Recurrent symptoms after achalasia treatment: The value of impedance analysis

We present the case of a 51-year-old female patient with a history of type 3 achalasia, who underwent Heller's myotomy and laparoscopic Nissen fundoplication (LNF) in 2018. Postoperatively, she experienced recurrent episodes of thoracic and epigastric pain after meals. Her symptoms were unresponsive to pharmacological treatment, prompting a referral to our center in 2024 for evaluation of Per-oral endoscopic myotomy (POEM). A barium esophagogram showed a non-dilated esophagus with normal barium clearance, and episodes of abrupt esophageal dilation after swallowing, with gas entrapment in the gastric fundus (Figure 1). Subsequent High-resolution manometry (HRM) with impedance showed a normal esophagogastric junction response to swallowing, absent peristalsis (supplementary material), and confirmed the presence of supragastric belches seen on the barium esophagogram, followed by episodes of gastric (abdominal) and esophageal pressurization associated with repetitive supragastric belches (Figure 2). She was diagnosed with gas-bloat syndrome with secondary supragastric belches. POEM was not performed, and a flap re-do surgery was recommended. Barium esophagogram demonstrating a normal esophagus with proper clearance of barium contrast (left white arrows). Following the swallowing, abrupt esophageal dilation is observed (right white arrows). In both images, a gastric bubble of trapped air is clearly visible in the fundus (yellow arrow). High-resolution manometry with impedance tracing illustrating a supragastric belch (white arrows) followed by two episodes of abdominal and esophageal pressurization (a and b), likely representing straining efforts to release trapped air from the stomach, as observed on a barium esophagogram. The differential diagnosis of recurrent symptoms in patients treated for achalasia is broad, including incomplete disruption of the lower esophageal sphincter (LES), residual spastic contractions, anatomical abnormalities or LNF-associated complications.1, 2 Gas-bloat syndrome is a recognized complication of LNF, characterized by epigastric pain, bloating, and abnormal belching patterns, likely as an ineffective attempt to vent trapped air.3 In HRM studies, esophageal pressurizations and spastic contractions from bolus compartmentalization (suggestive of LES obstruction) may be indistinguishable from other causes of esophageal pressurizations such as abdomino-thoracic straining to clear trapped air. The presence of esophageal dilation episodes (Figure 1) and the concomitant supragastric belches and gastroesophageal pressurization observed on HRM with impedance (Figure 2) demonstrate the benefit of impedance in evaluating patients with treated achalasia, as it allows for the assessment of both bolus clearance and gas movement, leading to a more precise diagnosis. Luis G Alcala-Gonzalez, Ariadna Aguilar-Cayuelas and Jordi Serra participated equally in conceptualization, data curation, supervision, writing, editing and reviewing. Sergi Quiroga provided the radiological images and revised the final manuscript. None. All authors declare no conflicts of interest. Informed consent was obtained from the patient for the publication of this case. The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.