It has been noted that patients with achalasia often develop gastroesophageal reflux (GER)-related symptoms and complications following per-oral endoscopic myotomy (POEM). It is considered that the reflux symptoms occur as a result of GER and the current treatment of post-POEM GER is aimed at acid suppression using proton pump inhibitors (PPI).

A recent review by Ramchandani and colleagues discussed about the mechanisms behind reflux symptoms in achalasia patients after POEM and the therapeutic interventions tailored to each mechanism.

Reflux symptoms in patients with achalasia after POEM can occur as a result of true reflux, nonreflux esophageal acidification on account of stasis or acid fermentation, or esophageal hypersensitivity to chemical or mechanical stimuli. True acidic reflux is not necessarily the reason behind reflux symptoms every time. It is thus important to conduct 24-hour pH monitoring with impedance in order to distinguish between the causes of esophageal acidification.

PPI therapy can help only in true acidic reflux. In order to detect acid fermentation, manual review of a 24-h pH study needs to be done, since an automated review may overestimate acid exposure time because it is not capable of differentiating true reflux from fermentation.

Stasis of ingested acidic food calls for assessment of esophageal emptying using timed barium esophagogram. If there is inadequate emptying, assessment of esophagogastric junction (EGJ) distensibility can be done using a functional lumen imaging probe. Impaired distensibility along with inadequate emptying points to failure of treatment intervention. Esophageal hypersensitivity must be considered in treatment-refractory patients and neuromodulators should be used.

The diagnostic approach to post-POEM reflux symptoms must develop to determine the patterns of esophageal acidification, esophageal emptying patterns, distensibility of EGJ, and hypersensitivity. The treatment of GER after POEM must involve other causes of acidification and esophageal hypersensitivity besides esophageal acidification by reflux.

Source: Ramchandani M, Pal P, Singla N, Reddy DN. Post-per-oral endoscopic myotomy heartburn: Its not always reflux: Expert review. Dig Endosc. 2022 Jan;34(2):325-333.