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Original research
Reflux symptoms and oesophageal acidification in treated achalasia patients are often not reflux related
  1. Fraukje A Ponds,
  2. Jacobus M Oors,
  3. André J P M Smout,
  4. Albert J Bredenoord
  1. Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
  1. Correspondence to Dr Fraukje A Ponds, Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands; f.a.ponds{at}


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.

  • achalasia
  • oesophageal ph monitoring
  • visceral hypersensitivity
  • oesophageal motility disorder
  • gastroesophageal reflux disease

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  • Contributors Study concept and design: FAP, JMO, AJS and AJB. Planning and conducting study: FA-MP, JMO of the data: FAP, JMO and interpretation of the data: FAP, JMO, AJS and AJB. Drafting the manuscript: FAP. Critically reviewed manuscript for intellectual content: FAP, JMO, AJS and AJB. Approval final submitted draft: FAP, JMO, AJS and, AJB.Guarantor of the article: FAP. Department of Gastroenterology & Hepatology, Amsterdam UMC, University of Amsterdam, declare that I accept full responsibility for the conduct of the study.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests FAP: None. JMO: Received speaker and/or consulting fees from Laborie. AJS: None. AJB: Received research funding from Nutricia, Norgine and Bayer and received speaker and/or consulting fees from Laborie, EsoCap, Diversatek, Medtronic, Falk Pharma, Calypso Biotech, Thelial, Robarts, Reckett Benkiser, Regeneron, Celgene, Bayer, Norgine, AstraZeneca, Almirall, Arena and Allergan.

  • Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.

  • Patient consent for publication Not required.

  • Ethics approval The institutional review board of the Amsterdam UMC approved the study protocol (internal reference number 2012_318#B2013208a; approved January 2013).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available on reasonable request. All data relevant to the study are included in the article or uploaded as online supplementary information. Deidentified data, that underlie the results reported in this article, will be shared with third parties after written request to the corresponding author describing intention of data usage and full affiliation of the requesting organisation. To gain access to the data, a data access agreement need to be signed. The study protocol is openly accessible and added as a supplementary to the manuscript.

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