Post written by Aniruddha Pratap Singh, MD, DM, Neeraj Singla, MD, DM, Ekant Budhwani, MD, Wladyslaw Januszewicz, MD, PhD, Zaheer Nabi, MD, DNB, Nitin Jagtap, MD, DNB, Rakesh Kalapala, MD, DNB, Sundeep Lakhtakia, MD, DM, Santosh Darisetty, DA, Sana Fathima Memon, MBA, Duvuur Nageshwar Reddy, MD, DM, and Mohan Ramchandani, MD, DM, from the Asian Institute of Gastroenterology Hospitals, Hyderabad, India.

The focus of this study was to investigate the incidence of “true acid reflux” in patients undergoing a peroral endoscopic myotomy (POEM) procedure for achalasia by characterizing different acidification patterns through manual analysis of pH tracings.

The symptoms of reflux in achalasia patients undergoing POEM are believed to result from gastroesophageal reflux, and prevalence <58% has been reported, possibly attributed to a lack of specific definitions and measurements of reflux. Current treatment primarily focuses on acid suppression. However, other factors such as nonreflux acidification caused by fermentation or stasis also might play a role.

Our study included one of the largest cohorts of treatment-naïve achalasia patients undergoing POEM. Fifty-four achalasia patients aged 18 to 80 years with predominantly type II achalasia underwent POEM with significant symptomatic improvement. True acid reflux was noted in 29.6% of patients, overestimated as 64.8% on automated analysis. Acid fermentation (AF) was the predominant nonreflux acidification pattern seen in 42.7% of patients.

On multivariable logistic regression analysis, increasing age and preprocedural integrated relaxation pressure were significantly associated with true acid reflux in patients after POEM. Identifying high-risk patients with high preprocedural integrated relaxation pressure >45 mm Hg and age will guide selecting these patients to receive an antireflux procedure at the outset.

Early identification of true acid reflux by manual analysis is crucial because long-term proton pump inhibitors and fundoplication are unnecessary in most patients. Further objective testing with high-resolution manometry and an endoluminal functional lumen imaging probe (EndoFLIP) may be required to offer personalized treatment options for patients with different acidification patterns.

We recommend manual evaluation in all post-POEM patients. The need to consider reducing the pH cutoff to 3 from the existing 4 on ambulatory pH studies to exclude AF on automated analysis in post-POEM patients requires additional research. Future studies also should examine the long-term outcomes in patients who have AF as the dominant acidification pattern.

Acid fermentation patterns on ambulatory 24-hour pH-impedance study. A, Acid reflux with normal clearance. B, Acid reflux with delayed clearance. C, Acid fermentation. D, Stasis of ingested acidic food.

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