Peroral endoscopic myotomy and gastroesophageal reflux: A word of caution!

Abstract

A 56-year-old man with a history of dysphagia had received a diagnosis of type II achalasia, for which he had undergone peroral endoscopic myotomy (POEM) about 1 year earlier. Nearly complete resolution of symptoms was documented on subsequent follow-up visits at 1, 3, and 6 months. Evaluation for gastroesophageal reflux at 3 months revealed mild (grade A) esophagitis. During the visit at 12 months, he described occasional dysphagia and chest pain. There was no heartburn or regurgitation. A barium swallow revealed free flow of barium across the gastroesophageal junction, with minimal retention at 5 minutes. Gastroscopy revealed a dilatated esophagus with no resistance at the gastroesophageal junction. In addition, linear erosions and a reddish tonguelike projection could be visualized at the lower end of the esophagus (A). Narrow-band imaging revealed a regular mucosal and vascular pattern in the tonguelike projection (B, C). Examination of the biopsy specimen from this area revealed columnar lined mucosa with intestinal metaplasia, with periodic acid-Schiff and alcian blue staining of small intestinal–type epithelium with mucin-secreting goblet cells (stained blue, orig. mag. ×40), thereby confirming the diagnosis of Barrett’s metaplasia (D).