HEARTBURN IN PATIENTS WITH ACHALASIA

Heartburn, the main symptom of gastrooesophageal reflux disease (GORD) , might be expected to occur infrequently in achalasia, a disorder cha racterised by a hypertensive lower oesophageal sphincter (LOS) that fa ils to relax. Nevertheless, it is often described by patients with ach alasia. The medical records of 32 patients with untreated achalasia wh o complained of heartburn, and of 35 similar patients who denied the s ymptom, were reviewed to explore the implications of heartburn in this condition. Data on endoscopic and manometric findings, and on the ons et and duration of oesophageal symptoms were collected. Three patterns of heartburn were observed: (1) in 8 patients (25%) the onset of hear tburn followed the onset of dysphagia, (2) in 15 patients (47%) heartb urn preceded the onset of dysphagia and persisted as dysphagia progres sed, and (3) in 9 patients (28%), heartburn preceded the onset of dysp hagia and stopped as dysphagia progressed. The mean (SD) basal LOS pre ssure in the patients with heartburn (38 (16) mm Hg) was significantly lower than that in patients without the symptom (52 (26) mm Hg); the lowest LOS pressure (29 (11) mm Hg) was observed in the subset of pati ents whose heartburn preceded the onset of dysphagia and then stopped. It is concluded that patients who have achalasia with heartburn have lower basal LOS pressures than patients who have achalasia without thi s symptom. In some patients with achalasia, the appearance of dysphagi a is heralded by the disappearance of longstanding heartburn. For thes e patients, it is speculated that achalasia develops in the setting of underlying GORD.