Endoscopic Approaches in Treating Achalasia Cardia: A Case Study Analysis

Introduction

Achalasia cardia is a rare but significant esophageal motility disorder that can severely affect a patient’s quality of life. Characterized by the absence of esophageal peristalsis and failure of the lower esophageal sphincter (LES) to relax, this condition can lead to symptoms like dysphagia, regurgitation, and weight loss. Timely diagnosis and effective endoscopic intervention can greatly improve patient outcomes. This article discusses the clinical presentation, diagnostic modalities, and advanced endoscopic treatment options available for achalasia cardia, with a focus on the Peroral Endoscopic Myotomy (POEM) procedure.

What is Achalasia Cardia?

Achalasia cardia is a motility disorder of the esophagus caused by the degeneration of inhibitory neurons at the LES and excitatory neurons in the esophageal body. The condition is idiopathic and leads to loss of peristalsis in the esophageal body and failure of the LES to relax, making the passage of food into the stomach difficult.

Symptoms of Achalasia Cardia

• Dysphagia to both solids and liquids

• Non-cardiac chest pain, often worsened by swallowing

• Regurgitation of undigested food

• Unintended weight loss

Achalasia is frequently misdiagnosed as gastroesophageal reflux disease (GERD). A diagnosis of achalasia should be considered in GERD patients who also experience persistent chest pain, regurgitation, and significant weight loss. In long-standing cases, the esophagus may become dilated, and dysphagia symptoms may diminish, leading patients to underreport or overlook this key symptom.

Diagnosis

The gold standard for diagnosing achalasia is High-Resolution Esophageal Manometry (HREM). Based on manometric patterns, achalasia is classified into three subtypes. HREM is also instrumental in diagnosing other esophageal motility disorders.

Other diagnostic tools include:

• Upper GI Endoscopy: To rule out malignancy or mechanical obstruction

• Barium Swallow: Typically shows a “bird beak” appearance in achalasia patients

Treatment Options

Historically, laparoscopic Heller myotomy was the standard treatment, involving the surgical division of LES muscles. However, with advancements in endoscopic techniques, gastroenterologists can now manage achalasia less invasively and with comparable long-term outcomes.

Endoscopic Therapies Include:

1. Pneumatic Balloon Dilatation of LES

   • A balloon is guided across the LES and inflated to forcibly dilate the sphincter.

   • The procedure often requires repetition, and over 30% of patients experience recurrence within 5 years.

2. Botulinum Toxin (Botox) Injection

   • Reduces LES pressure by chemically relaxing the muscles.

   • Effects are temporary (about 6 months).

   • Typically used in elderly or high-risk patients who are unfit for more definitive procedures.

3. Peroral Endoscopic Myotomy (POEM)

   • The treatment of choice for achalasia cardia today.

   • An advanced endoscopic procedure involving myotomy of the esophageal and LES muscles.

   • Performed via natural orifice (endoscope through the mouth) with no external incision.

   • Comparable outcomes to surgery and superior to balloon dilatation, with up to 80% long-term success over 10 years.

Case Report

A young female presented to our Gastroenterology OPD with symptoms of persistent food regurgitation, mild dysphagia, non-cardiac chest pain, and significant weight loss (over 10 kg in two years). She had previously been treated as a GERD case without any relief. Based on clinical suspicion, she underwent endoscopy and HREM, which confirmed achalasia cardia.

She subsequently underwent the POEM procedure, which was uneventful. Over the course of a year of follow-up, she remained symptom-free and had regained 15 kg.

Image 1: Dilated esophagus with stasis of food contents, suggestive of achalasia cardia. (Image credit: Dr. Naveen Kumar)

Image 2: Barium swallow demonstrating achalasia cardia—with findings of a dilated esophagus and narrowing at the lower esophageal sphincter (LES). The contrast medium is retained in the esophagus, showing a column of barium and the classic “bird’s beak” appearance.

Steps of the POEM Procedure

1. Submucosal Injection: A bleb is created in the esophageal mucosa above the LES to separate the mucosal layer from the submucosa.

   

   Image 3: Creation of a mucosal bleb by injecting methylene blue solution. (Image credit: Dr. Naveen Kumar)

2. Mucosal Incision: Entry is made into the submucosal space.

   

   Image 4: Incision of the mucosa using an endoscopic knife. (Image credit: Dr. Naveen Kumar)

3. Submucosal Tunneling: A tunnel is created under the mucosa, extending past the LES into the gastric cardia.

   

   Image 5: Entry through the mucosal incision to dissect the submucosa and create a tunnel using spray coagulation current. (Image credit: Dr. Naveen Kumar)

4. Myotomy: Circular and longitudinal muscles of the esophagus and LES are cut.

   

   Image 6: Dissection of the muscularis propria. (Image credit: Dr. Naveen Kumar)

5. Closure: The mucosal entry site is sealed with endoscopic clips.

   

   Image 7: Closure of the entry site using endoscopic clips. (Image credit: Dr. Naveen Kumar)

Image 8: Pictorial representation of the POEM (Peroral Endoscopic Myotomy) procedure.

Post-procedure care:

• Patients are kept nil per oral (NPO) for 48 hours to allow healing of the mucosal incision.

• After 48 hours, a liquid diet is initiated, followed by a gradual progression to soft and then solid foods.

Conclusion

Achalasia cardia is a chronic, progressive esophageal disorder that requires a high index of suspicion for accurate diagnosis. While traditional surgical treatments remain effective, endoscopic techniques—especially POEM—have revolutionized management by offering a minimally invasive, highly effective alternative with excellent long-term results. Early diagnosis and expert intervention can dramatically improve a patient's quality of life, as seen in the case reported above. As endoscopic skills and technologies continue to evolve, more patients stand to benefit from such cutting-edge therapies.

About the Author

Dr. Naveen Kumar, MBBS, MD, DM (Gastroenterology, PGIMER Chandigarh)Director, Department of GastroenterologySri Harihar Hospital and Research Center, Gutkar, District Mandi, Himachal Pradesh

Dr. Naveen Kumar

Dr. Naveen Kumar is a highly respected gastroenterologist with advanced training from the prestigious PGIMER, Chandigarh. As the Director of the Department of Gastroenterology at Sri Harihar Hospital and Research Center, he brings exceptional expertise in diagnosing and managing a wide spectrum of digestive disorders, with a strong focus on advanced endoscopic techniques.

He is the first and only gastroenterologist in Himachal Pradesh performing endoscopic ultrasound (EUS) and cutting-edge procedures like Peroral Endoscopic Myotomy (POEM) for achalasia cardia, setting new standards in gastrointestinal care across the region.

Renowned for his patient-centered care and commitment to clinical excellence, Dr. Naveen also plays an active role in medical education and public awareness through his writings and academic contributions.

He is the editor of this article, and all endoscopic images included are credited to him.

📧 Email: contact@drnaveenkumargastro.com🐦 Twitter: @drnaveenm