Heller's myotomy; Belching; Thoracic painMiotomia de Heller; Eructes; Dolor toràcicMiotomía de Heller; Eructos; Dolor torácic

Aguilar, Ariadna

Alcalá-González, Luis Gerardo

Quiroga Gómez, Sergi

Serra, Jordi

United European Gastroenterology Journal

English

Scientia, Dipòsit d’Informació Digital del Departament de Salut

Received: 16 September 2024 - Accepted: 30 September 2024DOI: 10.1002/ueg2.12692C L I N I C A L IMAG ERecurrent symptoms after achalasia treatment: The value ofimpedance analysisLuis G. Alcala‐Gonzalez1 | Ariadna Aguilar‐Cayuelas1,2 | Sergi Quiroga3 |Jordi Serra1,21Digestive System Research Unit, Department of Digestive Diseases, Vall d’Hebron University Hospital, Barcelona, Spain2Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd), Barcelona, Spain3Radiology Department, Vall d’Hebron University Hospital, Barcelona, SpainCorrespondenceLuis G. Alcala‐Gonzalez, Digestive System Research Unit, University Hospital Vall d'Hebron, Barcelona 08035, Spain.Email: luisgerardo.alcala@vallhebron.catK E YWORD Sbelching, esophageal manometry, esophagus, failure, Heller's myotomy, motility disorders, nissen fundoplication, therapy, thoracic painCASE SUMMARYWe present the case of a 51‐year‐old female patient with a history oftype 3 achalasia, who underwent Heller's myotomy and laparoscopicNissen fundoplication (LNF) in 2018. Postoperatively, she experiencedrecurrent episodes of thoracic and epigastric pain after meals. Hersymptoms were unresponsive to pharmacological treatment, prompt-ing a referral to our center in 2024 for evaluation of Per‐oral endo-scopic myotomy (POEM). A barium esophagogram showed a non‐dilated esophagus with normal barium clearance, and episodes ofabrupt esophageal dilation after swallowing, with gas entrapment inthe gastric fundus (Figure 1). Subsequent High‐resolution manometry(HRM) with impedance showed a normal esophagogastric junctionresponse to swallowing, absent peristalsis (supplementary material),and confirmed the presence of supragastric belches seenon the bariumesophagogram, followed by episodes of gastric (abdominal) andesophageal pressurization associated with repetitive supragastricbelches (Figure 2). She was diagnosed with gas‐bloat syndrome withsecondary supragastric belches. POEM was not performed, and a flapre‐do surgery was recommended.DISCUSSIONThe differential diagnosis of recurrent symptoms in patientstreated for achalasia is broad, including incomplete disruption ofthe lower esophageal sphincter (LES), residual spastic contractions,anatomical abnormalities or LNF‐associated complications.1,2Gas‐bloat syndrome is a recognized complication of LNF, charac-terized by epigastric pain, bloating, and abnormal belching pat-terns, likely as an ineffective attempt to vent trapped air.3 In HRMstudies, esophageal pressurizations and spastic contractions frombolus compartmentalization (suggestive of LES obstruction) may beindistinguishable from other causes of esophageal pressurizationssuch as abdomino‐thoracic straining to clear trapped air.The presence of esophageal dilation episodes (Figure 1) andthe concomitant supragastric belches and gastroesophagealpressurization observed on HRM with impedance (Figure 2)demonstrate the benefit of impedance in evaluating patients withtreated achalasia, as it allows for the assessment of bothbolus clearance and gas movement, leading to a more precisediagnosis.This is an open access article under the terms of the Creative Commons Attribution‐NonCommercial‐NoDerivs License, which permits use and distribution in anymedium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.© 2024 The Author(s). United European Gastroenterology Journal published by Wiley Periodicals LLC on behalf of United European Gastroenterology.488 - United European Gastroenterol J. 2025;13:488–490. wileyonlinelibrary.com/journal/ueg2AUTHOR CONTRIBUTIONSLuis G Alcala‐Gonzalez, Ariadna Aguilar‐Cayuelas and Jordi Serraparticipated equally in conceptualization, data curation, supervision,writing, editing and reviewing. Sergi Quiroga provided the radiolog-ical images and revised the final manuscript.ACKNOWLEDGMENTSNone.CONFLICT OF INTEREST STATEMENTAll authors declare no conflicts of interest.DATA AVAILABILITY STATEMENTThedata that support the findings of this study are available on requestfrom the corresponding author. The data are not publicly available dueto privacy or ethical restrictions.INFORMED CONSENT STATEMENTInformed consent was obtained from the patient for the publicationof this case.ORCIDLuis G. Alcala‐Gonzalez https://orcid.org/0000-0002-8332-5139Ariadna Aguilar‐Cayuelas https://orcid.org/0000-0002-2040-311XSergi Quiroga https://orcid.org/0000-0001-8671-7616Jordi Serra https://orcid.org/0000-0003-2120-6270REFERENCES1. Oude Nijhuis RAB, Zaninotto G, Roman S, Boeckxstaens GE, FockensP, Langendam MW, et al. European guidelines on achalasia: unitedEuropean gastroenterology and European society of neuro-gastroenterology and motility recommendations. United Eur Gas-troenterol J. 2020;8(1):13–33. https://doi.org/10.1177/20506406209032132. Milito P, Siboni S, LoveceA, Andreatta E, Asti E, Bonavina L. Revisionaltherapy for recurrent symptoms after Heller myotomy for achalasia. JGastrointest Surg. 2022;26(1):64–9. https://doi.org/10.1007/s11605‐021‐05098‐83. Broeders JA, Bredenoord AJ, Hazebroek EJ, Broeders IA, GooszenHG, Smout AJ. Effects of anti‐reflux surgery on weakly acidic refluxF I GUR E 1 Barium esophagogram demonstrating a normalesophagus with proper clearance of barium contrast (left whitearrows). Following the swallowing, abrupt esophageal dilation isobserved (right white arrows). In both images, a gastric bubble oftrapped air is clearly visible in the fundus (yellow arrow).F I GUR E 2 High‐resolution manometry with impedance tracing illustrating a supragastric belch (white arrows) followed by two episodes ofabdominal and esophageal pressurization (a and b), likely representing straining efforts to release trapped air from the stomach, as observedon a barium esophagogram.ALCALA‐GONZALEZ ET AL. - 489 20506414, 2025, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/ueg2.12692 by Spanish Cochrane National Provision (Ministerio de Sanidad), Wiley Online Library on [25/04/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons Licenseand belching. Gut. 2011;60(4):435–41. https://doi.org/10.1136/gut.2010.224824SUPPORTING INFORMATIONAdditional supporting information can be found online in the Sup-porting Information section at the end of this article.How to cite this article: Alcala‐Gonzalez LG, Aguilar‐CayuelasA, Quiroga S, Serra J. Recurrent symptoms after achalasiatreatment: The value of impedance analysis. United EuropeanGastroenterol J. 2025;13(3):488–90. https://doi.org/10.1002/ueg2.12692490 - UNITED EUROPEAN GASTROENTEROLOGY JOURNAL 20506414, 2025, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/ueg2.12692 by Spanish Cochrane National Provision (Ministerio de Sanidad), Wiley Online Library on [25/04/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License

Recurrent symptoms after achalasia treatment: The value of impedance analysis

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Recurrent symptoms after achalasia treatment: The value of impedance analysis

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