We present the case of a 28-year-old female who presented for primary care at 22-week gestation with type II achalasia and worsening solid/liquid dysphagia leading to pregnancy weight loss. Considering that durable therapies such as surgical myotomy and pneumatic dilatation have considerable risk, botulinum A toxin injection was selected as a temporizing bridging therapy. She had an uncomplicated post procedure course and had significant rapid improvement in dysphagia symptoms, which enabled her to progress to normal peripartum weight. This case highlights the need for early recognition of achalasia and an unique niche for use of botulinum toxin A as a temporizing therapy in this risk averse population.

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A 22-year-old man ingested 2 tablespoons of elemental mercury from a home chemistry set in a suicide attempt. On presentation, he denied any symptoms. Vital signs and routine laboratory test results were unremarkable. His 24-hour urine mercury test result was 44 ug/L. An acute abdominal series showed scattered radiopaque material throughout the small bowel, large bowel, and right lower lung (Figure A). He was given 4 L polyethylene glycol to facilitate wholebowel irrigation. Serial abdominal plain films showed reduction of radiopaque material and the patient remained asymptomatic. Mercury is found in 3 distinct forms: elemental, organic, and inorganic mercury salts. Elemental mercury is found mainly in thermometers/barometers, dental fillings, and artisanal gold mining. The acute gastrointestinal manifestations are most dramatic with organic and inorganic mercury salts and may include hemorrhagic gastroenteritis. Given that elemental mercury vaporizes at room temperature, most absorption is pulmonary, with little gastrointestinal absorption. Most clinical manifestations of elemental mercury poisoning include stomatitis, cough, chest pains, nausea, vomiting, and diarrhea. Elemental mercury toxicity treatment is based on the patient's symptoms and a 24-hour urine mercury test >100 mcg/L. Those patients should receive chelation therapy and supportive treatment. Performing a bowel preparation to facilitate whole-bowel irrigation also is beneficial to reduce exposure.

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