Successful POEM Procedure Improved Swallowing in a 29 Y.O. Male with Type II Achalasia Cardia

Chief Complaints 

A 29-year-old male patient with a Body Mass Index (BMI) of 17 presented to the Gastroenterology Department at PACE Hospitals, Hitech City, Hyderabad, with difficulty swallowing both solid and liquid foods for the past 1 year. The symptoms had worsened over the last 6 months. He also had weight loss, regurgitation, and a globus sensation after food intake. 

The patient was a known case of Type II achalasia cardia. There was no history of other comorbidities, and no history of chest pain was reported. 

On examination, the patient was conscious, coherent, oriented and hemodynamically stable. No pallor or icterus was noted. His abdomen was soft, non-tender, and without distension. There were no signs of an acute abdominal complication, and the remaining systemic examination was within normal limits.

Upon admission to PACE Hospitals, the Gastroenterology team evaluated the patient for long-standing difficulty in swallowing both solid and liquid foods, which had been present for 1 year and had worsened over the last 6 months. The patient also had weight loss, regurgitation, and globus sensation after food intake.

A detailed clinical assessment was performed, followed by diagnostic investigations including upper gastrointestinal endoscopy, barium swallow, and esophageal manometry. Upper gastrointestinal endoscopy helped assess the esophagus, stomach, and gastroesophageal junction, while barium swallow was performed to evaluate food passage and esophageal emptying. Esophageal manometry confirmed Type II achalasia cardia with an Eckardt score of 9 and a median integrated relaxation pressure of 22.1 mmHg, indicating impaired relaxation at the lower oesophageal sphincter. 

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. 

After detailed consultation with Dr. Govind Verma (Interventional Gastroenterologist and Hepatologist), the patient’s symptoms, clinical findings, and diagnostic reports were reviewed to determine the most appropriate treatment plan. The patient had difficulty swallowing both solid and liquid foods for 1 year, with worsening symptoms over the last 6 months, along with regurgitation, weight loss, and globus sensation after food intake.

Diagnostic evaluation with upper gastrointestinal endoscopy, barium swallow, and esophageal manometry confirmed Type II achalasia cardia with an Eckardt score of 9 and elevated integrated relaxation pressure, indicating significant obstruction at the lower oesophageal sphincter.

Considering the severity of dysphagia and impaired relaxation at the gastroesophageal junction, it was determined that Peroral Endoscopic Myotomy (POEM) was the most appropriate treatment strategy. The procedure was intended to relieve the tight lower esophageal sphincter, improve passage of food and liquids into the stomach, reduce regurgitation, and help the patient resume comfortable oral intake.

The patient was counselled regarding the disease condition, treatment approach, procedure details, expected benefits, possible risks, need for post-procedure nil-by-mouth care, Gastrografin assessment, diet progression, and follow-up after discharge. Consent was obtained before proceeding with the POEM procedure. 

Following the decision, the patient was scheduled to undergo a Peroral Endoscopic Myotomy (POEM) procedure in Hyderabad at PACE Hospitals, under the care of the Interventional Gastroenterology Department.

The procedure involved the following steps: 

• Patient Preparation and Anaesthesia: The patient was kept fasting before the procedure and was administered general anaesthesia with airway protection. Prophylactic antibiotics were given to reduce the risk of infection, and carbon dioxide insufflation and continuous monitoring were maintained throughout the procedure.

• Initial Upper Gastrointestinal Endoscopy: An upper gastrointestinal endoscopy was performed to assess the esophagus, gastroesophageal junction, and stomach. Moderate resistance was noted while passing the endoscope across the gastroesophageal junction, located approximately 40 cm from the incisors.

• Submucosal Injection and Mucosal Entry: Diluted methylene blue solution was injected into the esophageal submucosa approximately 9 cm above the gastroesophageal junction. A small mucosal incision was then created using an endoscopic knife to gain access to the submucosal space.

• Submucosal Tunnelling: A submucosal tunnel was carefully created and extended towards and across the gastroesophageal junction. Any visible blood vessels encountered during tunnelling were coagulated using haemostatic forceps to minimise bleeding.

• Endoscopic Myotomy: The circular muscle fibres of the lower oesophagus and gastro-oesophageal junction were divided using an endoscopic knife. This myotomy reduced the abnormal muscular tightness responsible for impaired oesophageal emptying and difficulty swallowing.

• Closure and Completion of the Procedure: After confirming adequate myotomy and haemostasis, the mucosal entry site was closed securely using endoscopic clips. The endoscope was then passed across the gastroesophageal junction with noticeably reduced resistance. The procedure was completed successfully without any immediate complications. 
  

The procedure was completed successfully without any immediate complications. Following the procedure, the patient was closely monitored and managed with intravenous fluids and supportive care. The patient was kept nil by mouth for 2 days to allow the esophageal mucosal entry site to heal.

An oral water-soluble contrast study was subsequently performed, which showed no evidence of contrast leakage. Transient retention of contrast was noted in the lower esophagus, without contrast extravasation. The patient remained clinically stable and was gradually started on oral liquids. He tolerated the liquid diet well without significant difficulty, vomiting, or other immediate post-procedure concerns.

Upon discharge, the patient was prescribed medicines for infection prevention, gastric protection, pain relief, blood pressure control, nutritional support, and other supportive care as required. He was advised to take all medicines as prescribed and follow the medical team’s instructions.

The patient was advised to follow a liquid diet for four days, followed by a soft diet for the next five days. He was instructed to eat slowly, take small portions, chew food thoroughly, and follow the dietary progression recommended by the treating team. 

The patient was advised to report immediately to the emergency ward at PACE Hospitals in case of the development of symptoms such as fever, persistent abdominal or chest pain, repeated vomiting, breathing difficulty, worsening difficulty swallowing, or inability to tolerate liquids. 

The patient was advised to return for a follow-up consultation with a Gastroenterologist in Hyderabad at PACE Hospitals after 1 week. 

This case highlights the successful management of Type II achalasia cardia using POEM. The patient presented with progressive dysphagia, regurgitation, globus sensation, and weight loss. Esophageal manometry confirmed Type II achalasia, and the procedure was completed without complications. The patient recovered well, tolerated oral intake, and was discharged in stable condition with appropriate dietary and follow-up advice.