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

Abstract

Background: Treatment options for achalasia include endoscopic and surgical techniques that carry the risk of esophageal bleeding and perforation. The rare coexistence of esophageal varices has only been anecdotally described and treatment is presumed to carry additional risk. Methods: Experience from physicians/surgeons treating this rare combination of disorders was sought through the International Manometry Working Group. Results: Fourteen patients with achalasia and varices from seven international centers were collected (mean age 61 AE 9 years). Five patients were treated with botulinum toxin injections (BTI), four had dilation, three received peroral endoscopic myotomy (POEM), one had POEM then dilation, and one patient underwent BTI followed by Heller's myotomy. Variceal eradication preceded achalasia treatment in three patients. All patients experienced a significant symptomatic improvement (median Eckardt score 7 vs 1; p < 0.0001) at 6 months follow-up, with treatment outcomes resembling those of 20 noncirrhotic achalasia patients who underwent similar therapy. No patients had recorded complications of bleeding or perforation. Conclusion: This study shows an excellent short-term symptomatic response in patients with esophageal achalasia and varices and demonstrates that the therapeutic outcomes and complications, other than transient encephalopathy in both patients who had a portosystemic shunt, did not differ to disease-matched patients without varices.

Successful Treatment of Achalasia With Endoscopic Ultrasound–Guided Botulinum Injection in Setting of Esophageal Varices

“…This patient reportedly experienced improvement of dysphagia and was without complication, as described in our patient. 15 Given our experience and evidence from the few previous cases, EUS-guided Botox injection to avoid varices followed by variceal ligation is potentially a safer method for delivering botulinum toxin to the LES.…”

Evaluating the Non-conventional Achalasia Treatment Modalities

“…Some case reports suggested the use of BTX for achalasia during pregnancy (Level 4; Grade: C) (52)(53)(54). Some authors also suggest endoscopic ultrasound-guided BTX injection for treating achalasia patients with esophageal varices (Level 4; Grade: C) (50,55). Theoretically, due to the short-term efficacy, BTX could also be used as a therapeutic test for uncertain esophageal dysmotility conditions (Level 5; Grade: D).…”

Peroral endoscopic myotomy after transjugular intrahepatic portosystemic shunt and variceal embolization for a patient with achalasia and esophageal varices

“…It is technically challenging for endoscopists to implement POEM in patients with esophageal varices 1 . The high risk of bleeding and difficult operation usually caused POEM to be abandoned 2 . In this case, treatment of varices by TIPS plus variceal embolization effectively reduced the risk of bleeding and enhanced the operability of POEM.…”