Erroneous diagnosis of gastroesophageal reflux disease in achalasia

Most experienced gastroenterologists have seen one or several cases of achalasia patients who have been erroneously diagnosed with gastroesophageal reflux disease (GERD) or even underwent antireflux surgery. We aim to describe the current knowledge about the diagnostic features of achalasia and their overlap with GERD. Furthermore, we present 3 cases in which achalasia was mistaken for GERD. Search of the literature published in English using the PubMed database and relevant abstracts presented at international conventions. Typical features of GERD such as heartburn, retrosternal pain, esophagitis, and pathologic acid exposure can be observed in achalasia patients. Diagnostic tests such as endoscopy and radiography lack sensitivity and specificity for achalasia. Current diagnostic guidelines for antireflux surgery do not stipulate that achalasia should be ruled out preoperatively. Clinical presentation as well as the diagnostic work-up of achalasia patients can show overlap with GERD. Mistaking achalasia for GERD can be avoided by esophageal manometry and this should therefore be performed in all patients undergoing surgical fundoplicatio

Objective manometric criteria for the rumination syndrome

The rumination syndrome is a behavioral disorder resulting in recurrent regurgitation of undigested food. The diagnosis of this syndrome is currently based on clinical features. We aimed to determine criteria for the rumination syndrome based on physiological measurements. We studied patients with clinically confirmed rumination syndrome and gastroesophageal reflux disease (GERD) patients with predominant symptoms of regurgitation. All patients underwent combined high-resolution manometry and pH-impedance measurement after a standardized meal. All reflux events extending to the proximal esophagus were analyzed. Furthermore, ambulatory measurements were performed in the majority of patients. In the rumination group, the amplitude of the abdominal pressure increase during proximal reflux events and the esophageal pressure peaks were significantly higher compared with GERD patients. None of the GERD patients exhibited abdominal pressure peaks >30 mm Hg, whereas in the rumination patients 70% of the pressure peaks had an amplitude >30 mm Hg. Abdominal pressure patterns were also observed during ambulatory pH impedance-pressure monitoring in the rumination patients. pH-impedance monitoring alone could not differentiate between GERD and rumination, however, a higher percentage of reflux events reached the proximal esophagus in the rumination patients. Notably, three different mechanisms of rumination were observed: (i) primary rumination, in which the abdominal pressure increase preceded the retrograde flow, (ii) secondary rumination, consisting of an increase in abdominal pressure following the onset of a reflux event and (iii) supragastric belch-associated rumination, consisting of a supragastric belch immediately followed by a rumination event. The diagnosis of the rumination syndrome can be made when reflux events extending to the proximal esophagus that are closely associated with an abdominal pressure increase >30 mm Hg and an esophageal pressure increase are observed during combined pressure-impedance monitorin

Current diagnosis and management of the rumination syndrome

The rumination syndrome is a behavioral condition characterized by postprandial regurgitation. In contrast to what many think, the disorder does not exclusively occur in mentally disabled patients or children but also in otherwise healthy adults. As symptoms of postprandial regurgitation are often mistaken for gastroesophageal reflux disease or vomiting, the rumination syndrome is an underappreciated condition. Rumination episodes are caused by an intragastric pressure increases which forces the gastric content into the esophagus and mouth and occurs during 3 distinct mechanisms: primary rumination, secondary rumination, and supragastric belch-associated rumination. Combined manometry-impedance can distinguish rumination from gastroesophageal reflux disease. Treatment of the rumination syndrome consists of a thorough explanation of the mechanisms underlying the rumination episodes and behavioral therapy. As behavioral therapy is a time-consuming and often expensive treatment, we propose that a clinical suspicion of the disorder is always confirmed by a manometry-impedance measuremen

The Pathophysiology, Diagnosis and Treatment of Excessive Belching Symptoms

Excessive belching is a commonly observed complaint in clinical practice that can occur not only as an isolated symptom but also as a concomitant symptom in patients with gastroesophageal reflux disease (GERD) or functional dyspepsia. Impedance monitoring has revealed that there are two mechanisms through which belching can occur: the gastric belch and the supragastric belch. The gastric belch is the result of a vagally mediated reflex leading to relaxation of the lower esophageal sphincter and venting of gastric air. The supragastric belch is a behavioral peculiarity. During this type of belch, pharyngeal air is sucked or injected into the esophagus, after which it is immediately expulsed before it has reached the stomach. Patients who belch excessively invariably exhibit an increased incidence of supragastric, not of gastric belches. Moreover, supragastric belches can elicit regurgitation episodes in patients with the rumination syndrome and sometimes appear to induce reflux episodes as well. Behavioral therapy has been proven to decrease belching complaints in patients with isolated excessive belching, but its effect is unknown in frequently belching patients with GERD, functional dyspepsia or ruminatio

Efficacy of Treatment for Patients With Achalasia Depends on the Distensibility of the Esophagogastric Junction

BACKGROUND & AIMS: Many patients with persistent dysphagia and regurgitation after therapy have low or no lower esophageal sphincter (LES) pressure. Distensibility of the esophagogastric junction (EGJ) largely determines esophageal emptying. We investigated whether assessment of the distensibility of the EGJ is a better and more integrated parameter than LES pressure for determining efficacy of treatment for patients with achalasia. METHODS: We measured distensibility of the EGJ using an endoscopic functional luminal imaging probe (EndoFLIP) in 15 healthy volunteers (controls; 8 male; age, 40 +/- 4.1 years) and 30 patients with achalasia (16 male; age, 51 +/- 3.1 years). Patients were also assessed by esophageal manometry and a timed barium esophagogram. Symptom scores were assessed using the Eckardt score, with a score 3 (1.6 +/- 0.3 vs 4.4 +/- 0.5mm(2)/mm Hg; P = .001). Even when LES pressure was low, EGJ distensibility could be reduced, which was associated with impaired emptying and recurrent symptoms. CONCLUSIONS: EGJ distensibility is impaired in patients with achalasia and, in contrast to LES pressure, is associated with esophageal emptying and clinical response. Assessment of EGJ distensibility by EndoFLIP is a better parameter than LES pressure for evaluating efficacy of treatment for achalasi

Impedance measurements and high-resolution manometry help to better define rumination episodes

Rumination syndrome is a disorder of unknown etiology characterized by regurgitation of recently ingested food. We aimed to improve the diagnosis of rumination syndrome by classification of separate rumination symptoms using (1) an ambulatory manometry/impedance (AMIM) measurement and (2) a single-catheter high-resolution manometry/impedance (HRIM) measurement. A total of 96 symptoms during AMIM and 37 symptoms during HRIM were analyzed in five patients with clinically diagnosed rumination syndrome. AMIM identified rumination events in 85 out of 96 reported symptoms (symptom index (SI): 89%). Of these events, 63% were non-acidic and would have been missed by pH-metry. HRIM identified 32 out of 37 reported symptoms (SI: 86%). Upper esophageal sphincter (UES) relaxation was observed during all rumination events identified by HRIM and could be an additional criterion in the definition of rumination events. Impedance measurement and high-resolution manometry contribute to a more detailed description of rumination events. Rumination events defined as gastric strain, common cavity phenomenon, retrograde esophageal fluid flow, and UES relaxation show a high SI when measured with AMIM or single-catheter HRI

Effects of anxiety and depression in patients with gastroesophageal reflux disease

Increased levels of anxiety and depression have been associated with esophageal hyperalgesia and an increased risk of gastroesophageal reflux disease (GERD). We investigated the effects of anxiety and depression on GERD symptoms and the perception of reflux episodes in a well-characterized group of patients. We performed a prospective study of 225 consecutive patients who had symptoms of GERD evaluated. Patients underwent ambulatory 24-hour pH impedance monitoring, and levels of anxiety and depression were assessed using the Hospital Anxiety and Depression Scale. GERD was diagnosed in 147 patients (78 patients had functional heartburn); 36 patients were hypersensitive to gastroesophageal reflux. Among patients with GERD, increased levels of anxiety were associated with more severe retrosternal pain and retrosternal burning. Furthermore, increased levels of anxiety and depression each were associated with lower scores of the mental component of quality of life questionnaire. Levels of anxiety or depression were not associated with the number of reflux symptoms reported during 24-hour pH impedance monitoring or with the number of symptoms associated with a reflux event. Among GERD patients with hypersensitivity to reflux, levels of anxiety and depression and decreases in quality of life were similar to those of other patients with GERD. Patients with functional heartburn had higher levels of anxiety than patients with GERD. In patients with GERD, increased levels of anxiety are associated with increased severity of retrosternal pain and heartburn and reduced quality of life. Patients with GERD with hypersensitivity to gastroesophageal reflux have similar levels of anxiety and similar quality-of-life scores as other patients with GER