Type II Achalasia With Recurrent Dysphagia and Post-Dilation Esophageal Tear | Esophageal Assessment in a Patient With Interstitial Lung Disease Being Evaluated for Lung Transplantation

24 Mar 2022 11:30 13:00
Boston
Hiroshi Mashimo Host

Case 1

Patient Profile & Clinical History

  • Patient: 78-year-old male

  • Initial Diagnosis: Type II achalasia, previously managed with dilation.

  • Recurrence: Patient presented with recurrent dysphagia.

  • Previous Treatment: Reportedly had a diagnosis of achalasia at an outside hospital in the past, managed with repeated Botox injections over a few years.

Diagnostic Evaluation

  • High-Resolution Manometry and Timed Barium Esophagram: Repeated studies were consistent with type II achalasia.

  • Upper Endoscopy with Functional Luminal Imaging Probe (FLIP) Planimetry: Showed low distensibility at the lower esophageal sphincter and absent contractility to volumetric distention in the esophageal body.

Therapeutic Procedure

  • Dilation: Dilation at the lower esophageal sphincter was performed using the EsoFLIP 30-mm balloon.

  • Complication: A deep, long linear tear was noted post-dilation, concerning for full-thickness tear/perforation.

  • Immediate Management: An esophageal stent was immediately placed to cover the linear tear.

Post-Procedural Course

  • Hospital Observation: The patient was observed in the hospital for two days.

  • Clinical Course: He remained stable and was able to advance his diet to full liquid prior to discharge without requiring surgery.

Figures

Figure 1. Time Barium Swallow

Time barium swallow demonstrating retained column of barium at 5 minutes.

Figure 2. Lower Esophagus at the Time of Endoscopy

Figure 3. EndoFLIP at 60 mL

Demonstrating low distensibility and absent contractility.

Figure 4. Lower Esophagus Following EsoFLIP Dilation

Demonstrating full-thickness tear.

Figure 5. Esophagus Following Stent Placement

Figure 6. Upper GI Series Following Stent Placement

Figure 7. Endoscopic Stent Removal

Figure 8. Lower Esophagus at Follow-up Endoscopy Following Stent Removal

Presentation of the Case

Mayssan Muftah, MD, Gastroenterology Fellow

Discussion Points

  1. Assessment of patients with achalasia presenting with recurrent dysphagia

  2. The anatomy, physiology and physics relevant to achalasia evaluation and management

  3. Treatment of patients with achalasia and how to choose therapy

  4. Surgical and endoscopic management of post-dilation complications

Case 2

Patient Profile & Clinical History

  • Patient: 55-year-old patient with interstitial lung disease

  • Clinical Context: Referred for pre-surgical assessment for lung transplantation.

  • Respiratory History: Diagnosed with interstitial lung disease with declining pulmonary function over the years.

  • Transplant Evaluation: Underwent comprehensive evaluation for lung transplantation.

  • Esophageal Symptoms: Denied heartburn, reflux, regurgitation, or dysphagia.

Diagnostic Evaluation

  • High-Resolution Esophageal Manometry: Performed as part of routine pre-transplantation esophageal assessment.

Presentation of the Case

Mayssan Muftah, MD, Gastroenterology Fellow

Discussion Points

  1. The role of esophageal testing in patients with advanced lung disease

  2. Options and selection of diagnostic testing for esophageal assessment in lung transplant patients

  3. Management strategies for esophageal dysfunction and reflux to optimize pulmonary and transplant outcomes

Panel for Discussion

All members from Harvard Medical School: Jennifer Cai (Assoc. Director, GI Motility and Physiology) | Walter Chan (Director, GI Motility and Physiology) | Wai-Kit Lo (Assoc. Director, GI Motility) | Hiroshi Mashimo (Director, GI Motility and Advanced Imaging) | Mayssan Muftah (Gastroenterology Fellow) | Ann DeBord Smith (Chief, Bariatric Surgery) | Jon Wee (Section Chief, Esophageal Surgery)