Successful Peroral Endoscopic Myotomy (POEM) for Achalasia Cardia with Esophageal Candidiasis in a 66 Y.O. Male
PACE Hospitals
PACE Hospitals’ expert Gastroenterology team successfully performed Peroral Endoscopic Myotomy (POEM) on a 66-year-old male patient diagnosed with achalasia cardia associated with Kodsi Grade A esophageal candidiasis. The procedure aimed to relieve the functional obstruction at the lower esophageal sphincter, improve swallowing, support better food passage, and enhance the patient’s nutritional status and quality of life.
Chief complaints
A 66-year-old male patient with a
body mass index (BMI) of 18 presented to the Gastroenterology Department at
PACE Hospitals, Hitech City, Hyderabad, with complaints of severe difficulty in swallowing both liquids and solids for the past 4 months.
Past Medical history
The patient had no significant documented past medical history or chronic gastrointestinal illness. He had a recent history of progressive swallowing difficulty associated with weight loss and nutritional challenges. There was no history of previous gastrointestinal surgery or other significant chronic medical conditions.
On Examination
On examination, the patient was conscious, coherent, and oriented, with stable vital signs. General examination suggested moderate nutritional depletion associated with recent weight loss. The abdomen was soft and non-tender, with no palpable mass or signs of acute abdominal pathology. Respiratory examination showed no acute distress, and the remaining systemic examination was normal.
Diagnosis
Upon admission to PACE Hospitals, following a detailed clinical assessment, the Gastroenterology team evaluated the patient for severe difficulty in swallowing both liquids and solids, persistent cough, and significant unintentional weight loss over the preceding months.
Clinical assessment and upper gastrointestinal endoscopy were performed to evaluate the esophagus and gastroesophageal junction. Upper gastrointestinal endoscopy showed findings suggestive of achalasia cardia and evidence of esophageal candidiasis. High-resolution esophageal manometry was used to confirm achalasia cardia. Routine preoperative investigations were also performed to assess the patient's overall condition and fitness for the planned intervention.
Based on the clinical and endoscopic findings, the patient was advised to undergo
achalasia cardia Treatment in Hyderabad, India, associated with Kodsi Grade A esophageal candidiasis, under the expert care of the Gastroenterology Department.
Medical decision making (MDM)
After a detailed consultation with Dr. Govind Verma (Interventional Gastroenterologist) and Dr. M. Sudhir (Senior Consultant Gastroenterologist), a comprehensive clinical evaluation was performed to determine the most appropriate therapeutic approach for the patient presenting with severe dysphagia to both liquids and solids, persistent cough, and significant weight loss.
Considering the patient's clinical presentation and upper gastrointestinal endoscopy and manometry findings confirming achalasia cardia with Kodsi Grade A esophageal candidiasis, the treatment plan was formulated to address the functional obstruction at the lower esophageal sphincter while managing the associated esophageal infection. The patient underwent appropriate preoperative evaluation and was assessed for fitness for the planned endoscopic intervention.
Based on the clinical assessment and endoscopic findings, it was determined that Peroral Endoscopic Myotomy (POEM) was the most appropriate minimally invasive treatment for achalasia cardia. The procedure was planned to relieve the functional obstruction, improve passage of food into the stomach, and reduce dysphagia and associated symptoms. Medical treatment was also planned for the associated esophageal candidiasis.
The patient and his family members were counselled regarding the diagnosis, planned endoscopic procedure, expected benefits, potential risks, postoperative dietary progression, recovery, and the importance of regular follow-up.
Surgical Procedure
Following the clinical evaluation and confirmation of the diagnosis, the patient was scheduled to undergo Peroral Endoscopic Myotomy (POEM) in Hyderabad at PACE Hospitals, under the expert care of the Gastroenterology Department.
The procedure involved the following steps:
- Patient Preparation and Anaesthesia : The patient was kept fasting before the procedure and underwent the necessary pre-procedure assessment. General anaesthesia with appropriate airway protection was administered, and standard aseptic precautions were maintained throughout the procedure.
- Upper Gastrointestinal Endoscopy: An upper gastrointestinal endoscopy was initially performed to assess the esophagus and gastroesophageal junction. The esophageal mucosa was evaluated, including the previously identified Kodsi Grade A esophageal candidiasis.
- Mucosal Entry and Submucosal Tunnelling: A small mucosal incision was created in the esophageal wall to gain access to the submucosal layer. A submucosal tunnel was then carefully created and extended towards the gastroesophageal junction.
- Endoscopic Myotomy: The circular muscle fibres of the lower esophageal sphincter and gastroesophageal junction were divided using an endoscopic knife. This myotomy reduced the abnormal muscular tightness and relieved the functional obstruction responsible for the patient's swallowing difficulty.
- Haemostasis and Closure: Visible blood vessels encountered during the procedure were appropriately managed to achieve haemostasis. After confirming adequate myotomy, the mucosal entry site was securely closed using endoscopic clips.
- Completion of Procedure: The gastroesophageal junction was reassessed endoscopically, and improved passage across the junction was confirmed. The procedure was completed successfully without immediate complications, and the patient was shifted for postoperative monitoring.
Postoperative Care
Following the procedure, the patient was closely monitored for chest or abdominal pain, fever, vomiting, difficulty swallowing, and any signs of procedure-related complications. He received intravenous fluids to maintain hydration, medicines to prevent and treat infection, medicines to treat the associated esophageal fungal infection, medicines to reduce gastric acid production, and other supportive treatment as required.
A Gastrografin swallow study was performed and showed transient retention of contrast in the lower esophagus without evidence of leakage. The patient remained hemodynamically stable and showed satisfactory clinical recovery without significant post-procedure complications.
Discharge Medications
Upon discharge, the patient was prescribed medicines to treat the esophageal fungal infection, prevent or manage infection, reduce gastric acid and protect the esophageal lining, relieve pain, and control other symptoms as required. He was advised to take all prescribed medicines as directed and attend the scheduled follow-up.
Advice on Discharge
The patient was advised to follow a clear liquid diet for 7 days, followed by a liquid diet for the next 7 days, and then gradually transition to a soft diet as tolerated. He was advised to maintain adequate hydration and follow the dietary instructions provided by the treating Gastroenterology team.
Emergency Care
The patient was advised to report immediately to the emergency ward at PACE Hospitals in case of development of symptoms such as fever, severe chest or abdominal pain, persistent vomiting, difficulty swallowing, breathing difficulty, inability to tolerate liquids, bleeding, or any other emergency symptoms.
Review and Follow-up Notes
The patient was advised to return for a follow-up visit with the Gastroenterologist in Hyderabad at PACE Hospitals after 6 weeks.
Conclusion
This case highlights the successful management of achalasia cardia associated with Kodsi Grade A esophageal candidiasis using Peroral Endoscopic Myotomy (POEM) and antifungal treatment. The minimally invasive procedure was completed successfully without significant complications. The patient showed satisfactory postoperative recovery and was discharged in a hemodynamically stable condition with appropriate dietary advice, supportive treatment, and scheduled follow-up.
POEM for Achalasia Cardia with Esophageal Candidiasis
Peroral Endoscopic Myotomy (POEM) is an advanced minimally invasive endoscopic treatment for achalasia cardia that helps relieve obstruction at the lower esophageal sphincter and improve the passage of food and liquids into the stomach. The procedure involves creating a submucosal tunnel and selectively dividing the dysfunctional muscle fibres responsible for impaired sphincter relaxation.
In patients with associated esophageal candidiasis, appropriate antifungal treatment and supportive care are important alongside definitive management of achalasia. Careful pre-procedure evaluation, precise endoscopic technique, postoperative monitoring, gradual dietary progression, and regular follow-up with a
Gastroenterologist/Gastroenterology Doctor are essential for safe recovery and sustained symptom improvement.
Frequently Asked Questions (FAQs)
Why is POEM performed for achalasia cardia?
POEM is performed to relieve the tightness of the lower esophageal sphincter, which normally opens to allow food and liquids to enter the stomach. In achalasia, this muscle does not relax properly, causing food to remain in the esophagus. POEM loosens this muscle and improves the passage of food into the stomach.
How does POEM improve swallowing?
During POEM, the gastroenterologist creates a small tunnel within the esophageal wall and carefully cuts the abnormal muscle fibres responsible for the tight lower esophageal sphincter. This reduces resistance at the gastroesophageal junction, allowing food and liquids to pass more easily into the stomach and improving swallowing.
What is esophageal candidiasis?
Esophageal candidiasis is a fungal infection of the lining of the esophagus, most commonly caused by Candida. It can cause painful or difficult swallowing, chest discomfort, and sometimes reduced food intake. It is treated with appropriate antifungal medication prescribed by a doctor.
Can esophageal candidiasis occur along with achalasia cardia?
Yes, esophageal candidiasis and achalasia can occur in the same patient. Achalasia can cause food and secretions to remain in the esophagus for prolonged periods, which may contribute to changes in the esophageal environment. When both conditions are present, treatment is directed at relieving the esophageal obstruction and treating the fungal infection appropriately.
Can achalasia cause malnutrition and significant weight loss?
Yes, severe achalasia can make it difficult for patients to swallow and obtain adequate nutrition. Food may remain in the esophagus instead of reaching the stomach, and patients may eat less because of their symptoms. Over time, this can result in weight loss and nutritional deficiencies.
Can weight loss caused by achalasia improve after POEM?
Yes, when POEM successfully improves the passage of food into the stomach, patients can generally eat and drink more comfortably. This may help improve nutritional intake and allow weight lost because of achalasia to be gradually regained. Recovery of weight varies depending on the patient's nutritional status and overall health.
How long does recovery take after POEM?
POEM generally allows relatively quick recovery because it is performed endoscopically without an external surgical incision. Patients are usually monitored in the hospital for a short period before gradually restarting oral intake. The overall recovery period varies, and patients should follow their gastroenterologist's dietary and activity instructions.
When can patients return to a normal diet after POEM?
The diet is usually advanced gradually to allow the esophageal entry site to heal. Patients may initially receive clear liquids, followed by liquids and then soft foods before returning to a normal diet. The exact timing depends on the patient's recovery and the treating team's instructions.
Why does food remain stuck in the esophagus in achalasia?
In achalasia, the lower esophageal sphincter does not relax normally when a person swallows. At the same time, the normal muscular contractions that move food down the esophagus may also be impaired. As a result, food and liquids can collect in the esophagus instead of passing smoothly into the stomach, causing swallowing difficulty and regurgitation.
Can esophageal candidiasis cause difficulty swallowing?
Yes, esophageal candidiasis can cause difficulty or pain while swallowing because the infection inflames and irritates the esophageal lining. Patients may also experience chest discomfort or reduced food intake. Appropriate antifungal treatment usually helps resolve the infection and improve these symptoms.
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