Type II achalasia with post-POEM recovery of esophageal motility.

Abstract

54-year-old woman with acromegaly due to pituitary macroadenoma that consulted for dysphagia for solids. In gastroscopy, it is observed difficulty in passing in the esophagogastric junction (EGJ). Under the suspect of Achalasia, a high-resolution esophageal manometry (HRM) was performed, observing a complete absence of motility of the esophageal body, panesophageal pressurization in > 20% of swallows and IRP of 21mmHg, confirming the diagnosis of type II Achalasia. Peroral endoscopic myotomy (POEM) is performed. After the intervention, the patient presented clinical improvement. In the control HRM carried out one year after the POEM, in addition to a decrease in IRP, is remarkable a partial recovery of motility in the upper and middle third of the esophagus. DISCUSSION: Achalasia is an esophageal motor disorder characterized by incomplete relaxation of the lower esophageal sphincter and a complete absence of peristalsis in the esophageal body. The cause of the absence of motility is the loss of the inhibitory neurons of the myenteric plexus, but the accurate etiopathogenesis is still unknown. Therefore, there is no curative treatment and all therapeutic options are symptomatic, aimed to relieve the obstruction of the EGJ. POEM is the newest method. Absence of motility of the esophageal body in patients with achalasia was believed to be irreversible. Nevertheless, more and more studies describe a partial recovery of motility observed in manometry after POEM, especially in type II Achalasia. The exact pathophysiological mechanism of this recovery is still unknown. IMAGES DESCRIPTION: Figure 1 (Before POEM): High-resolution manometry with a diagnosis of type II Achalasia: Absence of motility, panesophageal pressurization and IRP 21mmHg Figure 2 (After POEM): High resolution manometry showing ineffective esophageal motility (partial recovery of motility) after POEM with IRP of 4mmHg.