INTRASPHINCTERIC BOTULINUM TOXIN IMPROVES DYSPHAGIA IN SUSPECTED PSEUDOACHALASIA

Abstract

Injection of botulinum A toxin into the LES is an accepted therapeutic option for patients with primary achalasia and significant dysphagia who are poor candidates forpneumatic balloon dilation or surgery. However, there are few reports using botox in the treatment of pseudoachalsia-associated dysphagia. We herein describe a case of suspected pseudoachalasia in a patient with squamous cell lung cancer. A 73 yo male presented with dyshagia to solids and liquids ×4 weeks with regurgitation, 10 pound weight loss, and orthopnea. Dysphagia was described as food sticking behind his neck or mid-chest. He denied heartburn or odynophagia. Nine months earlier, pulmonary function testing was performed for mild nocturnal dyspnea that showed evidence of COPD. He was a smoker of cigarettes but quit 30 years ago. Past history was notable for vocal cord cancer treated by radiotherapy thirty years earlier. On physical exam, pt was a well nourished white male with telangiectasias over his anterior neck, but no lymphadenopathy. Lung fields were clear bilaterally. Cardiac and abdominal exams were unremarkable. A video barium swallow study showed pooling in the vallecula, laryn-geal penetration, aspiration, and a markedly dilated esophagus with distal esophageal stricture at the level of the EG junction. An esophageal manom- etry confirmed total esophageal aperistalsis. CT of chest/abdomen demonstrated a spiculated 1.3 cm right upper lobe nodule and mediastinal lymphadenopathy; PET imaging revealed intense uptake in these areas. A CT-guided biopsy of the right upper lobe lesion was positive for squamous cell carcinoma. Endoscopy was performed to 1. treat dysphagia and, 2. staging. EGD with intrasphincteric injection of botulinum toxin type A, 20 units × 4 resulted in significant relief of dysphagia and regurgitation, and no procedure related complications. Pt was free of symptoms more than 60 days post-procedure and had mild weight gain after this single treatment session. Although no evidence of malignancy on FNA of mediastinal nodes was found during EUS, tumor was staged as T1N2M0. Injection of botulinum toxin into LES is an effective treatment for patients with suspected pseudoachalsia. To our knowledge, this represents the first report of successful treatment in a patient with squamous cell lung cancer.