Successful POEM Procedure for Type I Achalasia Cardia Relieved Severe Dysphagia in a 43 Y.O. Female

A 43-year-old female patient with a body mass index (BMI) of 16 presented to the Gastroenterology Department at PACE Hospitals, Hitech City, Hyderabad, with complaints of difficulty swallowing both liquids and solids for the past 20 days. She also reported regurgitation of food, excessive belching, and progressive weight loss. The patient had a known history of mild swallowing difficulty (dysphagia) for nearly two years, which had gradually worsened.

The patient had a history of mild dysphagia for nearly two years and was also diagnosed with bronchial asthma. No other significant comorbidities, such as diabetes, hypertension, heart disease, kidney disease, or liver disease, were reported. There was no documented history of previous major surgeries or known medication allergies.

On examination, the patient was conscious, coherent, oriented, and hemodynamically stable. There was no pallor or icterus. The general physical examination was normal. Respiratory examination revealed bilateral normal vesicular breath sounds, while cardiovascular, abdominal, and neurological examinations were within normal limits. No other significant abnormalities were noted during the systemic examination.

Upon admission to PACE Hospitals, following a detailed clinical assessment, the Gastroenterology team evaluated the patient for progressive difficulty in swallowing both liquids and solids, along with a history of regurgitation, excessive belching, weight loss, and chronic dysphagia.

Clinical evaluation raised suspicion of an oesophageal motility disorder. Upper gastrointestinal endoscopy demonstrated moderate resistance at the gastroesophageal junction, while a barium swallow study showed impaired oesophageal emptying with features suggestive of achalasia. High-resolution oesophageal manometry subsequently confirmed Type I Achalasia Cardia with a significantly elevated Integrated Relaxation Pressure (IRP), consistent with impaired lower oesophageal sphincter relaxation. The patient was also diagnosed with bronchial asthma during the evaluation.

Routine investigations, including complete blood picture, renal function tests, liver function tests, serum electrolytes, coagulation profile, and other pre-anaesthetic investigations, were performed to assess the patient's overall medical fitness before the planned endoscopic intervention. These investigations were within acceptable limits and served as supportive preoperative assessments.

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 Dr. Govind Verma (Interventional Gastroenterologist, Transplant Hepatologist, Pancreatologist, and Endosonologist), along with a cross-consultation with Dr. Pradeep Kiran Panchadi (Consultant Interventional Pulmonologist), for the management of bronchial asthma, a comprehensive evaluation was performed to determine the most appropriate diagnostic and therapeutic approach.

Considering the patient’s progressive difficulty in swallowing both liquids and solids, weight loss, regurgitation, excessive belching, and long-standing history of dysphagia, further evaluation with upper gastrointestinal endoscopy, barium swallow, and high-resolution oesophageal manometry confirmed Type I Achalasia Cardia with an Eckardt score of 11 and markedly elevated Integrated Relaxation Pressure. Routine laboratory and pre-anaesthetic investigations showed acceptable parameters for the planned intervention.

Based on the confirmed diagnosis, severity of symptoms, manometric findings, and overall clinical fitness, it was determined that Peroral Endoscopic Myotomy under general anaesthesia was the most appropriate and effective treatment strategy. This minimally invasive endoscopic approach was chosen to divide the abnormally tight lower oesophageal sphincter muscle, improve oesophageal emptying, relieve dysphagia and regurgitation, support better oral intake, and enhance the patient’s overall quality of life.

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

Following the decision, the patient was scheduled for Peroral Endoscopic Myotomy in Hyderabad at PACE Hospitals, under the expert care of the Gastroenterology Department.

The following steps were carried out during the procedure:

• Patient Preparation and Anaesthesia: After obtaining informed consent, the patient was taken up for the POEM procedure under short-acting general anaesthesia. Intravenous antibiotics were administered before the procedure to reduce the risk of infection, and continuous carbon dioxide monitoring was maintained throughout.

• Initial Upper Gastrointestinal Endoscopy: An upper gastrointestinal endoscopy was performed to examine the oesophagus, gastroesophageal junction, and stomach. The fundus appeared normal, but moderate resistance was noted while passing the endoscope across the gastroesophageal junction, confirming functional obstruction.

• Mucosal Entry and Submucosal Tunnelling: Diluted methylene blue was injected into the oesophageal mucosa above the gastroesophageal junction to create a submucosal lift. A small mucosal incision was then made using a T-knife, and a submucosal tunnel was carefully created towards the lower oesophageal sphincter.

• Endoscopic Myotomy: The circular muscle fibres of the lower oesophagus and lower oesophageal sphincter were divided using a hybrid knife. Any blood vessels encountered during the procedure were coagulated with a coagulation grasper to maintain adequate haemostasis.

• Tunnel Closure and Final Assessment: After completing the myotomy, the mucosal entry site was securely closed using endoscopic clips. A final endoscopic examination showed that the endoscope could pass across the gastroesophageal junction more easily, confirming successful release of the obstruction. The procedure was completed without complications.
  

The patient had an uneventful postoperative recovery and remained hemodynamically stable throughout her hospital stay. She received intravenous fluids and medications for infection prevention, pain control, stomach protection, and supportive care. Oral intake was withheld initially to allow adequate healing of the oesophagus. A postoperative oral Gastrografin contrast swallow study was performed, which demonstrated no evidence of contrast leak (extravasation), with only transient retention of contrast in the lower oesophagus. Following satisfactory imaging findings, the patient was gradually started on a liquid diet and was discharged in stable condition with appropriate medical advice.

Upon discharge, the patient was prescribed oral medications to prevent infection, reduce the risk of fungal overgrowth, control gastric acidity, protect the oesophageal lining, relieve allergic symptoms, and support comfortable recovery after the procedure. She was advised to take all prescribed medications regularly and complete the recommended course as instructed by the treating gastroenterologist.

The patient was advised to continue a liquid diet initially, followed by a soft diet for the next five days before gradually returning to a regular diet as tolerated. She was instructed to avoid very cold liquids during the early recovery period and to follow all dietary and lifestyle recommendations carefully to promote proper oesophageal healing and recovery.

The patient was informed 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 vomit, or any other unusual symptoms.

The patient was advised to return for a follow-up visit with the Gastroenterologist in Hyderabad at PACE Hospitals after 5 days.

This case highlights the successful management of Type I Achalasia Cardia through Peroral Endoscopic Myotomy. The procedure effectively relieved lower oesophageal sphincter obstruction, improved swallowing, and supported better oral intake. The patient had an uncomplicated recovery, tolerated a liquid diet well, and was discharged in stable condition with appropriate dietary advice and follow-up recommendations.