Case Study 4: Chest Pain, Heartburn, Regurgitation, Mid/Low Dysphagia and Mild Gastritis

A 61-year-old patient presented with chest pain, heartburn, regurgitation and mid/low dysphagia.  AN OGD showed mild gastritis and there was no hiatus hernia visible.

High resolution manometry and 24-hour pH/impedance reflux monitoring was carried out.

High Resolution Manometry

HRM results showed the following:

  • The upper oesophageal sphincter was hypertensive and showed incomplete relaxation on wet swallows.
  • The oesophagus produced panoesophageal pressurisations on ≥ 20% of swallows and no peristaltic contraction.
  • The lower oesophageal was normotensive and showed incomplete relaxation on wet swallows.
  • There was a 1.3 cm hiatus hernia.

These results based on the Chicago Classification indicated Type II Achalasia (with oesophageal compression).  However, there was clear pathological reflux which is not common in achalasia.  A small hiatus hernia was also detected by HRM. 

24-hour pH-Impedance Reflux Monitoring Off PPI

The pH-impedance reflux monitoring showed the following results:

  • Distal sensor at 31.5 (5 cm above the LSO up-border) and the test showed gastric acid starting from 39 cm (LOS lower-borer) and IP at 40.1 cm (indicating a small hiatus hernia).
  • Proximal oesophagus: total 0 episodes, normal <31 (impedance).
  • Distal oesophagus: total 12.5%, normal < 4.2%; upright 20.9%, normal <6.3%; supine 0%, normal < 1.2%; DeMeester score: 33.9, normal <14.72; number of reflux events (impedance): total 14, normal < 73 (off PPI).
  • Reflux symptom correlations: chest pain 10 episodes, SI = 10%, SAP = 0%; regurgitation 2 episodes, SI = 50%, SAP = 0%; heartburn 5 episodes, SI = 0%, SAP = 0%; positive SI ≥ 50%, positive SAP > 95%.

 Interpretation and Next Steps

  1. Type II achalasia was indicated however since there is clear pathological reflux which is not common in achalasia, pseudo-achalasia resultant from chronic acid reflux (not a common aetiology) or other causes such as malignancies need to be excluded (EUS/CT Scan).  A treatment plan could potentially include hiatus hernia repair and gastroesophageal junction dilatation.
  2. High intra-gastric pressure (>20 normal is about 6 – 10 mm Hg) may influence GORD.
  3. Post treatment re-evaluation could be valuable for the future approach to this patient as literature is lacking in the area particularly using pH-impedance monitoring.

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