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Mean lower esophageal sphincter pressure, esophageal baseline pressure, and sphincter vector volume (SVV) in patients with achalasia. Patients exhibiting slow decline below pH 4 have similar characteristics to those with normal pH record.
Source publication
An abnormal score during 24-hr esophageal pH monitoring in achalasia may be associated either with a slow steady drift to below pH 4, or else multiple sharp dips characteristic of typical gastroesophageal reflux. To test the hypothesis that the former pattern was due to food fermentation and not reflux, samples of chewed bland food (N = 22) were in...
Context in source publication
Context 1
... preoperative patients were classi® ed accord- ing to the presence or absence of abnormal acid exposure, the manometric features, whether resting pressure of the LES, sphincter vector volume, or the esophageal body baseline pressure, were similar, re- gardless of the pattern of acid exposure (Figure 3). No patient had esophagitis on endoscopy preopera- tively, but all four patients with a slow steady drift below pH 4 had retained food particles, whereas only two of 15 patients with a normal pH score had visible food particles (P 5 0.001, chi-square test). ...
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Citations
... Despite the high incidence rate, only 10% of patients are symptomatic [9]. In those patients, a high AET can be attributed to either real GER, characterized by an acute decrease in pH below 3 with sluggish clearance during pH monitoring, or to fermentation of residual food due to long-standing achalasia, resulting in a gradual reduction in pH usually above 3.7 [11]. Diagnosis of GER using pH monitoring should be postponed for more than 1 mo following POEM to prevent inaccurate results due to mucosal edema and damage[10]. ...
In this editorial, we respond to a review article by Nabi et al, in which the authors discussed gastroesophageal reflux (GER) following peroral endoscopic myotomy (POEM). POEM is presently the primary therapeutic option for achalasia, which is both safe and effective. A few adverse effects were documented after POEM, including GER. The diagnostic criteria were not clear enough because approximately 60% of patients have a long acid exposure time, while only 10% experience reflux symptoms. Multiple predictors of high disease incidence have been identified, including old age, female sex, obesity, and a baseline lower esophageal sphincter pressure of less than 45 mmHg. Some technical steps during the procedure, such as a lengthy or full-thickness myotomy, may further enhance the risk. Proton pump inhibitors are currently the first line of treatment. Emerging voices are increasingly advocating for the routine combining of POEM with an endoscopic fundoplication method, such as peroral endoscopic fundoplication or transoral incisionless fundoplication. However, more research is necessary to determine the safety and effectiveness of these procedures in the long term for patients who have undergone them.
... Specifically, our findings demonstrated an association between a poor esophageal clearance pattern and an average longest reflux episode of > 20 min. Two smaller studies have reported on this topic suggesting between one-third and one-half of abnormal pH studies are attributable to poor esophageal clearance rather than a typical acid reflux pattern [18,19], thus the findings in our larger cohort are in line and confirmatory. ...
Introduction
With the advent of the laparoscopic era in the 1990s, laparoscopic Heller myotomy replaced pneumatic dilation as the first-line treatment for achalasia. An advantage of this approach was the addition of a fundoplication to reduce gastroesophageal reflux disease (GERD). More recently, Peroral Endoscopic Myotomy has competed for first-line therapy, but the postoperative GERD may be a weakness. This study leverages our experience to characterize GERD following LHM with Toupet fundoplication (LHM+T ) so that other treatments can be appropriately compared.
Methods
A single-institution retrospective review of adult patients with achalasia who underwent LHM+T from January 2012 to April 2022 was performed. We obtained routine 6-month postoperative pH studies and patient symptom questionnaires. Differences in questionnaires and reflux symptoms in relation to pH study were explored via Kruskal–Wallis test or chi-square tests.
Results
Of 170 patients who underwent LHM+T , 51 (30%) had postoperative pH testing and clinical symptoms evaluation. Eleven (22%) had an abnormal pH study; however, upon manual review, 5 of these (45.5%) demonstrated low-frequency, long-duration reflux events, suggesting poor esophageal clearance of gastric refluxate and 6/11 (54.5%) had typical reflux episodes. Of the cohort, 7 (15.6%) patients reported GERD symptoms. The median [IQR] severity was 1/10 [0, 3] and median [IQR] frequency was 0.5/4 [0, 1]. Patients with abnormal pH reported more GERD symptoms than patients with a normal pH study (3/6, 50% vs 5/39, 12.8%, p = 0.033). Those with a poor esophageal clearance pattern (n = 5) reported no concurrent GERD symptoms.
Conclusion
The incidence of GERD burden after LHM+T is relatively low; however, the nuances relevant to accurate diagnosis in treated achalasia patients must be considered. Symptom correlation to abnormal pH study is unreliable making objective postoperative testing important. Furthermore, manual review of abnormal pH studies is necessary to distinguish GERD from poor esophageal clearance.
... There are few consistent study results in the literature regarding achalasia and subsequent pH disorders and their correlation with carcinogenesis. Crookes et al. [32] demonstrated in an in vitro study that chewed food with saliva at body temperature undergoes lactobacilli fermentation and generates lactic acid, leading to below 4.0 pH measures. Moreover, the lack of peristalsis and further poor acid clearance leads to prolonged contact between gastric reflux and esophageal mucosa and a pH drop. ...
Background:
Microorganisms provide various benefits to their human hosts, including assisting with digestion, synthesizing certain vitamins, developing the gastrointestinal and immune systems, regulating metabolism, and protecting against some pathogens. However, microbial imbalances can cause tissue damage and contribute to inflammatory disorders and cancers. Microbial dysbiosis refers to an imbalance or disruption in the normal composition and function of the microbial communities that inhabit various body parts, including the gut, oral cavity, skin, and reproductive tract. Emerging research suggests that microbial dysbiosis plays a significant role in cancer development and progression. This issue is particularly relevant in achalasia, in which food stasis, changes in endoluminal pH, and poor esophageal clearance might contribute to esophageal microbial dysbiosis. This study aimed to evaluate the association between dysbiosis and esophageal cancer development, focused on esophageal dysmotility disorders.
Methods:
This study is a critical review, gathering the current evidence for the association between dysbiosis and the development of esophageal cancer.
Results:
Studies have shown that microbiota play a role in cancer development, although the mechanisms for how they do so are not yet fully understood. One possible explanation is that microbiota alterations can lead to chronic inflammation, promoting cancer cell growth. Additionally, some bacteria produce toxins that can damage DNA and cause genomic instability, and certain bacterial products can promote tumor growth.
Conclusion:
Despite the close relationship between dysbiosis and cancer development in esophageal dysmotility disorders, further investigations are still needed to elucidate the precise mechanisms by which dysbiosis contributes to cancer development and to identify potential therapeutic interventions targeting the microbiota to prevent or treat cancer.
... results Total acid exposure time during 24 hours ph-impedance was not significantly different between patients with (rs+) and without (rs−) reflux symptoms. in rs+ patients, acid fermentation was higher than in rs− patients (rs+: mean 6.6% (95% ci 2.96% to 10.2%) vs rs−: 1.8% (95% ci −0.45% to 4.1%, p=0.03) as well as acid reflux with delayed clearance (rs+: 6% (95% ci 0.94% to 11%) vs rs−: 3.4% (95% ci −0.34% to 7.18%), p=0.051). reflux symptoms were not related to acid in both groups, reflected by a low symptom index. ...
... achalasia patients correlate poorly. [10][11][12][13][14][15] True reflux as the cause of reflux symptoms was inconsistently observed. Nevertheless, it is common practice to consider reflux symptom of treated achalasia patients as GORD and start proton pump inhibitors (PPI), which has variable efficacy. ...
... Among the four patterns leading to prolonged acidification in achalasia patients, acid fermentation of oesophageal food residues has gained most attention in previous studies. 10 12 42 In their in vitro study, Crookes et al observed that the pH of saliva incubated with chewed food at body temperature slowly drifted to a median pH of 4, in a period of approximately 6 hours. 10 The acid fermentation observed in our study showed a more rapid pH drift and often reached values below 4, with the lowest pH ranging from 3 to 1. ...
Objective
After treatment, achalasia patients often develop reflux symptoms. Aim of this case–control study was to investigate mechanisms underlying reflux symptoms in treated achalasia patients by analysing oesophageal function, acidification patterns and symptom perception.
Design
Forty treated achalasia patients (mean age 52.9 years; 27 (68%) men) were included, 20 patients with reflux symptoms (RS+; Gastro-Oesophageal Reflux Disease Questionnaire (GORDQ) ≥8) and 20 without reflux symptoms (RS−: GORDQ <8). Patients underwent measurements of oesophagogastric junction distensibility, high-resolution manometry, timed barium oesophagogram, 24 hours pH-impedance monitoring off acid-suppression and oesophageal perception for acid perfusion and distension. Presence of oesophagitis was assessed endoscopically.
Results
Total acid exposure time during 24 hours pH-impedance was not significantly different between patients with (RS+) and without (RS−) reflux symptoms. In RS+ patients, acid fermentation was higher than in RS− patients (RS+: mean 6.6% (95% CI 2.96% to 10.2%) vs RS−: 1.8% (95% CI −0.45% to 4.1%, p=0.03) as well as acid reflux with delayed clearance (RS+: 6% (95% CI 0.94% to 11%) vs RS−: 3.4% (95% CI −0.34% to 7.18%), p=0.051). Reflux symptoms were not related to acid in both groups, reflected by a low Symptom Index. RS+ patients were highly hypersensitive to acid, with a much shorter time to heartburn perception (RS+: 4 (2–6) vs RS−:30 (14-30) min, p<0.001) and a much higher symptom intensity (RS+: 7 (4.8–9) vs RS−: 0.5 (0–4.5) Visual Analogue Scale, p<0.001) during acid perfusion. They also had a lower threshold for mechanical stimulation.
Conclusion
Reflux symptoms in treated achalasia are rarely caused by gastro-oesophageal reflux and most instances of oesophageal acidification are not reflux related. Instead, achalasia patients with post-treatment reflux symptoms demonstrate oesophageal hypersensitivity to chemical and mechanical stimuli, which may determine symptom generation.
... For this purpose, pH-impedance testing or endoscopic surveillance can be used. It should be noted that achalasia patients have a high rate of positive pHimpedance studies, caused by esophageal stasis and poor acid clearance [78,79]. Endoscopy may therefore be the appropriate tool of choice in the follow-up of GERD postachalasia intervention, as it is able to detect esophagitis, as well as long-standing reflux complications, such as Barrett's esophagus and peptic strictures. ...
Introduction: Achalasia is a rare esophageal motility disorder. Much of the literature is based on the adult population. In adults, guidance of therapeutic approach by manometric findings has led to improvement in patient outcome. Promising results have been achieved with novel therapies such as PerOral Endoscopic Myotomy (POEM).
Areas covered: In this review, we provide an overview of the novel diagnostic and therapeutic tools for achalasia management and in what way they will relate to the future management of pediatric achalasia. We performed a PubMed and EMBASE search of English literature on achalasia using the keywords “children”, “achalasia”, “pneumatic dilation”, “myotomy” and “POEM”.
Cohort studies < 10 cases and studies describing patients ≥ 20 years were excluded. Data regarding patient characteristics, treatment outcome and adverse events were extracted and presented descriptively, or pooled when possible.
Expert Commentary: Available data report that pneumatic dilation and laparoscopic Heller’s myotomy are effective in children, with certain studies suggesting lower success rates in pneumatic dilation. POEM is increasingly used in the pediatric setting with promising short-term results. Gastro-esophageal reflux disease (GERD) may occur post-achalasia intervention due to disruption of the LES and therefore requires diligent follow-up, especially in children treated with POEM.
... In untreated patients, postprandial stasis and fermentation of food in the esophagus due to impaired esophageal emptying are thought to cause these symptoms. [13][14][15] Additionally, dysphagia is frequently reported by patients with GERD. 16 Therefore, achalasia can be erroneously diagnosed as GERD. ...
... These patients might have more prominent postprandial stasis, fermentation of food and poor esophageal clearance, which cause pseudo-gastroesophageal reflux. [13][14][15]17 A previous study showed a high prevalence of heartburn in achalasia patients, although objective evidence of GERD was weak. 18 Another study suggested that other processes such as esophageal muscle spasm, ischemia, or esophageal distension might account for the heartburn and chest pain in patients with achalasia. ...
Background/aims:
Patients with untreated achalasia frequently complain of heartburn and regurgitation. The diagnosis of achalasia might be delayed because these symptoms are misinterpreted as gastroesophageal reflux. We aim to evaluate the clinical presentation, radiologic, and manometric findings in patient untreated achalasia.
Methods:
The records of patients diagnosed with primary achalasia between July 2004 and January 2012 at Gangnam Severance Hospital, Seoul, Korea were evaluated. We reviewed their clinical history and the results of barium esophagogram, endoscopy, and esophageal transit scintigraphy. We also compared the clinical and radiologic and manometric findings of patients according to heartburn symptoms and proton pump inhibitor use.
Results:
Our study included a total of 64 patients with a median age of 44.5. The median duration of symptoms was 23.5 months. Sixty-four patients (100%) had dysphagia, 49 (76.6%) had regurgitation, 35 (54.7%) had chest pain, and 38 (59.4%) had heartburn. Typical clinical features of GERD such as regurgitation, heartburn and chest pain were observed in more than 50% of achalasia patients. Proton pump inhibitors were prescribed for 16 patients (25%) on the assumption that they had refractory GERD. Patients with heartburn were more likely to experience weight loss (P = 0.009), regurgitation (P = 0.001), or chest pain (P = 0.019).
Conclusions:
Heartburn, regurgitation, and chest pain were commonly observed in patients with untreated achalasia. Patients with heartburn were more likely to experience weight loss regurgitation or chest pain.
... 10 Interestingly, in the same study was shown that in the context of ''nonreflux'' diagnoses, such as achalasia, some patients had an abnormal pH monitoring score, confirming the importance of the esophageal manometry to rule out motility disorders, and the need to analyze the tracing to distinguish between real and false reflux. 4,5 Likewise, our study provides the evidence that in patients with refractory GERD, further investigation, including esophageal manometry and pH monitoring, is essential to define the proper diagnosis and plan a correct therapeutic approach. Unfortunately, in many cases, these tests are not performed and patients are treated with acid-reducing medication for a long period of time or even referred for LARS. ...
Background:
Patients who have heartburn are treated with acid-reducing medications on the assumption that gastroesophageal reflux disease (GERD) is causing the symptom. In the absence of a response to therapy, patients are often assumed to have refractory GERD, and they are referred for laparoscopic antireflux surgery (LARS), often without further diagnostic evaluation.
Hypothesis:
We hypothesized that (1) in some patients with refractory GERD, the heartburn is not secondary to reflux, but rather to stasis and fermentation of food in the presence of achalasia and (2) esophageal manometry and pH monitoring are essential to establish proper diagnosis.
Patients and methods:
Five hundred twenty-four patients, whose final diagnosis was achalasia, were referred to two quaternary care centers. Symptomatic evaluation, barium swallow, endoscopy, manometry, and pH monitoring were performed in all patients.
Results:
One hundred fifty-two patients (29%) had been treated with acid-reducing medications for an average of 29.3 months, and were referred for LARS because of lack of response to medical therapy. One patient had already been treated with a Nissen fundoplication. All patients were diagnosed with achalasia and underwent Heller myotomy and partial fundoplication.
Conclusions:
The results of this study showed that (1) one-third of achalasia patients complained of heartburn and (2) patients with heartburn not responding to medical treatment must be carefully evaluated before referral to surgery. These data confirm the importance of esophageal manometry and pH monitoring in any patient considered for LARS.
... However, in untreated achalasia patients, these symptoms are believed to be caused by the stasis and fermentation of residual food in the esophagus secondary to the impaired esophageal emptying, rather than by real GER. [16] Approximately 86% of our referred patients were taking PPIs to suppress their GER symptoms. In 80% of the type III achalasia cases, a barium swallow did not result in a diagnosis of achalasia, and a diagnosis of either GERD or a nonspecific esophageal motility disorder was made. ...
High-resolution manometry (HRM) has improved the accuracy of manometry in detecting achalasia and determining its subtypes. However, the correlation of achalasia subtypes with clinical, endoscopic, and radiologic findings has not been assessed. We aimed to evaluate and compare the clinical, endoscopic, and fluoroscopy findings associated with three subtypes of achalasia using HRM.
The retrospective clinical data, HRM, endoscopy, and radiologic findings were obtained from the medical records of untreated achalasia patients.
From 2011 to 2013, 374 patients underwent HRM. Fifty-two patients (14%) were diagnosed with achalasia, but only 32 (8.5%) of these patients had not received treatment and were therefore included in this study. The endoscopy results were normal in 28% of the patients, and a barium swallow was inconclusive in 31% of the achalasia patients. Ten patients (31%) were classified as having type I achalasia, 17 (53%) were classified as type II, and 5 (16%) were classified as type III. Among the three subtypes, type I patients were on average the youngest and had the longest history of dysphagia, mildest chest pain, most significant weight loss, and most dilated esophagus with residual food. Chest pain was most common in type III patients, and frequently had normal fluoroscopic and endoscopic results.
The clinical, radiologic, and endoscopic findings were not significantly different between patients with type I and type II untreated achalasia. Type III patients had the most severe symptoms and were the most difficult to diagnose based on varied clinical, radiologic, and endoscopic findings.
... However, the underlying mechanism for their heartburn is different. The symptoms of heartburn are thought to be due to stasis and fermentation of food in the esophagus after impaired emptying causing irritation rather than by reflux of acidic gastric contents [26][27][28]. Long-term effects of food retention include progressive esophageal dilation, nocturnal regurgitation, aspiration in 12 %, and weight loss in 35 % [25, 29]. ...
The goal of this review is to illustrate our approach to patients with achalasia in terms of preoperative evaluation and surgical technique. Indications, patient selection and management are herein discussed. Specifically, we illustrate the pathogenetic theories and diagnostic algorithm with current up-to-date techniques to diagnose achalasia and its manometric variants. Finally, we focus on the therapeutic approaches available today: medical and surgical. A special emphasis is given on the surgical treatment of achalasia and we provide the reader with a detailed description of our pre and postoperative management.
... Crookes et al. looked at 20 patients before surgery for achalasia and found that five (20%) had abnormally high esophageal acid exposure. Of those five patients, only one (5%) had sudden pH drops characteristic of GER.44 Evidence is lacking, but theoretically, these patients might be at a higher risk for postprocedure reflux, and should be counseled accordingly.45 ...
... Fermentation is the breakdown of carbohydrates into acids or alcohol under the right conditions, and this can take place in the esophagus of a patient with esophageal outflow obstruction. Crookes et al.44 showed that chewed samples incubated in vitro with saliva but never exposed to gastric acid slowly ferment. The pH of these samples gradually drops to around 4, but usually not below that. ...
... In addition to dysphagia recurrence, patients undergoing ED can experience the onset of GER, with 33% of patients reporting symptomatic GER at 4 years.78–80 When 24-h pH monitoring was used as a proxy, more than 30% of patients had an increase in episodes and duration of reflux.44,81 ...
Esophageal achalasia is a rare neurodegenerative disease of the esophagus and the lower esophageal sphincter that presents within a spectrum of disease severity related to progressive pathological changes, most commonly resulting in dysphagia. The pathophysiology of achalasia is still incompletely understood, but recent evidence suggests that degeneration of the postganglionic inhibitory nerves of the myenteric plexus could be due to an infectious or autoimmune mechanism, and nitric oxide is the neurotransmitter affected. Current treatment of achalasia is directed at palliation of symptoms. Therapies include pharmacological therapy, endoscopic injection of botulinum toxin, endoscopic dilation, and surgery. Until the late 1980s, endoscopic dilation was the first line of therapy. The advent of safe and effective minimally invasive surgical techniques in the early 1990s paved the way for the introduction of laparoscopic myotomy. This review will discuss the most up-to-date information regarding the pathophysiology, diagnosis, and treatment of achalasia, including a historical perspective. The laparoscopic Heller myotomy with partial fundoplication performed at an experienced center is currently the first line of therapy because it offers a low complication rate, the most durable symptom relief, and the lowest incidence of postoperative gastroesophageal reflux.
