What are the potential causes and management options for a middle-aged or older adult with a history of achalasia and previous Peroral Endoscopic Myotomy (POEM) surgery, who continues to experience occasional chest pain?

Post-POEM Chest Pain: Critical Surveillance and Management

This patient requires urgent evaluation for gastroesophageal reflux disease (GERD) and its complications, as well as assessment for disease progression or treatment failure, given the high-risk nature of post-POEM patients two years out from surgery. 1

Primary Concerns to Evaluate

GERD and Erosive Esophagitis (Most Common Cause)

• 41-65% of post-POEM patients develop esophagitis, with 25% being asymptomatic 1
• Chest pain may represent symptomatic reflux or complications of silent erosive disease 1
• Objective testing with endoscopy and pH monitoring is mandatory - symptoms alone are insufficient to rule out pathologic acid exposure 1
• Up to 31% of patients with initially normal endoscopy develop esophagitis at subsequent surveillance (mean 29 months), including Barrett's esophagus in some cases 1

Disease Progression or Treatment Failure

• 10-15% of patients experience persistent or recurrent symptoms after initial myotomy 1
• Achalasia is a chronic progressive condition requiring ongoing surveillance 1
• Chest pain may indicate incomplete myotomy or disease recurrence 1

Esophageal Cancer Risk

• Patients with achalasia have a 5-fold increased risk of esophageal cancer (HR 4.6; 95% CI 2.3-9.2) 1
• This elevated risk persists after treatment and warrants endoscopic surveillance 1

Immediate Diagnostic Workup Required

Comprehensive Evaluation Protocol

• Upper endoscopy to assess for erosive esophagitis, Barrett's esophagus, strictures, and malignancy 1
• 24-hour pH monitoring (off PPI for 7 days) to objectively document pathologic acid exposure 1
• High-resolution manometry (HRM) to assess lower esophageal sphincter function and rule out treatment failure 1
• Timed barium esophagram to evaluate structural changes, esophageal clearance, and EGJ opening 1

Critical Diagnostic Nuance

• Reflux symptoms after POEM may not be due to acid reflux - consider nonreflux esophageal acidification from food stasis, acid fermentation, or visceral hypersensitivity 1
• Objective testing distinguishes true pathologic reflux from these alternative etiologies 1

Management Based on Findings

If GERD/Esophagitis Confirmed

• Optimize PPI therapy - ensure proper timing (30-60 minutes before meals) for adequate absorption 1
• Lifelong PPI therapy is likely required given the 41-56% rate of abnormal acid exposure post-POEM 1
• If persistent esophagitis despite PPI, consider additional testing for other etiologies and escalate reflux management 1

If Treatment Failure Suspected

• Comprehensive re-evaluation must include repeat EGD, HRM, and timed barium esophagram at minimum 1
• Repeat POEM may be superior to pneumatic dilation for failed initial POEM (62% vs 27% success rate in randomized trial) 1
• Decision should account for etiology of failure, local expertise, and patient preferences 1

If Findings Are Normal

• Consider visceral hypersensitivity, esophageal spasm, or non-esophageal causes of chest pain 1
• Maintain surveillance protocol regardless of symptom resolution 1

Long-Term Surveillance Strategy

Ongoing Monitoring Requirements

• Endoscopic surveillance is strongly recommended for all post-POEM patients to monitor disease progression and identify asymptomatic GERD complications 1
• Consider alternating esophagram and endoscopy to monitor structural changes, esophageal clearance, and mucosal abnormalities 1
• Integrate FLIP (functional lumen imaging probe) during endoscopy to assess EGJ opening 1
• Specific surveillance intervals remain under investigation, but regular monitoring is essential given cancer risk and high rate of silent esophagitis 1

Critical Pitfalls to Avoid

• Never rely on symptoms alone - 25% of patients with erosive esophagitis are asymptomatic 1
• Do not assume chest pain is benign - it may herald serious complications including esophagitis, Barrett's, or malignancy 1
• Do not delay objective testing - erosive disease can progress to strictures or Barrett's esophagus if unrecognized 1, 2
• Do not discontinue surveillance even if initial post-POEM endoscopy was normal - delayed esophagitis development is common 1