CASE PRESENTATION
A 22-year-old female patient from Hetauda presented to OPD on
7th December 2018, with a one-month history of persistent dysphagia for
both solids and liquids, accompanied by nausea and vomiting of
undigested food. She also gave a history of weight loss of five
kilograms in the last three months. She reported experiencing similar
symptoms intermittently over the last two years and her condition did
not improve with antacid treatment. The patient does not have any
reported allergies and is not currently taking any medications.
Importantly, there is no notable medical or family history, and
psychosocial factors were considered irrelevant to the presentation. A
thorough physical examination revealed normal vital signs, absence of
palpable masses or tenderness upon abdominal assessment, and intact
cranial nerve functions, as well as normal motor and sensory responses
on neurological examination, highlighting the need for further
diagnostic investigations.
Subsequent diagnostic assessments including upper gastrointestinal (UGI)
endoscopy, barium esophagogram, and manometry, were planned to elucidate
the underlying cause of the patient’s distressing symptoms. Initially,
an upper gastrointestinal endoscopy performed on December 8, 2018,
detected dilation in the lower portion of the esophagus (Fig-3). On
December 9, 2018, a barium esophagogram performed revealed narrowing at
the distal thoracic gastroesophageal junction with dilation of the mid
and distal thoracic esophagus, causing mild anterior displacement of the
trachea and carina(Fig-1). Manometry confirmed ineffective esophageal
motility showing raised Integrated Relaxation Pressure(IRP) with failed
peristalsis in all swallows and pan esophageal pressurization suggestive
of type II Achalasia Cardia(Fig-2). The patient was thoroughly explained
about the diagnosis, the treatment options available, and potential
complications if left untreated. She was prescribed Pantop 40 mg per
oral once daily, Ondem 4mg as needed, and sucralfate 10ml per oral
thrice a day for two months. Since advanced surgical techniques such as
pneumatic balloon dilatation were not accessible at that facility, the
patient was referred to a tertiary center in Kathmandu for additional
treatment.
On June 6, 2019, about six months after diagnosis, the patient and her
guardian sought care at a tertiary center in Kathmandu. During these
six-month periods, she visited multiple healthcare facilities for her
regurgitation and received antacid therapy for reflux. After assessing
her symptoms and examining her reports, she was presented with options
of pneumatic balloon dilatation (PBD) or surgical myotomy, accompanied
by comprehensive discussions outlining the advantages and disadvantages
of each procedure. She opted for PBD and was admitted on June 7, 2019,
where she followed a clear liquid diet regimen before undergoing the
procedure two days later
The PBD procedure was done on 9th June 2019 by sedating the patient with
midazolam (15 mcg/kg, IV) and propofol (2 mg/kg, IV). Her vital signs
were monitored throughout the procedure by the team of anesthesiologists
and gastroenterologists performing it. Upper GI endoscopy revealed a
dilated esophagus with a relatively tight lower esophageal sphincter
(LES) but no obvious stricture. A foreign body of meat bolus was found
and removed with a dormia basket. The second part of the Duodenum(D2),
fundus, and pseudo-achalasia were ruled out. The esophagogastric
junction (ECJ) was identified at 40 cm from the incisor and marked
accordingly on the Rigiflex 30 mm balloon. A guidewire was placed across
the ECJ, and the rigiflex balloon was introduced. The balloon was
dilated with 16 psi until the disappearance of the waist for about a
minute. At the end of the procedure, the balloon was withdrawn,
revealing a tinge of fresh blood on it. Post-procedure gastroscopy was
repeated revealing a relatively easily giving LES and no obvious tear or
active bleeding (Fig 4). Following the procedure, the patient
experienced notable clinical improvement, with relief from dysphagia,
and regurgitation during subsequent assessment. Regular follow-up
appointments were scheduled to monitor the long-term efficacy of the
intervention, assess adherence, and evaluate tolerability. Additionally,
vigilance for potential adverse events such as esophageal perforation or
bleeding was prioritized to ensure timely detection and management.