, Volume 42, Issue 7, pp 1354-1361

Gastroesophageal Reflux in Achalasia (When Is Reflux Really Reflux?)

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Abstract

An abnormal score during 24-hr esophageal pHmonitoring in achalasia may be associated either with aslow steady drift to below pH 4, or else multiple sharpdips characteristic of typical gastroesophageal reflux. To test the hypothesis that the formerpattern was due to food fermentation and not reflux,samples of chewed bland food (N = 22) were incubatedwith saliva at 37°C for 24 hr and the pH monitored (in vitro study). Further, the pH tracings of20 patients with achalasia before operation and 12patients after operation were studied (in vivo study).The pH of chewed food fell to a median of pH 4.0 during incubation and in seven of 22 samplesfell to below pH 4. Preoperatively, four of the fivepatients with an abnormal pH score showed a slow steadydrift, and all of these had evidence of retained food at endoscopy. Postoperatively, three ofthe six patients with an abnormal pH score had a slowsteady drift to below pH 4. Use of pH 3 as a thresholdclearly distinguished true reflux from foodfermentation, since the patients with reflux all had anabnormal percentage of time below pH 3.