Aster Hospital, Mankhool recently encountered the case of a young 25-year-old male patient, suffering from Achalasia Cardia. The patient had undergone laparoscopic Heller’s myotomy 3 years ago, which is a standard surgical procedure for this condition in which muscle fibers at the GE junction are divided. The patient did not have complete relief of dysphagia and underwent a repeat Laparoscopic Heller’s myotomy procedure at another hospital in Dubai. Following the second surgery, the patient had complete relief in dysphagia but presented with history recurrent vomiting that persisted for two weeks. The vomitus included stale food, which was suggestive of gastric outlet obstruction or gastroparesis. An upper GI endoscopy showed significant gastric residue but no obstruction at the pylorus. A CT scan showed grossly distended stomach.
These findings were consistent with gastroparesis. This was most likely related to vagal nerve injury that is well-known sequelae of esophageal surgery. The patient did not improve with pro-kinetics and was referred for further management. Apart from operative vagal nerve injury, gastroparesis can occur in patients with diabetes, scleroderma, Parkinson’s disease, multiple sclerosis, and hypothyroidism. It is more common in females and a significant number of patients are idiopathic. Patients usually present with feeling of fullness after a small meal, nausea, recurrent vomiting typically containing stale food, acid reflux, and weight loss. Diagnosis requires assessment of gastric emptying either by traditional barium meal examination or gastric emptying scintigraphy.
The patient underwent balloon dilation of pyloric channel (gastric outflow tract) with a 30 mm balloon. He tolerated it well and there were no complications. There was no recurrence of vomiting after the procedure and at 6 weeks follow-up the patient continues to do well.
Endoscopic balloon dilation of pyloric channel is a well-accepted means of management of gastroparesis. Normally, balloons as large as 15 mm are used to dilate the gastric outlet tract because larger balloons are associated with risk of perforation. Other than endoscopic balloon dilation, gastroparesis can also be treated with injection of botulinum toxin into the pyloric canal, gastric electrical stimulation using an implantable device or by a procedure known as gastric per-oral endoscopic myotomy (G-POEM). Surgical pyloromyotomy also is an option. Endoscopic balloon dilation is a simple procedure and should be the initial consideration. The recurrence rate following use of 15 or 20 mm balloon is higher compared to a 30 mm balloon. We chose to adopt this modality in this young patient so as to offer him a good and durable recovery.
Senior Consultant in Hepatology and Liver Transplantation
Aster Hospital, Mankool