1763 Chronic Opioid Use and EGJ Outflow Obstruction: An Important Culprit to Address Before Expensive Management

Abstract

INTRODUCTION: With the opioid epidemic on the rise, a more thorough understanding of opioid’s side effects on esophageal motility is necessary. Esophageal motility disorders are an unrecognized association with opioid use. CASE DESCRIPTION/METHODS: Case 1: 58-year old female was referred to our clinic for second opinion. She presented with has intermittent solid and fluid dysphagia with sensations of food stuck in her esophagus and subsequent development of severe chest pain. She has a history of a cervical fracture and has been on oxycodone 15 mg TID. Extensive workup was performed, including endoscopy, EUS, CAT scan, cardiac stress test, all of which were negative. HRM showed EGJ outflow obstruction and features of jackhammer esophagus. Her esophagram showed delayed emptying of LES. Case 2: 65-year old female with history of skull fracture and was on hydromorphone 4 mg every 4 hours. She presents with weight loss, esophageal dysphagia, recurrent aspiration pneumonia, and refractory reflux. Upper endoscopy showed hypertonic LES with resistance passing the scope. Barium study showed delayed passage of tablet at the EGJ. HRM showed EGJ outflow obstruction. Symptoms improved with reduction of opioid dose. DISCUSSION: While opiates are known to cause gastrointestinal distress, their effect on esophageal motility is recently being investigated. As the opioid epidemic continues to grow and spread both in the US and abroad, it is vital for health care providers to recognize underreported symptoms caused by opioids. One of the symptoms recently identified in association with opioid use is dysphagia. It has been shown that the lower esophageal sphincter contains opioid receptors which when activated, elicit pathologic deglutition. EGJ outflow obstruction can be caused by chronic opioid use. Achalasia, jackhammer, and esophageal spasm have also been reported with opioid use, although this is less established. When encountering esophageal motility disorder in patients with chronic opioid use, providers should first attempt to reduce opioid dose, instead of using more invasive techniques such as myotomy and dilation. Babaei A, et al. Chronic daily opioid exposure is associated with dysphagia, esophageal outflow obstruction, and disordered peristalsis. Neurogastroenterol Motil. 2019 Ravi, K et al. Achalasia and chronic opiate use: innocent bystanders or associated conditions? Dis Esophagus. 2016;29:15‐21.