Critical Care Medicine-Gastrointestinal, Nutrition and Genitourinary Disorders>>>>>Esophagus
Question 5#

A 60-year-old man with a history of heart failure with reduced ejection fraction (HFrEF), chronic obstructive pulmonary disease (COPD) requiring home oxygen, and GERD presents with dysphagia of solid and liquid foods, which has worsened over the last year. An esophagogastroduodenoscopy (EGD) is performed is performed, which reveals normal esophageal mucosa with negative biopsy results. High-resolution manometry reveals an integrated relaxation pressure of 20 mm Hg and a distal contractile integral (DCI <100 mm Hg/s/cm) of 100%. Esophagram demonstrates a dilated esophagus with poor emptying of barium.

Which of the following therapies would be the most appropriate for this patient? 

A. Nissen fundoplication
B. Botulinum toxin injection
C. Esophageal pneumatic dilation (PD)
D. Peroral endoscopic myotomy (POEM)

Correct Answer is C


Correct Answer: C

Achalasia is a primary esophageal disorder with a pathologic consequence of degeneration of ganglion cells in the myenteric plexus of the esophageal body and the lower esophageal sphincter (LES) of unknown etiology. The degeneration leads to insufficient relaxation of the LES. Esophagraphy typically reveals esophageal aperistalsis with proximal dilation and minimal LES opening resulting in a “bird’s beak” appearance. At present, achalasia is incurable and management consists of palliation of symptoms. In patients who are felt to be good surgical candidates, laparoscopic myotomy with partial fundoplication is an effective strategy for long-term resolution of symptoms. However, in patients who are highrisk surgical candidates, initial treatment with graded PD is recommended. A prospective randomized multicenter European trial comparing graded PD to surgical myotomy in 200 patients revealed no difference in success rate after 2 years of follow-up (92% for PD vs 87% for surgical myotomy).

Complete 360-degree fundoplication would exacerbate the symptoms of dysphagia and is not an appropriate intervention for achalasia. Botulinum toxin is an attractive and user-friendly approach which interrupts the release of acetylcholine from presynaptic vesicles causing an interruption of a neurogenic component but has no effect on the myogenic component of the LES. Although the initial 1-month response rate is close to 75%, the therapeutic effect wears off and approximately 50% of patients relapse and require repeat treatment at 6- to 24-month intervals. POEM is a novel method of endoluminal myotomy performed by traversing the esophageal mucosa. Although the technique is promising, it requires advanced endoscopic skills. In addition, POEM has been shown in 50% of patients to promote further acid reflux. 


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  3. Annese V, Bassotti G, Coccia G, et al. A multicentre randomised study of intrasphincteric botulinum toxin in patients with esophageal achalasia. GISMAD Achalasia Study Group. Gut. 2000;46:597-600.