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What could have caused this weight loss?

  • Rachid Mahmoudi
    Affiliations
    Department of Internal Medicine and Gerontology, University Hospital, Maison Blanche Hospital, Reims F-51092, France

    University of Reims Champagne-Ardenne, Faculty of Medicine, E.A 3797, Reims F-51092, France
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  • Patrick Manckoundia
    Correspondence
    Corresponding author at: Pôle Personnes Âgées Hôpital de Champmaillot CHU BP 87 909, 2, rue Jules Violle, F21079 Dijon Cedex, France. Tel.: +33 3 80 29 39 70; fax: +33 3 80 29 36 21.
    Affiliations
    Department of Geriatrics, University Hospital, Champmaillot Hospital, Dijon F-21079, France

    Inserm/U1093 Cognition Action Plasticity, University of Burgundy Franche Comté, F-21078 Dijon, France
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  • Jean Luc Novella
    Affiliations
    Department of Internal Medicine and Gerontology, University Hospital, Maison Blanche Hospital, Reims F-51092, France

    University of Reims Champagne-Ardenne, Faculty of Medicine, E.A 3797, Reims F-51092, France
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      Highlights

      • Achalasia is rare and often diagnosed late.
      • It is characterized by functional gastro-oesophageal sphincter obstruction.
      • Aspiration pneumonia may complicate the achalasia.
      • 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. 1
      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).
      What is the diagnosis?

      2. Diagnosis

      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 [
      • Boeckxstaens G.E.
      • Zaninotto G.
      • Richter J.E.
      Oesophageal motility disorders.
      ]. Achalasia is rare (prevalence 10/100,000) [
      • Enestvedt B.K.
      • Williams J.L.
      • Sonnenberg A.
      Epidemiology and practice patterns of achalasia in a large multi-centre database.
      ] and often diagnosed late. The symptoms, mainly solid and liquid dysphagia, chest pain and regurgitation develop progressively [
      • Boeckxstaens G.E.
      • Zaninotto G.
      • Richter J.E.
      Oesophageal motility disorders.
      ]. 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 [
      • Dughera L.
      • Battaglia E.
      • Maggio D.
      • et al.
      Botulinum toxin treatment of oesophageal achalasia in the old old and oldest old: a 1-year follow-up study.
      ]. 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 [
      • Dughera L.
      • Battaglia E.
      • Maggio D.
      • et al.
      Botulinum toxin treatment of oesophageal achalasia in the old old and oldest old: a 1-year follow-up study.
      ]. 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.

      Acknowledgments

      The authors are grateful to Mr. Philip Bastable.

      Appendix A. Supplementary data

      References

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