A Case Report on Peroral Endoscopic Myotomy for Achalasia Cardia with Dilated Esophagus: A Minimally Invasive Victory

Abstract

Achalasia cardia is a rare esophageal smooth muscle motility disorder that occurs due to a failure of relaxation of the lower esophageal sphincter. This condition causes a functional obstruction at the gastroesophageal junction. This condition is characterized by impaired esophageal peristalsis and LES relaxation. It can be leading to difficulty in swallowing, regurgitation, and other digestive issues. A 20-year-old female patient came in gastroenterology department with complaints of multiple episodes of vomiting of 1-week duration. She had multiple episodes of vomiting and dysphagia during this period. The patient was having no family or social history. She had a known history of achalasia cardia for which she had previously undergone balloon dilatation. However, this intervention had been unsuccessful in alleviating the symptoms. Upon admission, the patient underwent endoscopic evaluation, which confirmed the diagnosis of achalasia cardia. The endoscopic findings revealed a dilated esophagus, a classic sign of the condition, indicative of the esophageal motility disorder where the lower esophageal sphincter (LES) fails to relax properly. The patient's history of inadequate response to balloon dilatation lead to proceed with a Peroral Endoscopic Myotomy (POEM), a more advanced and minimally invasive treatment approach. The POEM procedure was performed successfully, involving the creation of an incision in the esophageal mucosa, followed by myotomy (cutting) of the LES muscle, which is aimed at restoring normal esophageal function by relieving the obstruction. Following the POEM procedure, the patient experienced significant symptomatic relief, with a reduction in vomiting and an improvement in ability to swallow. No immediate complications were noted, and the patient was discharged after a short recovery period. This case report emphasizes the need of early diagnosis and utilization of proper therapeutic techniques.

Keywords

Introduction

Figure 1: Upper GI Endoscopy

5. Diagnosis

Achalasia Cardia (Type I) with marked esophageal dilation and food stasis, likely long-standing and advanced.

5. MANAGEMENT AND PROCEDURE

Management was done with IV antibiotics, T. ESOMEPRAZOLE, and other symptomatic treatment was provided.

• POEM (Peroral Endoscopic Myotomy):

POEM ia s minimally invasive endoscopic procedure used to treat achalasia. It is also use to treat other swallowing disorders as well. POEM is used to perform a myotomy of LES (Lower Esophageal Spinchter) for treatment of achalasia which relieves symptoms in around 90% and also results in a quick recovery. POEM is a form of natural orifice transluminal endoscopic surgery that is completed by creating a subucosal tunnel in the lower part of esophagus to reach the inner circulation muscle bundles of the LES to perform myotomy, while preserving the outer longitudinal muscle bundles. It results in the decreased resting pressure of the LES, facilitating the passage of the ingested food materals. In this case POEM performed successfully under general anesthesia. A mucosal incision was made on the posterior esophageal wall, and submucosal tunneling was carried out. Myotomy was completed up to the LES and a few centimeters into the gastric cardia. The mucosal entry was closed with endoscopic clips. There were no intraoperative complications. Postoperative recovery was uneventful. The patient was started on liquids, progressing to soft solids over 3 days. She reported significant improvement in swallowing within one week of the procedure and was discharged on Day 5 post-POEM. Advice on discharge was to take T. CEFIXIME 200 mg 1-0-1 for 5 days, T. SOMPRAZ (ESOMEPRAZOLE) 80 mg, 1-0-1 & SYP. SUCRAFIL (SUCRALFATE) 10 ml 1-1-1 for 10 days.

5. Clinical Significance

• Early Diagnosis: Delayed diagnosis can lead to megaesophagus, malnutrition, and increased risk of aspiration.
• POEM as First-Line Therapy: Demonstrates the safety and efficacy of POEM even in patients with advanced dilation.
• Minimally Invasive Option: Offers quicker recovery, less postoperative discomfort, and no external scars.
• To describe the clinical presentation and symptoms of achalasia cardia.
• To outline the diagnostic approach, including the role of endoscopy in confirming the condition.
• To explore the management strategies for achalasia cardia, with a particular focus on the effectiveness of Peroral Endoscopic Myotomy (POEM) as a therapeutic intervention.
• To emphasize the benefits of POEM in providing symptomatic relief for patients with achalasia cardia, especially those who have not responded to conventional treatments.

DISCUSSION

Achalasia cardia is an idiopatic condition that causes a functional obstruction at the gastroesophageal junction. It occurs when nerves in the esophagus become paralyzed and dilated over time leading to abnormal functioning of the esophageal smooth muscle. It occurs when nerves in the esophagus become paralyzed and dilated over time. The symptoms presented by the patient include dysphagia, regurgitation & vomiting (especially after taking food), weight loss. In this case the patient’s young age with advanced achalasia and esophageal dilation is significant. Challenges faced by patients with achalasia includes difficulty in swallowing food, indigestion of food and its regurgitation, weight loss and malnutrition, sleep disturbance and psychological disturbances, etc. Similarly, Deepak Subedi, et al. documented a case report of achalasia cardia in a young female. They used various diagnostic procedures such as endoscopy, barium esophagogram, manometry to find out the condition [12]. Early diagnosis remains as a challenge as achalasia is a rare condition. Diagnostic clarity through endoscopic imaging without the need for barium swallow or manometry (not commonly available in all settings) was done. Early diagnosis was clinically relevant here.  In a case report by Evsyutina YV, et al. the diagnostic procedure used was contrast enhanced X-ray examination of the esophagus, esophagogastroduodenoscopy, barium meal test & the treatment provided was with spasmolytics, antacids and 3 sessions of pneumatic dilatation was done in 58-year-old lady [13]. Whereas, endoscopy was used as diagnosis and POEM was done as treatment in this case report. The case report highlights the usage of advanced procedure called POEM which has a wide range of advantages over the pneumatic dilatation and includes less need of retreatment, generally low adverse events & long-term efficacy. Successful utilization of POEM, which is still a developing technique in many parts of the world, especially in resource-limited settings is done. POEM is a minimally invasive option offering quick recover & less postoperative discomfort. Effective use of POEM lead to short hospital stay and rapid recovery [8,9]. POEM is also effective in patients with prior failed interventions. ( Eg: pneumatic dilation) [10,11]. Postoperative recovery was uneventful. The patient was started on liquids, progressing to soft solids over 3 days and reported significant improvement in swallowing within one week of the procedure and was discharged. The early diagnosis and proper usage of POEM technique in this young female lead to an improve in patients’ symptoms and quality of life.

CONCLUSION

Achalasia cardia is a rare esophageal disorder that impairs motility and leads to significant symptoms such as dysphagia and vomiting. Conventional treatments like balloon dilation often fail to provide long-term relief. In this case, POEM proved to be an effective and minimally invasive treatment option, providing significant improvement in the patient's quality of life. POEM offers a promising alternative to conventional therapies, for management of achalasia cardia. This case emphasizes the importance of considering achalasia in young adults presenting with dysphagia, vomiting, etc. The remarkable esophageal dilation and prompt resolution of symptoms post-POEM underscore the necessity of early endoscopic evaluation and the efficacy of minimally invasive techniques in treating even advanced cases.

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