A Rare Case of Coincident Barrettʼs Esophagus in Untreated Achalasia

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Achalasia is characterized by failure of the lower esophageal sphincter (LES) to relax, with high basal LES pressure as well as failure of esophageal peristalsis. The disease manifests with primary symptoms of dysphagia and regurgitation. In contrast, Barrett's esophagus is linked to chronic gastroesophageal reflux disease (GERD) that results from chronic acid exposure related to excessive relaxation of the LES. This makes coexistence of conditions unusual. We report a case in which achalasia and Barrett's esophagus were diagnosed prior to treatment for achalasia. A 31-year-old male with a five-year history of GERD presented for evaluation of progressively worsening symptoms. Reflux symptoms had increased in frequency with several episodes of vomiting. Lifestyle modifications were recommended and he was started on daily omeprazole. One year later, he continued to complain of reflux symptoms, though he had noted some improvement. He had difficulty swallowing, with regurgitation of undigested food. A barium esophagram suggested achalasia. Esophagogastroduodenoscopy demonstrated narrowing of the gastroesophageal junction with a dilated esophagus, as well as a short tongue of salmon-colored mucosa (Prague classification C0M1). Histology demonstrated intestinal metaplasia without dysplasia. High-resolution esophageal manometry demonstrated a pattern consistent with type II achalasia. Laparoscopic Heller's myotomy was recommended, but the patient declined intervention. He was treated with submucosal injection of botulinum toxin with temporary symptom relief. Barrett's esophagus and achalasia do not typically co-exist, as they result from opposing dysfunctions of the LES. When achalasia is treated, excess acid reflux may occur from the resulting laxity of the LES, eventually leading to Barrett's esophagus in some patients. However, the diagnosis of both conditions in an individual patient prior to surgical or endoscopic interventions is exceedingly rare. This case reinforces the importance of careful inspection of the distal esophageal mucosa in patients with achalasia, as a patient with Barrett's esophagus at baseline may be at increased risk of progression of the Barrett's segment following therapeutic interventions.