in a Patient with Achalasia. Dysphagia 20:3, 238-240
   CrossRef

4. 4

   Ki Hoon Kang, Wook Hyun Cho, Myung Chan Kim, Hee Jong Chang, Jae Il Chung, Dong Jun Won. (2005) Cases of Swallow Syncope Induced by the Activation of Mechanorecepters in the Lower Esophagus. The Korean Journal of Internal Medicine 20:1, 68
   CrossRef

5. 5

   C. T. Paul Krediet, Arthur A. M. Wilde, Wouter Wieling, John R. Halliwill. (2004) Exercise related syncope, when it?s not the heart. Clinical Autonomic Research 14:S1, i25-i36
   CrossRef

6. 6

   Eugene Kroch, Raj Shah, Douglas Fisher, Evan Loh, J. Sanford Schwartz. 2001. Payment effects on resource utilization and outcomes for patients with congestive heart failure. , 411-449.
   CrossRef

7. 7

   (1999) More on Deglutition Syncope. New England Journal of Medicine 341:17, 1316-1317
   Full Text