Successful POEM Procedure for Type II Achalasia with Severe Dysphagia in a 41 Y.O. Female
PACE Hospitals
PACE Hospitals’ expert Gastroenterology team successfully performed a Peroral Endoscopic Myotomy (POEM) procedure on a 41-year-old female patient diagnosed with Type II achalasia cardia with a high Eckardt score. The procedure was performed to release the abnormally tight lower oesophageal muscle, improve the passage of food into the stomach, and relieve difficulty swallowing, regurgitation, and chest discomfort.
Chief Complaints
A 41-year-old female patient with a body mass index (BMI) of 18 presented to the Gastroenterology Department at PACE Hospitals, Hitech City, Hyderabad, with difficulty swallowing and chest tightness for the past three years. She also reported regurgitation and noticeable weight loss. Her symptoms had gradually worsened and were affecting her ability to eat comfortably.
Past Medical History
The patient had previously been diagnosed with Type II achalasia cardia at another healthcare facility. She had no known significant comorbidities or history of major surgery.
On Examination
On examination, the patient was conscious, coherent, oriented, and hemodynamically stable. There was no pallor or icterus. Her abdominal and systemic examinations were normal, with no signs of acute distress or other significant abnormalities.
Diagnosis
Upon admission to PACE Hospitals, the patient underwent a detailed clinical assessment for long-standing difficulty swallowing, chest tightness, regurgitation, and weight loss.
Upper gastrointestinal endoscopy was performed to examine the oesophagus, gastroesophageal junction, and stomach and to rule out any structural obstruction. The stomach appeared normal; however, moderate resistance was noted while passing the endoscope through the gastroesophageal junction.
A barium swallow study was performed to assess the passage of contrast through the oesophagus and identify changes associated with achalasia. This investigation provided information regarding oesophageal emptying, narrowing at the lower end of the oesophagus, and retention of contrast.
Esophageal manometry was subsequently performed to assess the pressure and coordination of the oesophageal muscles. The findings confirmed Type II achalasia cardia, with an elevated median integrated relaxation pressure and an Eckardt score of 9, indicating severe symptoms.
Based on the clinical findings and diagnostic investigations, the patient was advised to undergo Achalasia Cardia Treatment in Hyderabad, India, under the expert care of the Gastroenterology Department at PACE Hospitals.
Medical Decision Making (MDM)
After a detailed consultation with Dr. Govind Verma (Gastroenterologist, Hepatologist, and Therapeutic Endoscopist) , a comprehensive evaluation was performed to determine the most appropriate diagnostic and therapeutic approach.
Considering the patient’s history of progressive difficulty swallowing, chest tightness, regurgitation, and weight loss, further evaluation with upper gastrointestinal endoscopy, barium swallow, and oesophageal manometry confirmed Type II achalasia cardia with an Eckardt score of 9 and elevated integrated relaxation pressure.
Based on the clinical assessment and diagnostic investigations, it was determined that Peroral Endoscopic Myotomy under general anaesthesia was the most appropriate and effective management strategy. This approach was chosen to divide the tight circular muscle fibres at the lower end of the oesophagus, reduce resistance at the gastroesophageal junction, improve the passage of food and liquids into the stomach, and relieve dysphagia, regurgitation, and chest discomfort while ensuring better functional outcomes.
The patient and her family members were counselled regarding the diagnosis, clinical findings, planned procedure, and the importance of postoperative care and follow-up.
Surgical Procedure
Following the decision, the patient was scheduled for a Peroral Endoscopic Myotomy procedure in Hyderabad at PACE Hospitals under the expert care of the Gastroenterology team.
The following steps were carried out during the procedure:
- Patient Preparation and Anaesthesia: The patient was taken up for the procedure after appropriate pre-procedure evaluation and informed consent. General anaesthesia was administered, and continuous monitoring was maintained throughout the procedure.
- Initial Endoscopic Assessment: An upper gastrointestinal endoscopy was performed to examine the oesophagus, gastroesophageal junction, and stomach. The stomach appeared normal, while moderate resistance was noted at the gastroesophageal junction.
- Mucosal Infiltration and Entry: The oesophageal mucosa was infiltrated with diluted methylene blue solution approximately 9 cm above the gastroesophageal junction. A controlled mucosal incision was then made to create an entry point into the submucosal layer.
- Submucosal Tunnelling: A submucosal tunnel was carefully created towards the gastroesophageal junction and extended into the upper part of the stomach. Blood vessels encountered during tunnelling were coagulated to control bleeding.
- Endoscopic Myotomy: The tight circular muscle fibres of the lower oesophagus and gastroesophageal junction were carefully divided. This reduced the abnormal resistance responsible for difficulty swallowing.
- Assessment and Closure: Following myotomy, the endoscope passed through the gastroesophageal junction more easily, confirming improved opening. The mucosal entry site was securely closed using endoscopic clips.
Postoperative Care
The patient had an uneventful postoperative recovery and remained hemodynamically stable throughout the hospital stay. She received intravenous fluids for hydration, treatment to prevent infection, medication to reduce gastric acid, and other supportive care, and was kept nil by mouth for the initial two days. An oral contrast study confirmed the absence of leakage, following which oral liquids were introduced gradually. The patient tolerated the liquid diet well and was discharged in stable condition with dietary advice and follow-up instructions.
Discharge Medications
Upon discharge, the patient was prescribed oral medications for prevention of infection, reduction of gastric acid, protection of the oesophageal and stomach lining, control of pain or discomfort when required, and other supportive treatment.
Advice on Discharge
The patient was advised to begin with a liquid diet and gradually shift to soft foods. Small portions, proper chewing, adequate hydration, and avoidance of very hot, spicy, hard, or coarse foods were recommended. Prescribed treatment was to be continued as advised by the treating doctor.
Emergency Care
The patient was informed to contact the emergency ward at PACE Hospitals in case of any emergency or development of symptoms such as fever, persistent chest or abdominal pain, repeated vomiting, or difficulty swallowing liquids.
Review and Follow-up Notes
The patient was advised to return for a follow-up visit with the Gastroenterologist in Hyderabad at PACE Hospitals after 1 week.
Conclusion
This case highlights the successful management of Type II achalasia cardia using the POEM procedure. The treatment helped reduce resistance at the gastroesophageal junction and improved swallowing and food passage. The patient recovered without complications, tolerated a liquid diet, and was discharged in stable condition with dietary advice and follow-up instructions.
Oesophageal Manometry and Barium Swallow Comparison
Oesophageal manometry and a barium swallow are both used by a gastroenterologist / gastroenterology doctor to assess swallowing disorders, but each provides different information. A barium swallow uses contrast liquid and X-ray imaging to show the shape of the oesophagus, areas of narrowing, retained food or contrast, and the speed at which the oesophagus empties. It can also demonstrate delayed passage of contrast and characteristic changes seen in achalasia.
Oesophageal manometry uses a thin pressure-sensitive catheter to measure the strength, coordination, and relaxation of the oesophageal muscles during swallowing. It helps assess how well the lower oesophageal sphincter relaxes and identifies abnormal pressure patterns. While a barium swallow mainly shows structural and functional changes, manometry provides detailed pressure measurements and helps confirm achalasia and classify it as Type I, Type II, or Type III.
Frequently Asked Questions (FAQs)
Why was POEM recommended for this patient?
POEM was recommended because the patient had marked difficulty swallowing, along with regurgitation, chest tightness, and weight loss. Manometry confirmed Type II achalasia and showed poor relaxation at the lower end of the oesophagus. The high Eckardt score indicated that the condition was interfering with normal food intake. The procedure was therefore planned to ease the obstruction and improve swallowing.
Is POEM effective for Type II achalasia?
POEM is a suitable treatment for many patients with Type II achalasia. In this procedure, the tight muscle at the lower end of the oesophagus is cut carefully. This helps open the passage between the oesophagus and stomach. After treatment, food and liquids can move into the stomach with less difficulty.
What does an Eckardt score of 9 mean?
The Eckardt score is based on swallowing difficulty, regurgitation, chest pain, and weight loss. A score of 9 means that the patient had severe symptoms. It showed that the condition was affecting regular eating and daily comfort. The same score can be checked after treatment to see whether the symptoms have reduced.
Why was oesophageal manometry done before POEM?
Oesophageal manometry checks the pressure and movement of the muscles used for swallowing. It confirms achalasia and helps identify whether it is Type I, Type II, or Type III. It also shows whether the lower oesophageal muscle is relaxing properly. These findings help the gastroenterologist / gastroenterology doctor decide the right treatment.
Why were endoscopy and a barium swallow performed?
Endoscopy was done to look inside the oesophagus, the junction with the stomach, and the stomach. It helped check for retained food, narrowing, or any other blockage. A barium swallow showed how well the oesophagus was emptying. The results of both tests helped the medical team plan the POEM procedure.
How does POEM help improve swallowing?
During POEM, a small tunnel is made inside the wall of the oesophagus using an endoscope. The tight muscle near the lower end of the oesophagus is then cut. This reduces the blockage at the junction with the stomach. Food and liquids can then pass more comfortably.
Why was the patient kept nil by mouth after POEM?
The patient was not allowed to eat or drink for a short period so that the treated area could heal. This also reduced pressure on the procedure site. A contrast test was later done to check for any leakage. Liquids were started only after the test showed that it was safe.
What diet is advised after POEM?
A liquid diet can be started once the doctor confirms that there is no leakage. Soft foods may then be introduced gradually over the next few days. The patient should take small portions, eat slowly, and chew food properly. Very hot, spicy, hard, or coarse foods should be avoided until recovery improves.
Can acid reflux happen after POEM?
Some patients may develop acid reflux after POEM because the muscle at the lower end of the oesophagus becomes looser. This may allow stomach contents to move back into the oesophagus. Heartburn, a sour taste, or chest discomfort may occur. Follow-up helps the doctor identify and treat reflux early.
When should the patient seek medical help after POEM?
Medical help should be sought if the patient develops fever, severe chest pain, abdominal pain, or repeated vomiting. Difficulty swallowing liquids, breathing problems, vomiting blood, or black stools should also be reported. These signs may point to bleeding, infection, or leakage. Early treatment can help prevent the problem from becoming serious.
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