Utility of Combined Endoscopic Therapy With Balloon Dilation and Onabotulinum Toxin A Injection in a Patient With Gastroparesis Secondary to Hypertrophic Pylorus

Abstract

Introduction: Gastroparesis is a motility disorder of the gastrointestinal tract characterized by delayed gastric emptying. The diagnosis requires endoscopic evaluation to exclude mechanical obstruction and imaging; such as gastric emptying scintigraphy, to confirm delayed gastric emptying. Pharmacological therapy for gastroparesis is limited. Metoclopramide is the only FDA-approved medication with unproven long-term efficacy. Intrapyloric botulinum toxin injection is not currently a recommended treatment modality for gastroparesis. Here, we present a case with severe gastroparesis secondary to diffuse pylorospasm which improved with endoscopic botulinum toxin injection and pyloric dilation. Case report: A 70-year-old female patient with a history of asthma and a paraoesophageal hernia repair presented to our clinic for persistent nausea and vomiting. Physical examination and initial laboratory tests including complete blood counts, comprehensive metabolic panel, and thyroid function test were all unremarkable. She underwent an upper endoscopy that showed intact paraoesophageal hernia repair, normal gastric mucosa, but thickened and hypertrophied pylorus that was traversed with moderate resistance. Duodenum appeared normal. Nuclear gastric emptying scintigraphy showed markedly delayed gastric emptying with 14% gastric emptying at 4 hours. She underwent a repeat endoscopy with CRE pyloric balloon dilation from 12 mm to 15 mm, followed by intrapyloric onabotulinum toxin A injection in a 4 quadrant fashion. Her follow-up in 6 months showed a great improvement in her symptoms. Discussion: Endoscopic botulinum toxin injection has shown benefit in many gastrointestinal motility disorders, however, it is not currently recommended as a therapy for patients with gastroparesis by our gastrointestinal society. Botulinum toxin is a potent inhibitor of neuromuscular transmission and can improve spasm in tight gastrointestinal sphincters. Several open-label trials demonstrated clinical benefits of endoscopic intrapyloric botulinum toxin injection in patients with refractory gastroparesis. Herein, we describe a patient who benefited from combined therapy using balloon dilation and intrapyloric botulinum toxin injection. The therapy appeared effective and safe with no immediate or delayed complications. Further studies are needed to identify subset of patients who might benefit from combined endoscopic therapy with intrapylroic botulinum injection and balloon dilation.