Achalasia cardia associated with esophageal varices: a therapeutic dilemma
A 63-year-old male, chronic alcohol consumer, presented with progressively increasing dysphagia of 6 months duration. There was history of loss of weight. He was a known diabetic with blood sugar well controlled with oral drugs. However, after onset of dysphagia, his blood sugar control was erratic and had frequent episodes of hypoglycemia. Clinical examination revealed hepatomegaly. Laboratory examination revealed hypoalbuminemia with mildly elevated liver enzymes. Upper gastrointestinal endoscopy revealed dilated esophagus with residue. Esophageal varices were also noted but there was no history of gastrointestinal bleed (). Esophageal manometry revealed high resting lower esophageal sphincter (LES) pressure with non transmitted low amplitude contractions in esophageal body () suggesting classic achalasia cardia. A contrast-enhanced computed tomography of chest and abdomen revealed dilated esophagus enlarged liver with irregular outline and intra-abdominal collaterals. Endoscopic ultrasound (EUS) examination revealed peri-esophageal collaterals as well as prominent perforators at lower end of esophagus (). Patient was started on calcium channel blockers with no relief of symptoms. The co-existence of varices with achalasia is very rare and this case poses a difficult therapeutic dilemma as risk of bleeding from the varices limit the treatment options available. What to do next?\nBecause of risk of bleeding from varices following balloon dilatation, the patient underwent EUS-guided botulinum toxin injection. Using a linear echoendoscope with color Doppler, carefully avoiding varices and perforators, 80 units of botulinum toxin was injected into LES in four quadrants (20 units in each quadrant) (). Following this, the patient had marked improvement in his symptoms and was completely free of dysphagia 7 days later and also blood sugar was controlled with oral drugs. He is asymptomatic till the last follow up 3 months after injection. As the patient has chronic liver disease along with portal hypertension, he has been referred for work up for liver transplantation.