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.