case_images: PMC11785603_01
case_images: HRM study from the first visit of patient, where the relaxation pressure of lower esophageal sphincter was in physiological range (IRP 10,4 mmHg) with a 7 cm long spastic segment from 23 to 30 cm from nostrils
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case_images: PMC11785603_01_12328_2024_2066_Fig1_HTML.jpg
case_images: Fig1
case_images: High-resolution manometry (HRM) showed normal LES integrated relaxation pressure (IRP 10.4 mmHg), signs of propulsive peristalsis and no panesophageal pressurization (Fig. 1), however, it revealed a 7 cm long spastic segment extending from 23 to 30 cm from the nostrils (maximum pressure of 322 mmHg during the motility study within this segment), elevated distal contractile interval (DCI, maximum of 7762 mmHg in a single swallow, mean value 5482 mmHg). The spastic segment (Fig. 1) was in manometric study clear in 80% of 5 ml swallows in the upright position.
case_images: Upper endoscopy with no stenosis of the lumen and pseudodiverticular dilatation in the upper third of the esophagus, 2 arrows point at spastic segment and a star points at pseudodiverticulum
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case_images: PMC11785603_01_12328_2024_2066_Fig2_HTML.jpg
case_images: Fig2
case_images: We performed upper endoscopy (Fig. 2) that revealed no narrowing of the lumen however there was pseudodiverticular dilatation of esophageal lumen and tertiary spasms below.
case_images: EUS image of thickened muscular layer of the upper third of the esophagus, white two-sided arrow points at muscularis propria, white arrow points at mucosal and submucosal layer represented by hyperechogenic and hypoechogenic line between the muscularis propria and the probe
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case_images: PMC11785603_01_12328_2024_2066_Fig3_HTML.jpg
case_images: Fig3
case_images: Because of the EUS probe compression, the submucosal and mucosal layer are visible only as a thin hyperechogenic and hypoechogenic lines between probe and muscularis propria (Fig. 3). After localizing the thickened part of the esophageal wall (20-30 cm from front teeth according to the EUS), we applied botulinum toxin into 4 quadrants at the level of 24 cm from front teeth (muscularis propria layer thickness 8.8 mm) (Fig. 3) and 20 cm from front teeth (muscularis propria layer thickness 4.9 mm).
case_images: HRM study 3 weeks after the botulinum toxin application and restoration of the propulsive peristalsis, normal LES relaxation pressure
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case_images: PMC11785603_01_12328_2024_2066_Fig4_HTML.jpg
case_images: Fig4
case_images: At the checkup 3 weeks after the procedure the patient reported improvement of symptoms and restoration of propulsive peristalsis on HRM with total elimination of spastic segment (Fig. 4).
case_images: HRM image with panesophageal pressurization and elevated LES relaxation pressure suggesting type II. Achalasia (IRP 21 mmHg). HRM high resolution manometry, LES lower esophageal sphincter, IRP integrated relaxation pressure
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case_images: PMC11785603_01_12328_2024_2066_Fig5_HTML.jpg
case_images: Fig5
case_images: The COVID-19 pandemic postponed scheduled visits of the patient and as late as in 05/2022 during another follow-up visit HRM revealed features fulfilling the diagnosis of II type achalasia (Fig. 5), with panesophageal pressurization in 40% of swallows, IRP was 21 mmHg.