Successful POEM Procedure for Recurrent Achalasia Cardia in a 35 Y.O. Male

Chief Complaints

A 35-year-old male patient with a Body Mass Index (BMI) of 20 presented to the Gastroenterology Department at PACE Hospitals, Hitech City, Hyderabad, with swallowing difficulty for the past 1 month. The symptoms were more noticeable at night, and the patient was mostly able to consume liquids only. He also reported occasional central chest pain.

The patient was a known case of achalasia cardia for the past 11 years. He had previously undergone pneumatic dilatation for achalasia-related swallowing difficulty. Despite earlier treatment, he again developed worsening dysphagia and was admitted for further evaluation and management.

A history of hypertension was also noted, for which physician consultation and medical advice were followed during the hospital stay.

On examination, the patient was conscious, coherent, oriented, and hemodynamically stable. He had difficulty swallowing, especially at night, and was mainly tolerating liquids. Abdominal and systemic examinations were performed as part of the pre-procedure assessment. 

Upon admission to PACE Hospitals, the patient was evaluated by the Gastroenterology team for worsening swallowing difficulty, especially at night, with the patient mostly tolerating liquids and reporting occasional central chest pain.

The patient was a known case of achalasia cardia for 11 years and had previously undergone pneumatic dilatation. A detailed clinical assessment was performed, and investigations including upper gastrointestinal endoscopy and barium swallow were carried out to assess the esophagus and gastroesophageal junction.

Upper gastrointestinal endoscopy showed a normal gastric fundus with resistance at the gastroesophageal junction, supporting the diagnosis of achalasia cardia. Based on the clinical history, symptoms, and investigation findings, the patient was diagnosed with Type II achalasia cardia with an Eckardt score of 5.

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) and Dr. M Sudhir (Senior Consultant Gastroenterologist and Hepatologist), the patient’s condition was reviewed to determine the most appropriate treatment plan. The patient had a long-standing history of achalasia cardia for 11 years and had previously undergone pneumatic dilatation.

Despite earlier treatment, he presented again with swallowing difficulty for 1 month, worsening symptoms at night, mainly liquid intake, and occasional central chest pain. Based on clinical assessment, upper gastrointestinal endoscopy, barium swallow findings, and an Eckardt score of 5, Type II achalasia cardia was confirmed.

Considering the recurrence of symptoms and resistance at the gastroesophageal junction, it was determined that Peroral Endoscopic Myotomy (POEM) was the most appropriate treatment option. The procedure was planned to loosen the tight lower esophageal sphincter, improve the passage of food and liquids into the stomach, reduce swallowing difficulty, and help the patient eat more comfortably.

The patient was counselled regarding the diagnosis, need for the procedure, benefits, possible risks and complications, post-procedure diet restrictions, need for Gastrografin assessment, recovery plan, and follow-up after discharge.

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

The procedure involved the following steps:

• Pre-procedural Preparation: After obtaining informed consent and completing all necessary investigations and clearances, the patient was prepared for the POEM procedure under general anesthesia. Intravenous antibiotics were administered, and standard endoscopic precautions were followed.

• Marking and Mucosal Entry: A small area of the esophagus, approximately 9 cm above the gastroesophageal junction, was marked using dye. A specialised endoscopic knife was then used to make a small incision in the inner lining of the esophagus.

• Submucosal Tunnel Creation: A tunnel was carefully created beneath the inner lining of the esophagus to reach the tight muscle layer responsible for swallowing obstruction. Blood vessels encountered during the procedure were sealed to reduce the risk of bleeding.

• Endoscopic Myotomy: The tight muscle layer of the esophagus was cut endoscopically to loosen the lower esophageal sphincter and improve food passage from the esophagus into the stomach.

• Tunnel Closure: After completing the myotomy, the submucosal tunnel was closed using Olympus clips. A post-procedure endoscopic check showed that the scope passed easily through the gastroesophageal junction.

Following the procedure, the patient was closely monitored for pain, fever, vomiting, swallowing difficulty, abdominal discomfort, and any signs of post-procedure complications. He was kept nil by mouth for 2 days and received intravenous fluids and supportive care during the immediate recovery period.

An oral Gastrografin study was performed, which showed free flow of contrast across the gastroesophageal junction without retention or leakage. This confirmed a smooth passage after the procedure. The patient gradually achieved symptomatic stability, and a liquid diet was started.

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 5 days, followed by a soft diet for the next 5 days. He was advised to avoid cool liquids, eat slowly, take small portions, chew properly, and maintain adequate hydration.

The patient was advised to contact the emergency ward at PACE Hospitals immediately in case of the development of symptoms such as fever, abdominal pain, vomiting, worsening swallowing difficulty, chest discomfort, breathing difficulty, or any other concerning symptoms after the procedure.

The patient was advised to return for a follow-up visit with the Gastroenterologist in Hyderabad at PACE Hospitals after 6–8 weeks to assess swallowing improvement, dietary tolerance, recovery status, and any post-POEM symptoms. And follow-up with a general physician was also advised for hypertension management.

This case highlights the successful management of Type II achalasia cardia through Peroral Endoscopic Myotomy (POEM). The patient had long-standing achalasia with previous pneumatic dilatation and presented with recurrent swallowing difficulty, mainly tolerating liquids, and occasional central chest pain.

The POEM procedure helped relieve resistance at the gastroesophageal junction and improve passage of food and liquids into the stomach. Post-procedure Gastrografin study showed free flow across the gastroesophageal junction without retention or leakage. The patient gradually achieved symptomatic stability and was discharged with diet instructions, medications, and follow-up advice.