The relationship between gastro-oesophageal reflux symptoms and achalasia

Patients with achalasia can experience heartburn, which may be misinterpreted as gastro-oesophageal reflux disease (GORD), leading to a delay in diagnosis and subsequent treatment. We investigated the relationship between gastro-oesophageal reflux (GOR) and reflux symptoms in a large cohort of patients with achalasia.

The symptoms of all patients with a manometric diagnosis of achalasia made over the past 15 years were studied. The types of treatment, onset and pattern of heartburn, lower oesophageal sphincter pressure (LOSP) and 24-h oesophageal pH studies were compared.

A total of 110 out of 225 untreated (48.9%) and 57 out of 99 treated (57.6%) patients experienced heartburn. An oesophageal pH study was performed on 80 patients and GOR was found in only six out of 57 untreated (10.5%) and 10 out of 23 treated (43.5%) patients. A low LOSP (<10 mmHg) was associated with an increased risk of GOR [odds ratio (OR) 14.2; 95% confidence interval (CI) 1.6-128.7; P<0.02). Treated patients were also more likely to develop GOR (OR 7.9; 95% CI 2.0-32.1; P<0.005). Neither the LOSP nor previous treatment was, however, a predictor of heartburn. The timing of the onset of dysphagia and heartburn was categorized in 111 patients. There was no significant difference in mean (or median) LOSP between these three groups, indicating that the LOSP is unlikely to predict the occurrence of symptoms.

Heartburn is common in patients with untreated and treated achalasia, but is a poor predictor of GORD. Such patients should always be investigated with a 24-h oesophageal pH study to clarify the presence of GORD.