Anxiety diagnosis and mysterious heart palpitations. Gas trapped. GERD or celiac disease?

Posted on Thu, 5 Jul 2012 in Digestion and Bowels
Question: Hi there -

40 year old male, 6 feet (183cm), 192lbs (87kg), former competitive athlete. Have an anxiety (GAD w/ panic) diagnosis and 'mysterious' heart palpitations (not tachy, nor skipping beats or double beats, etc. heart just beating _harder_) that are hence assumed to be caused by the anxiety alone, but they occur without any anxiety and are mechanically reproducable, and I have an extreme amount of gas/trapped air so I think I either have GERD, or celiac disease, and/or just a distended abdomen and excessive gas caused by bacteria due to recent diatery changes or magnesium deficiency (proven by blood test) causing slow motility. In any event, the palpitations are often physically triggered and not due to anxiety. I'd like your opinion/possible diagnosis on this please.

2 x EKGs, 2 x blood tests, 2 x urine tests, chest x-ray, ultrasound, manual exam of the heart shows everything normal. Hence, the MD concluded that palpitations are caused by anxiety alone, and/or they subjectively appear to be more than what they are to me b/c I've been sensitized to being more aware of the heart. While both of these assessments are probably true, they do not explain:

- Why I can mechanically reproduce palpitations regardless of state of mind when laying on stomach or sides, putting pressure on abdomen or thorax in certain other ways, vasoconstriction of any kind (from belt tightening to alcohol consumption), eating after many hours on empty stomach, eating too fast or a heavy meal, even slouching/bad posture and bending over, etc.
- Why I can actually measure a jump of up to 30-35 in systolic pressure only (diastolic remains the same) when the palpitation is happening. Clearly, the heart is contracting much harder, but not beating faster -- I'm not imagining it. Example: Ate a heavier meal a bit too fast tonight, not enough chewing. It also contained grains/gluten. I should mention that I'm on 25mg of Metoprolol extended release beta blocker per day for the past month. My BP is now routinely 120s/80s, even 110s/70s during the day. After the meal, I got the palpitations, and measured systolic BP of 140s-160s while it was happening, while the diastolic remained in the 70s and 80s. Pulse is 60s to 70s while it's happening (in contrast to resting heart rate of about 58), so my heart is not racing, just contracting harder.

This was measured repeatedly while sitting slouched on the bed, where the full abdomen obviously applies some pressure on the thorax and heart. When I sit up straight in a chair and thus relieve the pressure, and especially when I follow the urge to burp repeatedly (many times, sometimes for minutes) during which nothing but trapped air seems to come out, the systolic pressure goes down as much as 20-30 points. In this case, it went from 160 to 140, then to 130, within a minute. Thus, I'm convinced that part is not anxiety.

My theory: I turned vegan overnight 6 months ago and have had tremendous amount of gas since. Obviously the intestinal flora is suffering from the sudden change from a standard American diet. Also, the blood tests found a magnesium deficiency, which may be causing slow motility leading to more gas. I lost a fair amount of weight during the same time period without even trying due to the vegan diet, but appear to still have a distended abdomen. I don't think that's all remaining belly fat. I think a lot it is bowel gas as well as trapped air in stomach. I feel constantly bloated. And burping seems to both alleviate the bloating and regulate the heart rhythm when I have palpitations. Sometimes I can burp for many minutes straight. So my potential self diagnoses are:

(a) The gas is swelling my stomach to the point it is pressing against my diaphragm. This is making it difficult to breathe as the expanding chest allows the swelling to push into the thorax rather than creating a larger place for the lungs. This is also the cause of the palpitations.
OR: (b) Trapped gas/air is backing into esophagus, irritating the vagus nerve.
OR: (c) I may have GERD b/c the palpitations are happening after meals, and I've also had chronic cough and sinus infections as per GERD. However, this still appears unlikely b/c I almost never have heartburn/acid reflux.
OR (d) Hiatus hernia. Again, no reflux or regurgitation, but the esophagus would trap gas when the hernia slides into the chest cavity. The trapped gas presses on the vagus nerve and causes heart palpitations. (c) and (d) are consistent b/c repeated burping and orthostatic repositioning seems to regulate the heart rhythm and make the palpitations go away. Orthostatic vitals were done but were not clinically significant. However, they weren't done while I was having the palpitations and I was thus not able to demonstrate that I'm able to relieve the palpitations orthostatically and by burping.
AND/OR: (e) I have celiac disease and developed gluten sensitivity since turning vegan.

Does this make sense? What do you think is going on, what's more vs. less likely, and what should I do about it? The palpitations are very disruptive. Sometimes they go on for a long time and when they happen at night, I end up losing much sleep. Many thanks in advance.
Answered by Dr. Ketan Vagholkar 5 hours later

From your elaborate history it appears to be a stress disorder. All your major investigations are normal. I would only like to suggest an upper GI (Gastrointestinal) endoscopy to rule out a hiatus hernia.

If I were your treating doctor, I would stop metoprolol immediately and I would also stop all the anxiolytics as well. These drugs cause slowing of bowel motility and function thus causing retention of food for a long time with lot of gas formation. Please discuss about these with your treating doctor before you go ahead any further.

I would also suggest you to revert back to your original diet which you used to have during health. As you have been on a non vegetarian diet initially, sudden change in the diet is going to cause problems as your enzymes to digest vegetarian food are going to be weak.

Restore to your original non vegetarian american diet, moderate exercises as before. Add some good food additives or vitamins and yogurts.

I am sure you should be ok.

Above answer was peer-reviewed by : Dr. Shanthi.E
Follow up: Dr. Ketan Vagholkar 6 hours later
Hello -

Thank you for your answer. I have already stopped the anxiolytics and have suffered from withdrawal and hightened anxiety (even more than before taking them) after only taking them a couple of weeks b/c I seem to be super-sensitive to pharmaceuticals. I have replaced them w/ a combination of over the counter supplements -- gaba, taurine, inositol and theanine. It seems to be working ok and as soon as I have "medical clearance" meaning when I find out that the anxiety doesn't have a medical cause, I'm starting CBT therapy.

But so much of the anxiety has been triggered by a health worry in the first place, it's hard to tell them apart. And in this instance, the palpitations are definitely triggering anxiety, and the palpitations themselves are definitely physiologically triggered so I need to take care of the gas issue. I will definitely tell the doctor about quitting the beta blocker b/c it slows down motility and I have many side effects anyway. One question: can the over the counter supplements (gaba, taurine, etc.) I'm taking for anxiety also be slowing motility? They do slow the nervous system down.

I've also seen a naturopathic doctor (ND) in addition the MD. The ND thinks that my high BP is caused by stress/anxiety + becoming insulin-resistant due to lifestyle. I've skipped meals and only eaten 1-2 times a day for years now, so he thinks that I'm hypoglycemic through much of the day except I trained my body to "not complain". This creates insulin resistance (IR), which in turn causes magnesium to be lost in urine and not stored. This theory is consistent w/ the magnesium deficiency found in my blood. Hence, IR causes high BP through magnesium deficiency, sodium retention, and excessive uric acid. And you're confirming the issue w/ the bacteria and enzymes in the intestines. So all things seem to point to stress + diet. What's your thought on this?

The only thing is, I don't want to return to eating meat, bad fat, and sugar. I lost a fair amount of weight, and have had higher energy (until the anxiety happened) and I just don't want to go back to being what I consider "part of the problem". Is there a middle of the road way? Can I take something for gas and can I do something to facilitate development of enyzmes and bacteria to digest vegan food? Take probiotic supplements or eat live bacteria such as yogurt? I'm willing to eat anything temporarily (such as yogurt, though it's dairy) to restore balance, seeing it as a stop-gap and a medicine, but I can't go back to a diet that will XXXXXXX my energy, cause me to gain weight again and long-term, create serious chronic illness.

Also, what does the trapped air in stomach have to do w/ bowel gas? The excessive bowel gas also exists, to be sure, but a lot of the burping that stops the palpitations seems to be releasing just air, not gas. Am I missing something? Are you saying if the food doesn't move out of the stomach fast enough, somehow air gets trapped in stomach? How does so much air get there in the first place? Many thanks again.
Answered by Dr. Ketan Vagholkar 20 hours later

Beta blockers slow the blood to bowel leading to slowing of motility. Food additives usually do cause much bowel problems. Consume bananas as they will help push the bowel movement. Continue with good food additives and yogurts.

Consult a dietician who can help you with selection of high protein vegetarian foods. Consume whole milk and egg every day as a combination of the two will satisfy most of the trace element requirements of the body.

A regular brisk walk will strengthen your cardiovascular system and will surely reduce stress and the frequency of panic attacks.

Lastly resort to yoga or meditation for stress attacks.

Above answer was peer-reviewed by : Dr. Shanthi.E
Answered by
Dr. Ketan Vagholkar

Gastroenterologist, Surgical

Practicing since :1989

Answered : 883 Questions


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