Novel Treatment for Achalasia in a First Trimester Pregnant Patient

Abstract

Esophageal achalasia is a rare idiopathic motility disorder characterized by an incomplete relaxation of the lower esophageal sphincter. Its prevalence is roughly 10 cases/100,000 population per year. Exact pathophysiology of achalasia has not been fully discerned, although functional loss of myenteric plexus ganglion cells in the distal esophagus and lower esophageal sphincter is postulated. Type II achalasia is characterized by lack of peristalsis and swallowing of water causes rapid pan esophageal pressurization, exceeding 30mm Hg. Treatment for type I and type II achalasia respond well to pneumatic dilation, Heller myotomy, or botulinum toxin injections. Botulism toxin is especially attractive for the use in high risk patient populations such as the elderly or pregnancy in which surgical therapy is relatively contraindicated. We report a unique case of a 28 year old female with type II achalasia, G2P0 at 30 weeks gestational age who presented with pregnancy weight loss secondary to worsening solid/liquid dysphagia. She was electively admitted to the hospital to undergo IV fluids, enteric nutritional supplementation and endoscopic therapy with Botox injections as treatment of her symptoms. The patient was brought to the operating room for botulism toxin A injections into the lower esophageal sphincter via EGD with anesthesia support. Pre and post procedure fetal heart tones were performed. A 5mm injector needle was used to inject 4 aliquots of 1cc (20 units) of botulism A toxin circumferentially 1cm proximal to the lower esophageal sphincter. The patient experienced no complications and fetal heart tones were within normal limits. She had immediate improvement, approximately 50% in dysphagia symptoms over the next 3 days post procedure and had near complete resolution of symptoms at follow up in 1 month.Botulism toxin A has had an increased role in medical management of various diseases. First described in 1994 by Pasricha et al for the use in achalasia, at 1 week 90% of Botulism toxin groups showed significant symptom reduction. This case displays an unique treatment modality for symptom relief in a pregnant patient. One must take into account the patient's history and identify those at deemed higher risk for procedural complications including pregnant patients and those with multiple comorbidities. Botox injections has a relatively low complication rate and has benign side-effects including epigastric pain, chest pain or heartburn post procedure.1754_A Figure 1 No Caption available.1754_B Figure 2 No Caption available.