Successful POEM Procedure Relieved Swallowing Difficulty in a 37 Y.O. Female with Achalasia Cardia

Chief Complaints

A 37-year-old female patient with a body mass index (BMI) of 17 presented to the Gastroenterology Department at PACE Hospitals, Hitech City, Hyderabad, with complaints of difficulty in swallowing for the past nine years. The difficulty was mainly associated with solid foods and had become more noticeable during the previous year. She also reported regurgitation, in which swallowed food or digestive contents returned to the mouth.

The patient had a nine-year history of achalasia cardia with progressive difficulty in swallowing, particularly for solid foods, along with regurgitation. There was no documented history of hypertension, diabetes mellitus, heart disease, chronic kidney disease, thyroid disorders, previous major surgery, or any other significant medical comorbidities.

On examination, the patient was conscious, coherent, oriented, and hemodynamically stable. Her abdomen was soft, non-tender, and without distension. There were no signs of an acute abdominal complication, and the remaining systemic examination was within normal limits.

Upon admission to PACE Hospitals, following a detailed clinical assessment, the Gastroenterology team evaluated the patient for long-standing difficulty in swallowing, which was more noticeable with solid foods, along with regurgitation.

Upper gastrointestinal endoscopy and a barium swallow study were performed to assess the oesophagus and gastroesophageal junction. Based on the patient’s symptoms, clinical findings, and diagnostic investigations, she was diagnosed with Achalasia Cardia with an Eckardt score of 5.

Achalasia Cardia is a condition in which the lower oesophageal sphincter does not relax properly, making it difficult for food and liquids to pass from the oesophagus into the stomach. The Eckardt score assesses the severity of achalasia by evaluating difficulty swallowing, regurgitation, chest pain, and weight loss.

Routine investigations, including complete blood picture, serum electrolytes, renal and liver function tests, coagulation profile, and pre-anaesthetic assessment, were performed to evaluate the patient’s overall fitness for the procedure. The findings were within acceptable limits and supported proceeding with endoscopic treatment.

Based on the confirmed diagnosis, the patient was advised to undergo Achalasia Cardia Treatment in Hyderabad, India, under the expert care of the Gastroenterology Department.

After a detailed consultation with the therapeutic endoscopist Dr. Govind Verma along with consultant gastroenterologist Dr. M. Sudhir, a comprehensive evaluation was performed to determine the most appropriate diagnostic and therapeutic approach.

Considering the patient’s nine-year history of difficulty swallowing, worsening difficulty with solid foods during the previous year, and episodes of regurgitation, further evaluation confirmed Achalasia Cardia with an Eckardt score of 5. Upper gastrointestinal endoscopy revealed moderate resistance at the gastroesophageal junction, while the barium swallow study supported the diagnosis.

Based on the clinical assessment, diagnostic findings, and stable pre-procedural investigations, it was determined that Per Oral Endoscopic Myotomy under general anaesthesia was the most appropriate and effective management strategy. This approach was selected to divide the tight circular muscle fibres at the lower oesophageal sphincter, reduce resistance at the gastroesophageal junction, improve swallowing, and relieve regurgitation without requiring an external surgical incision.

The patient and her family members were counselled regarding the diagnosis, clinical findings, planned procedure, expected benefits, possible complications, dietary modifications, and the importance of postoperative care and follow-up.

Following preoperative preparation and necessary clearances, the patient underwent a Peroral Endoscopic Myotomy (POEM) Procedure in Hyderabad at PACE Hospitals, under the expert care of the Gastroenterology Department.

The procedure included the following steps:

• Patient Preparation and Endoscopy: After induction of general anaesthesia, an upper gastrointestinal endoscope was introduced through the mouth to examine the oesophagus, gastroesophageal junction, and stomach.

• Assessment of the Gastroesophageal Junction: The fundus of the stomach appeared normal. Moderate resistance was noted at the gastroesophageal junction, located approximately 40 cm from the mouth. Carbon dioxide monitoring was continued throughout the procedure.

• Submucosal Tunnel Creation: At approximately 9 cm above the gastroesophageal junction, at the 6 o’clock position, a diluted dye solution was injected beneath the oesophageal lining to lift and identify the mucosal layer. A small mucosal incision was created using a T-knife, and a submucosal tunnel was carefully developed towards the lower oesophageal sphincter.

• Myotomy: The circular muscle fibres responsible for the obstruction were divided using a hybrid knife. Small blood vessels encountered during the procedure were coagulated to maintain haemostasis.

• Closure: After adequate muscle division, the mucosal entry site was closed securely using endoscopic clips. A final endoscopic examination confirmed smooth passage of the scope across the gastroesophageal junction. The procedure was completed successfully without any intraoperative complications.

Following the procedure, the patient was kept nil by mouth (NBM) for two days. Supportive care was provided to maintain hydration, prevent infection, control discomfort, and support healing.

A postoperative Gastrografin swallow study showed smooth passage of contrast across the gastroesophageal junction, with minimal retention in the lower oesophagus and no evidence of leakage. Oral intake was then restarted gradually, beginning with liquids. The patient experienced gradual improvement in swallowing and regurgitation.

At discharge, the patient was prescribed oral medications for infection prevention, pain relief as required, gastric acid suppression, and supportive care to promote healing during recovery.

The patient was advised to continue a liquid diet for five days, followed by a soft diet for another five days before gradually returning to a normal diet as tolerated. She was advised to avoid very cold liquids during the early recovery period and follow the dietary recommendations provided by the treating team.

The patient was advised to contact the emergency ward at PACE Hospitals in case of any emergency or development of symptoms such as fever, severe chest or abdominal pain, persistent vomiting, worsening difficulty in swallowing, breathing difficulty, blood in the vomit, abdominal swelling, or any other unusual symptoms after the procedure.

The patient was advised to return for a follow-up visit with the Gastroenterologist in Hyderabad at PACE Hospitals after one week.

This case highlights the successful use of the POEM procedure for treating achalasia cardia with long-standing swallowing difficulty and regurgitation. The procedure reduced resistance at the gastroesophageal junction and improved the passage of food and liquids into the stomach. Gradual symptom improvement was observed, followed by discharge with dietary advice and follow-up instructions.