This is an 82-year-old male with past medical history of hypertension, hyperlipedemia, gastresophageal reflux disease (GERD) and coronary artery disease. Patient presented with an eight month history of dysphagia for both liquid and solid food associated with regurgitation of a foamy like material at night. Patient limited his oral intake due to these symptoms and reported a 10 lb weight loss over the last eight months. Patient was treated for many years for GERD with proton pump inhibitors (PPI). Even after the dysphagia began the PPIs were continued but were ineffective. Patient then underwent an Esophagogastroduodenoscopy (EGD) which showed a dilated esophagus and some evidence of reflux esophagitis.
Achalasia was suspected so patient underwent an esophageal manometry study which confirmed the diagnosis of achalasia with an aperistaltic esophageal body and non relaxing lower esophageal sphincter. The patient was scheduled for pneumatic dilatation. An informed consent was obtained; all the risks, benefits and alternatives were discussed with the patient.
Under general anesthesia patient underwent pneumatic esophageal dilatation using a Rigiflex dilator with a 30 mm balloon employed and pressure of 16 PSI Endoscopy immediately after the procedure raised the concern of a small tear in the distal esophagus so a gastrografin swallow study was ordered to rule out any perforation. After extubation patient was complaining of mild to moderate epigastric pain but denied any chest pain, fever, cough or shortness of breath. The patient was afebrile and heamodynamically stable. The patient was kept NPO and the gastrografin study was performed which showed a contained perforation in the very distal esophagus just above the gastroesophageal junction level which was projecting about 1-2 cm into the mediastinum but localized with no leaking into the pleural cavity (Figure 1)
The patient was brought back to the endoscopy unit and a fully covered metallic stent was placed in the distal esophagus with a diameter of 23 mm and 10 cm in length. The time between the initial endoscopy and stent placement was approximately 6 hours. Patient was kept NPO and was started on intravenous broad spectrum antibiotic (Piperacillin-Tazobactam 4.5 Gm q8h) and admitted to the hospital to continue medical treatment.
Day 1 post-stenting the patient was complaining of mild nausea and epigastric discomfort; he remained afebrile and had stable vital signs with a small increase in white blood cell count to 14,000. Day 2 post- stenting he improved clinically without significant nausea or abdominal discomfort. A follow up gastrografin swallowing study was performed, which showed the stent in situ with a minute projection of contrast extravasation at the site of the previous perforation with some contrast hold up in the distal esophagus; however the contrast did pass to the stomach (Figure 2). Patient was allowed to start clear fluid diet.
Day 3 post-stenting the patient remained afebrile and heamodynamically stable and leukocytic count had returned to normal. He tolerated fluids well without nausea or vomiting and his diet was advanced to a regular soft. The patient was discharged home with Augmentin 850mg PO BID for 10 days; he was scheduled for an EGD and stent removal after 2 weeks.
When he presented at that time he had no dysphagia and he was eating a regular diet. The EGD was performed and a safe removal of the stent was accomplished. A white healed scar was seen at the area of the perforation.
A follow up gastrografin swallow showed no contrast extravasation and completely healed perforation (Figure 3). Follow up in clinic at one, six and twelve months later confirmed sustained symptom improvement. As far as no dysphagia occasional heartburn was still in the background as it had been for some years before the diagnosis of achalasia.