Successful POEM Procedure for Achalasia Cardia Type II in a 16 Y.O. Female from Tamil Nadu

Chief Complaints

A 16-year-old female patient with a body mass index (BMI) of 17 from Puducherry presented to the Gastroenterology Department at PACE Hospitals, Hitech City, Hyderabad, with complaints of progressive difficulty in swallowing (dysphagia) to both solid foods and liquids for one year. She also reported persistent heartburn and nocturnal cough, which had gradually worsened and affected her daily nutritional intake and quality of life.

The patient had no significant past medical illness, previous surgeries, or long-term medication use. There was no history of allergies or any significant family history of gastrointestinal disorders.

On examination, the patient was conscious, coherent, oriented, and hemodynamically stable. General physical examination was normal except for mild pallor. Abdominal examination was soft, non-tender, and without organomegaly or abdominal distension. There were no signs of respiratory distress or acute infection. The remaining systemic examination was within normal limits.

Upon admission to PACE Hospitals, the Gastroenterology team performed a detailed clinical evaluation for the patient's progressive dysphagia involving both solids and liquids, associated with heartburn and nocturnal cough.

Routine laboratory investigations demonstrated mild anemia with reduced red blood cell count and packed cell volume (PCV), while other baseline parameters were within acceptable limits for intervention.

Upper gastrointestinal endoscopy revealed a dilated and tortuous esophagus with resistance at the gastroesophageal junction, raising strong suspicion of achalasia.

A barium swallow study demonstrated a markedly dilated thoracic esophagus with smooth tapering at the gastroesophageal junction, findings suggestive of achalasia. High-resolution esophageal manometry subsequently confirmed Type II achalasia cardia.

Based on the clinical presentation, endoscopic findings, and radiological evaluation, the patient was advised to undergo Achalasia Cardia Treatment in Hyderabad, India, under the expert care of the Gastroenterology Department at PACE Hospitals.

Following a detailed consultation with Dr. Govind Verma, Interventional Gastroenterologist, Transplant Hepatologist, Pancreatologist and Endosonologist, along with Dr. M Sudhir, Senior Gastroenterologist and Hepatologist, the patient's symptoms, imaging findings, and endoscopic evaluation were thoroughly reviewed.

Considering the patient's progressive dysphagia, radiological evidence of lower esophageal sphincter obstruction, and confirmed diagnosis of Achalasia Cardia Type 2, Peroral Endoscopic Myotomy (POEM) was considered the most appropriate treatment option.

The minimally invasive endoscopic approach was selected to divide the dysfunctional lower esophageal sphincter muscle, thereby restoring esophageal emptying, improving swallowing, reducing reflux-related symptoms, and avoiding the morbidity associated with conventional surgery.

The patient and her family members were counselled regarding the diagnosis, procedural steps, expected benefits, possible risks, postoperative dietary modifications, and the importance of regular follow-up. After obtaining informed consent, the patient was scheduled for the procedure.

Following the decision, the patient was scheduled for Peroral Endoscopic Myotomy (POEM) in Hyderabad at PACE Hospitals, under the expert care of the Gastroenterology Department.

The following steps were carried out during the procedure:

• Patient Preparation and Anaesthesia: Following complete preoperative evaluation and informed consent, the patient was taken up for the procedure under general anaesthesia. Standard aseptic precautions were followed throughout the procedure.

• Endoscopic Assessment: A therapeutic endoscope was advanced into the esophagus. Careful inspection confirmed a dilated, tortuous esophagus with narrowing at the gastroesophageal junction, consistent with Achalasia Cardia.

• Submucosal Tunnel Creation: A small mucosal incision was made in the esophageal wall, followed by careful creation of a submucosal tunnel extending across the lower esophageal sphincter into the proximal stomach.

• Selective Myotomy: The circular muscle fibres of the lower esophageal sphincter and distal esophagus were selectively divided to relieve functional obstruction while preserving the outer esophageal wall.

• Closure and Completion: After confirming adequate myotomy, the mucosal entry site was closed using endoscopic clips. The procedure was completed successfully without any intraoperative complications.
  

Following the procedure, the patient was closely monitored and had an uneventful postoperative recovery. She received supportive treatment for maintenance of hydration, prevention of procedure-related infection, pain relief, control of nausea, and promotion of esophageal healing until oral intake was safely resumed. A postoperative Gastrograffin swallow study showed no evidence of contrast leak, and the patient remained hemodynamically stable without any complications throughout her hospital stay.

Upon discharge, the patient was prescribed medications for reduction of gastric acid secretion to promote healing of the esophagus, relief of pain or discomfort as needed, prevention of infection where indicated, and supportive management to facilitate recovery following the procedure. She was advised to take the medications as prescribed and to report any new or worsening symptoms during the recovery period.

The patient was advised to follow a liquid diet for the first 7 days, followed by a soft diet for the next 7 days before gradually resuming a regular diet as tolerated. She was instructed to eat small, frequent meals, maintain adequate hydration, avoid strenuous activities and foods that may irritate the esophagus during the recovery period.

The patient was informed to contact the emergency ward at PACE Hospitals in case of any emergency or development of symptoms such as severe chest pain, persistent vomiting, fever, difficulty swallowing, difficulty breathing, vomiting of blood, black stools, or any sudden worsening of her condition.

The patient was advised to return for a follow-up visit with the Interventional Gastroenterologist in Hyderabad at PACE Hospitals after 1 month.

This case highlights the successful management of Achalasia Cardia Type II in a 16-year-old female using Peroral Endoscopic Myotomy (POEM). The minimally invasive procedure effectively relieved lower esophageal sphincter obstruction, resulting in improvement of dysphagia and associated symptoms, with an uneventful recovery and discharge in a hemodynamically stable condition.