Author reply to Letter to the Editor: ‘Functional heartburn’: symptom for achalasia or hypertensive lower oesophageal sphincter? – Riegler et al.

Abstract

Sirs, We greatly appreciate the opportunity to further clarify the methodology of our routine daily activity adopted in our study.1 All patients referred to our open-access gastrointestinal service undergo a detailed interview and both specific and aspecific symptoms of GERD and dyspepsia are scored, dysphagia included. We omitted to report about the latter symptom but it was neither dominant nor co-dominant in any of our patients who finally received a diagnosis of functional heartburn (FH). The score for dysphagia was 0 (none) and 1 (mild; symptom could be ignored and was recalled only after specific inquiring) in 36 and 25 of the 61 FH cases, respectively. Oesophageal manometry is always performed before pH-monitoring in patients referred to our service using an 8-channel, water-perfused manometry catheter. With the stationary pull-through technique the lower oesophageal sphincter (LOS) is identified, and then, at each 0.5 cm station, the basal tone is measured at the end of expiration and the relaxation is assessed with wet swallows; the pressure inversion point is routinely identified. Oesophageal body peristalsis is assessed and pressures measured with at least 10 wet swallows. The upper oesophageal sphincter is finally identified and the catheter removed. By means of oesophageal manometry, we identified 36 new cases of achalasia (incomplete relaxation of the LOS and aperistalsis in the body of the oesophagus), and seven new cases of hypertensive LOS (some preserved peristalsis, mean resting LOS pressure >45 mmHg and/or LOS relaxation incomplete or of inadequate duration) during the study period (from February 1999 to February 2004). Heartburn score was 2 (moderate; symptom could not be ignored and was spontaneously reported, but neither daily activities nor sleep were influenced) and 1, in two and three of the 36 achalasia cases, respectively. Among the seven patients with hypertensive LOS the heartburn score was 1 in one case and 3 (severe; symptom influenced daily activities and/or sleep) in one case. However, achalasia and hypertensive LOS patients neither received a diagnosis of FH nor entered the study. The term FH has been proposed for endoscopy-negative patients with episodic retrosternal burning in the absence of pathological gastro-oesophageal reflux, pathology-based motility disorders or structural explanations.2 In our series, the diagnosis of FH was based on normal endoscopic (apart from hiatal hernia) and pH-metric findings, as well as on an adequate LOS relaxation with wet swallows at oesophageal manometry (pressure <8 mmHg above gastric pressure, the LOS contracting after it is traversed by the peristaltic wave).3 Patients who were not able to undergo an oesophageal manometric evaluation before pH-metric assessment were excluded from the study. Therefore, achalasia and hypertensive LOS were all firmly excluded in our series. We are pleased to reassure Dr Riegler and co-workers that the diagnosis of FH in our study was made with a high level of accuracy.