Origin of atypical reflux symptoms. A case study showing the importance of reflux composition and posture

In summary we evaluated a 39-year-old man two years after partial esophagectomy and gastroesophageal anastomosis. He had developed recurrent Barrett's esophagus and atypical reflux symptoms. We found free reflux and no antireflux barrier at the hiatus or the esophagogastric anastomosis. Three different reflux techniques performed simultaneously demonstrated that the composition of refluxant varied with posture, explaining the atypical nature of the symptoms. In the left recumbent posture, the refluxate was comprised of acidified liquid and gaseous gastric contents with the patient complaining of heartburn and chest pain. In the right recumbent posture the refluxate was composed of only nonacidic gas, and the patient complained of chest pain without heartburn. We propose that multiple reflux tests performed simultaneously in the setting where a patient experiences his atypical symptoms may help clarify their origin. Furthermore, this case illustrates how posture may dramatically influence refluxant composition.