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Department of Internal Medicine and Gerontology, University Hospital, Maison Blanche Hospital, Reims F-51092, FranceUniversity of Reims Champagne-Ardenne, Faculty of Medicine, E.A 3797, Reims F-51092, France
Department of Geriatrics, University Hospital, Champmaillot Hospital, Dijon F-21079, FranceInserm/U1093 Cognition Action Plasticity, University of Burgundy Franche Comté, F-21078 Dijon, France
Department of Internal Medicine and Gerontology, University Hospital, Maison Blanche Hospital, Reims F-51092, FranceUniversity of Reims Champagne-Ardenne, Faculty of Medicine, E.A 3797, Reims F-51092, France
It is characterized by functional gastro-oesophageal sphincter obstruction.
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Aspiration pneumonia may complicate the achalasia.
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Intrasphincteric botulinum toxin injection is one of the main treatments for achalasia.
1. Indication
An 87-year-old woman was hospitalized for a productive cough, wheezing and weight loss. Her medical history included recurring aspiration pneumonia. She had intermittent dysphagia that appeared 2 years earlier, predominantly for solids. She experienced up to 48 h of aphagia followed by dysphagia-free intervals of 4 to 5 days. There was also significant regurgitation of undigested food, causing coughing, bronchial obstruction and aspiration pneumonia. The patient reported worsening digestive disorders and a weight loss of 7 k in the previous 2 years. Biological screening showed hypoalbuminemia (28 g/L). Chest X-ray showed esophageal hydroaeric levels (Fig. 1a ). Barium swallow showed a discreetly tapering lower third of the esophagus with a bird's beak appearance, and esophageal dilatation consistent with megaesophagus and esophageal dyskinesia (Fig. 1b). Gastrointestinal endoscopy showed a dilated esophagus and a large volume of food debris, with no signs of tumor.
Fig. 1Chest X-ray which shows oesophageal hydroaeric levels (a) and Barium swallow which revealed a discreetly tapering lower third of the esophagus in the shape bird's beak, as well as oesophageal dilatation and dyskinesia (b).
After eliminating secondary causes of esophageal motility disorders, achalasia was diagnosed despite the absence of manometry (patient's refusal). Achalasia is characterized by the incomplete relaxation of the gastro-esophageal sphincter, an increase in esophageal resting pressure and impaired esophageal peristalsis, leading to functional gastro-esophageal sphincter obstruction, and then megaesophagus [
]. Weight loss and/or aspiration pneumonia can appear.
The treatment of achalasia includes medical therapy (calcium inhibitors/nitrate derivatives), pneumatic dilation, Heller's myotomy, and intrasphincteric botulinum toxin injection (IBTI). The results of medical therapy are disappointing and the adverse effects cannot be ignored, especially in the elderly [
]. Pneumatic dilation carries a risk of perforation. Heller's myotomy is rarely performed in the elderly because of surgical risk. Here, IBTI was performed. It led to immediate functional improvement with excellent tolerance. In the elderly, IBTI yields a clinical response in 40–60% of cases at 1-year after one injection, and up to 70% of cases after two injections [
]. In practice, in the elderly, the treatment choice is between medical therapy, although disappointing, pneumatic dilation and IBTI, depending on the patient's wishes and comorbidities.
The early diagnosis and management of achalasia would help to avoid recurrence or serious complications (aspiration pneumonia, malnutrition).
Conflict of interest statement
The authors have no conflicts of interest to declare.
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