Peroral Endoscopic Myotomy for the Treatment of Achalasia in a Patient with Esophageal Varices. A Case Report

Abstract

Achalasia is very uncommon, and rarely does achalasia co-exist with esophageal varices. We present a 62-year-old woman who was diagnosed with both achalasia and esophageal varices in December 2014 and had a past history of hematemesis. The patient’s achalasia symptoms’ Eckardt score was 9, and her hepatic function was Child-Pugh grade A6. After comprehensive assessment of the patient’s health and discussion of the pros and cons of various therapies for achalasia, the patient underwent a peroral endoscopic myotomy. She was symptom-free after the operation and had no recurrence of achalasia symptoms at 20-month follow-up. No adverse events were reported. Peroral endoscopic myotomy for achalasia with esophageal varices has not been previously reported in the English literature.Abbreviations: BTI: Botulinum toxin injections; EUS: Endoscopic ultrasonography; GEJ: Gastroesophageal junction; HIFU: High-intensity focused ultrasound; LHM: Laparoscopic Heller myotomy; PD: Pneumatic dilation; POEM: Peroral endoscopic myotomy; TIPS: Transjugular intrahepatic portosystemic shunt.

The treatment of achalasia patients with esophageal varices: an international study

“…Although recognized as one of the most common major esophageal motor disorders, achalasia represents a rare condition with an estimated prevalence of 10 in 10,000 and an incidence rate ranging from 1.07 to up to 2.8 new cases per year per 100,000 population 22 , 23 . The coexistence of esophageal varices with achalasia is therefore infinitely rare, and to the best of our knowledge, is described in literature in only a small number of isolated case reports 3–13 . A common presenting symptom of achalasia is restricted caloric intake and subsequent weight loss.…”

“…22,23 The coexistence of esophageal varices with achalasia is therefore infinitely rare, and to the best of our knowledge, is described in literature in only a small number of isolated case reports. 3–13 A common presenting symptom of achalasia is restricted caloric intake and subsequent weight loss. Malnutrition in patients with cirrhosis is of concern, ranging from 50% up to 90%, rising alongside Child–Pugh score.…”

“…The presence of portal hypertension with varices is infinitely rarely reported to occur in conjunction with achalasia and the choice of treatment in this context represents a challenging therapeutic dilemma, even in specialized centers. To the best of our knowledge, 12 cases reports have been described in the literature with only eight patients having received treatment 3–13 . The limitation of oral food intake and subsequent weight loss observed in achalasia will inevitably have detrimental consequences in cirrhotic patients; significant weight loss and malnutrition could aggravate pre‐existing hypoalbuminemia, precipitating cirrhosis complications (i.e.…”

“…To the best of our knowledge, 12 cases reports have been described in the literature with only eight patients having received treatment. 3–13 The limitation of oral food intake and subsequent weight loss observed in achalasia will inevitably have detrimental consequences in cirrhotic patients; significant weight loss and malnutrition could aggravate pre-existing hypoalbuminemia, precipitating cirrhosis complications (i.e. ascites and spontaneous bacterial peritonitis) and expose patients to cachexia and/or vitamin deficiency and its sequelae.…”

Safe Use of POEM in a Patient With Decompensated Cirrhosis and Severe Achalasia

“…3 Despite this, previous case report series have reported successful POEM in patients with cirrhosis (both with and without esophageal varices). [4][5][6] We present a case of a patient with decompensated Child C cirrhosis and achalasia who underwent successful POEM without immediate complications. To our knowledge, this is the first case report to describe large-volume ascites that was managed peri-POEM with transjugular intrahepatic portosystemic shunt (TIPS) and temporary ascites drain placement.…”