Successful POEM Procedure for Long-Standing Achalasia Cardia in a 36 Y.O. Male
PACE Hospitals
PACE Hospitals’ expert Gastroenterology team successfully performed Peroral Endoscopic Myotomy (POEM) on a 36-year-old male patient diagnosed with Type I achalasia cardia. The procedure aimed to relieve functional obstruction at the lower end of the esophagus, improve swallowing, reduce food regurgitation, and help the patient eat more comfortably.
Chief Complaints
A 36-year-old male patient with a Body Mass Index (BMI) of 18 presented to the Gastroenterology Department at PACE Hospitals, Hitech City, Hyderabad, with difficulty swallowing both liquids and solids for the past 2 years. He also had vomiting after food intake, intermittent chest pain, and weight loss of around 14 kg during this period.
Past Medical History
No significant past gastrointestinal surgeries or other chronic medical illnesses were reported.
On Examination
On examination, the patient was conscious, coherent, and oriented. He appeared thin due to long-standing difficulty in food intake and weight loss. Abdominal examination was performed as part of the gastroenterology evaluation, and further endoscopic assessment was planned.
Diagnosis
Upon admission to PACE Hospitals, the patient was thoroughly evaluated by the Gastroenterology team for long-standing difficulty in swallowing both liquids and solids, vomiting after food intake, intermittent chest pain, and significant weight loss.
A detailed clinical assessment and upper gastrointestinal endoscopic evaluation were performed to assess the esophagus, stomach, and gastroesophageal junction. The patient was diagnosed with Type I achalasia cardia, with an Eckardt score of 10, indicating severe symptoms.
During upper gastrointestinal endoscopy, the gastric fundus appeared normal, while resistance was noted at the gastroesophageal junction, approximately 40 cm from the mouth. These findings were consistent with achalasia cardia.
Based on the confirmed diagnosis, the patient was advised to undergo Achalasia Cardia Treatment in Hyderabad, India, under the expert care of the Gastroenterology Department.
Medical Decision-Making (MDM)
After detailed consultation with Dr. Govind Verma (Interventional Gastroenterologist and Hepatologist), along with Dr. M. Sudhir (Senior Consultant Gastroenterologist and Hepatologist), and the therapeutic endoscopy team, a comprehensive clinical evaluation was performed. The patient’s symptoms and diagnostic findings were reviewed to determine the most appropriate treatment plan.
The patient had Type I achalasia cardia with severe symptoms, including difficulty swallowing liquids and solids, vomiting after food intake, intermittent chest pain, and significant weight loss. Upper gastrointestinal endoscopy showed resistance at the gastroesophageal junction, supporting the diagnosis.
Based on the clinical assessment, it was determined that Peroral Endoscopic Myotomy (POEM) was the most appropriate definitive treatment. The procedure was planned to relieve the tight lower oesophageal sphincter, improve food passage into the stomach, reduce regurgitation, and help the patient eat more comfortably.
The patient and family were counselled regarding the diagnosis, POEM procedure, expected benefits, possible risks, post-procedure diet instructions, and the need for follow-up. After completing the required evaluations and obtaining consent, the patient was taken up for the procedure.
Surgical Procedure
Following the decision, the patient was scheduled for a Peroral Endoscopic Myotomy (POEM) Procedure in Hyderabad at PACE Hospitals, under the expert care of the Gastroenterology Department.
The procedure was carried out in the following steps:
- Pre-procedural Preparation: After completing the necessary investigations and obtaining required clearances, the patient was prepared for the POEM procedure. Intravenous antibiotics were administered before the procedure as part of pre-procedural care.
- Upper Gastrointestinal Endoscopic Assessment: Upper gastrointestinal endoscopy was performed to assess the esophagus, stomach, and gastroesophageal junction. The fundus appeared normal, while resistance was noted at the gastroesophageal junction, approximately 40 cm from the mouth.
- Mucosal Entry and Tunnel Creation: A dye was used to highlight the tissue plane, and a small mucosal incision was made using a T knife. A submucosal tunnel was then carefully created beneath the inner lining of the esophagus.
- Selective Myotomy: Blood vessels encountered during the procedure were sealed to reduce bleeding. The circular muscle fibres causing functional obstruction were cut using a hybrid knife to relieve tightness at the lower end of the esophagus.
- Closure of Entry Site: After completion of the myotomy, the tunnel was closed using endoscopic clips. A post-procedure endoscopic assessment showed that the scope passed smoothly through the gastroesophageal junction.
Postoperative Care
After the POEM procedure, the patient was kept nil by mouth for 2 days and closely monitored for pain, vomiting, fever, swallowing difficulty, and any signs of leak or complications. Supportive care was provided during the recovery period.
An oral Gastrografin study was performed, which showed smooth passage of contrast across the gastroesophageal junction without significant retention or leak. Following this, the patient gradually started a liquid diet and showed improvement in swallowing symptoms.
Discharge Medications
Upon discharge, the patient was prescribed medicines for infection prevention, gastric protection, pain relief, nausea and vomiting prevention, and other supportive care as required. He was advised to take all medicines as prescribed.
Advice on Discharge
The patient was advised to follow a liquid diet for 5 days, followed by a soft diet for the next five days. He was also advised to avoid cold liquids, take food slowly, chew properly, and follow the gastroenterology team’s instructions carefully during recovery.
Emergency Care
The patient was advised to contact the emergency ward at PACE Hospitals in case of any emergency or development of symptoms such as fever, vomiting, abdominal pain, or any other concerning complaints following the procedure.
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 1 month.
Conclusion
This case highlights the successful management of Type I achalasia cardia through Peroral Endoscopic Myotomy (POEM). The procedure helped relieve functional obstruction at the gastroesophageal junction, improved swallowing, and supported gradual symptom recovery. Post-procedure Gastrografin study showed smooth passage across the gastroesophageal junction without leak or significant retention. The patient was discharged with dietary instructions, medications, and follow-up advice.
POEM Procedure: A Modern Approach to Swallowing Disorders
Peroral Endoscopic Myotomy (POEM) is an advanced endoscopic treatment used for swallowing disorders such as achalasia cardia, where food and liquids do not pass smoothly from the oesophagus into the stomach. In patients with long-standing swallowing difficulty, vomiting after food intake, chest discomfort, and weight loss, timely evaluation and treatment are important to prevent worsening nutrition and quality of life.
POEM helps by cutting the tight muscle at the lower end of the oesophagus through an endoscopic approach, without external surgical cuts. Post-procedure assessment, such as a Gastrografin study, helps confirm smooth passage across the gastroesophageal junction and rule out leakage before starting oral intake. This case highlights the importance of advanced endoscopic care by a
gastroenterologist/gastroenterology doctor in improving swallowing function, supporting safe recovery, and helping patients return to better eating comfort.
Frequently Asked Questions (FAQs)
What is the Eckardt score in achalasia?
The Eckardt score is a symptom score used to understand how severe achalasia symptoms are. It looks at difficulty swallowing, food regurgitation or vomiting, chest pain, and weight loss. A higher score means symptoms are more severe and may need active treatment. In this case, the patient’s score was 10, which indicated significant swallowing difficulty and weight loss.
Why is upper gastrointestinal endoscopy done in achalasia?
Upper gastrointestinal endoscopy helps doctors examine the esophagus, stomach, and gastroesophageal junction directly. It helps rule out other causes of swallowing difficulty, such as narrowing, tumor, inflammation, or food blockage. In achalasia, endoscopy may show resistance at the lower end of the oesophagus, which supports the diagnosis and helps plan treatment.
Why is a Gastrografin test done after POEM?
A Gastrografin test is done after POEM to check whether liquid passes smoothly from the oesophagus into the stomach. It also helps doctors look for any leaks after the procedure. If the test shows good passage without leakage, the patient can usually start oral liquids gradually as advised.
Why was the patient kept nil by mouth after POEM?
The patient was kept nil by mouth after the POEM procedure to allow the treated area inside the esophagus to rest and heal. This also helps reduce the risk of irritation, vomiting, or leakage soon after the procedure. Oral intake is usually restarted gradually after the doctor confirms that swallowing is safe.
Can achalasia cardia worsen over time if untreated?
Yes, achalasia can worsen over time if not treated. Food and liquids may continue to collect in the esophagus, leading to increasing swallowing difficulty, repeated regurgitation, chest discomfort, poor nutrition, and weight loss. Early diagnosis and treatment can help improve swallowing and reduce long-term complications.
Why is manometry important in achalasia diagnosis?
Manometry is an important test because it measures the pressure and movement of the esophageal muscles. It helps confirm whether the lower esophageal sphincter is relaxing properly and identifies the type of achalasia. This helps doctors to choose the most suitable treatment approach.
What does resistance at the gastroesophageal junction mean?
Resistance at the gastroesophageal junction means there is tightness where the esophagus meets the stomach. In achalasia, this tightness occurs because the lower esophageal sphincter does not relax properly. As a result, food and liquids have difficulty passing into the stomach, causing swallowing problems and regurgitation.
Is POEM suitable for long-standing achalasia symptoms?
POEM can be suitable for patients with long-standing achalasia symptoms, depending on the patient’s condition, test findings, and specialist assessment. It helps relieve the tight muscle at the lower end of the oesophagus and improves food passage. The final decision is made after endoscopy, manometry, and overall clinical evaluation.
Can swallowing difficulty return after POEM?
In many patients, POEM provides good and lasting relief, but swallowing difficulty can return in some cases. This may happen due to incomplete response, scarring, reflux-related symptoms, or progression of oesophageal motility problems. Regular follow-up helps detect recurrent symptoms early and plan further treatment if needed.
How does POEM improve quality of life in achalasia patients?
POEM improves quality of life by helping food and liquids pass more easily from the oesophagus into the stomach. This can reduce swallowing difficulty, regurgitation, vomiting after meals, chest discomfort, and food-related anxiety. As eating becomes easier, nutrition, weight, energy levels, and daily comfort may also improve.
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