A 46 year-old African American woman with past medical history of diabetes mellitus type 1 for 22 years and gastroparesis for 12 years status post gastric pacemaker placement 2 years ago presented with abdominal pain, nausea, and recurrent vomiting for 2 days. The severity of her symptoms on the day of admission, as measured by the gastrointestinal symptom rating scale (GSRS), was 16. Due to the refractory nature of her symptoms, EUS-guided intrapyloric injection of botulinum toxin was performed. 100 units of botulinum toxin was diluted with normal saline to 25 U/ml and injected into 4 quadrants of muscularis propria of pyloric sphincter, with a 25-gauge FNA needle (Figure 1). On post procedure day one the patient demonstrated significant improvement in her symptoms and scored 11 on the GSRS. She was discharged from the hospital soon after. During follow up 3 weeks post procedure, she reported one episode of vomiting since being discharged and scored 8 on the GSRS. She was again seen on post procedure week 4 and reported only intermittent nausea with no further episodes of vomiting. Her GSRS score at 4 and 12 weeks post procedure were 5 and 4, respectively. Diabetic gastroparesis is a relatively common and often difficult to manage chronic motility disorder where there is delayed gastric emptying in the absence of mechanical obstruction. It is thought to arise from a complex interplay of factors including disturbances in fundic accommodation, gastric arrhythmia, impaired corpus-antral contractility, vagal neuropathy and pyloric dysfunction (in the form of pylorospasm). Symptoms include nausea, vomiting, early satiety and epigastric pain. The currently available modalities of treatment for this condition, including prokinetic medications and placement of gastric pacemaker, are often sub-optimally efficacious. Based on the theory that gastric emptying improves with decreased pyloric resting pressure, intrapyloric sphincter botulinum toxin injection was introduced in 1998. Since that time, its use has been reported to have variable clinical response in the medical literature. We postulate that inconsistencies in clinical response from botulinum toxin injection may be due, in part, to variability in injection sites, and propose that its efficacy may be improved by precise injection (via EUS guidance) into the muscularis propria of pyloric sphincter, as was demonstrated in our case. Further clinical studies in patients with are required to confirm our hypothesis.Figure: Linear array endoscopic ultrasonography-guided botulinum toxin injection by a 25-gauge needle (large arrow) into the muscularis propria (small arrow) of pylorus in a patient with refractory diabetic gastroparesis.