Cardiac arrhythmias on swallowing

A middle-aged male patient with cardiac arrhythmias on swallowing due to incoordinate peristaltic activity of the esophagus is reported. Medical treatment with propranolol and quinidine sulfate made the symptoms manageable initially but recurrence of symptoms made surgical treatment desirable. Barium sulfate with apple produced the incoordinate peristalsis with resultant arrhthmias as soon as it arrived at the junction between the middle and lower third of the esophagus. This was followed by a normal peristaltic wave which cleared the esophagus and brought the cardiac rhythm back to normal again. Balloon distension of the esophagus located the afferent stimuli as arising from the lower third of the esophagus. A circular esophageal myotomy at the junction of the middle and the lower third, although not completely abolishing the reflex, has made the symptoms less severe. However, this procedure has produced considerable ballooning of the mucosa at the myotomy site, and has resulted in some difficulty in swallowing.