Achalasia: an unusual cause of airway obstruction

A Case of Achalasia Presenting with Cardiac Arrest due to Left Atrial Compression

Achalasia is a rare primary esophageal motility disorder characterized by the loss of enteric neurons leading to an absence of peristalsis and impaired relaxation of the lower esophageal sphincter. The subsequent stasis of ingested food not only leads to symptoms of dysphagia, regurgitation, chest pain, and weight loss, but also results in an increased risk of esophageal carcinoma. Structural or functional pulmonary abnormalities occur in more than half of patients and may be due to recurrent aspiration or tracheal compression from a dilated esophagus. Delayed diagnosis or ineffective intervention may lead to progressive dilation of the esophagus and the development of a megaesophagus. Respiratory distress and cardiopulmonary arrest from tracheal or left atrial compression secondary to a megaesophagus are rare complications of achalasia. There is only limited evidence that pneumatic dilation may be used as a first-line therapy for a megaesophagus. The choice of definitive treatment will depend on many factors including achalasia type, patient wishes, performance status, and surgical expertise.

Oesophageal achalasia presents with acute stridor in the Emergency Department

Oesophageal achalasia is a condition of unknown aetiology that most commonly presents with dysphagia, oesophageal regurgitation or chest pain. A case is described of an 88-year-old lady who presented to the Emergency Department with acute stridor as the initial presentation of oesophageal achalasia. Key steps in management included prompt involvement of an appropriate multi-disciplinary team, control of the compromised airway and early decompression of the mega oesophagus. Our report particularly highlights the diagnostic challenges faced by clinicians dealing with this medical emergency. We recommend that a diagnosis of achalasia should be considered as part of the differential diagnosis in a patient who presents with acute stridor.

SVC obstruction and stridor relieved by nasogastric tube insertion

Achalasia is an idiopathic motility disorder of the oesophagus of increasing incidence. It is characterized by aperistalsis of the lower oesophagus and failure of relaxation of the lower oesophageal sphincter. Patients classically present with chronic symptoms of dysphagia, chest pain, weight loss and regurgitation, and they commonly suffer pulmonary complications such as recurrent microaspiration of static, retained food contents of the upper oesophagus. However, it has also been described, uncommonly, to present with megaoesophagus and secondary tracheal compression. We present a case of megaoesophagus secondary to achalasia which presented with stridor and signs of acute superior vena caval obstruction.

A rare manifestation of achalasia: huge esophagus causing tracheal compression and progressive dyspnea

Achalasia is a primary esophageal motility disorder characterized by the absence of primary peristalsis and a failure of the lower esophageal sphincter to relax, resulting in a dilated esophagus. Dysphagia is the classic and most common symptom. Respiratory obstruction due to tracheal compression caused by a massively dilated esophagus is a very rare but fatal complication. Herein, we report a case of a patient with long-standing achalasia who had tracheal compression secondary to a markedly dilated, giant esophagus. These findings are documented with CT scans. His symptoms regressed after a Heller myotomy and fundoplication operation.

Successful airway management in a patient with severe proximal achalasia requires interdisciplinary cooperation

We report a case of a patient undergoing esophagectomy for end-stage achalasia, a rare condition associated with potentially catastrophic ventilatory and circulatory complications. The complexity of the case necessitated preoperative planning with the surgical specialist, development of a novel algorithm for airway management, and careful implementation of our plan. Isolation of the lungs from the esophagus presented unique challenges due to not only the anatomic derangements that are the hallmark of this disease process but also an unusual anatomic finding seen in this patient.

Recurrent respiratory distress and cardiopulmonary arrest caused by megaoesophagus secondary to achalasia

INTRODUCTION

Respiratory distress and arrest from tracheal compression secondary to megaoesophagus are rare complications of achalasia. We present the case of a man with end-stage achalasia who required oesophagectomy to prevent recurrent life-threatening tracheal compression and respiratory arrest. A literature review is also presented.

PRESENTATION OF CASE

A 40-year old man presented with post-prandial stridor which resolved spontaneously, later being diagnosed with achalasia. He underwent pneumatic dilatation year later, intended as definitive treatment. Despite intervention, the patient had developed megaoesophagus. One month later he presented with tracheal compression and cardiorespiratory arrest but was successfully resuscitated. He subsequently underwent elective oesophagectomy.

DISCUSSION

Over 40 case reports of achalasia presenting with stridor have been published. However, only three cases (all female, age range, 35-79 years old) of cardiac, respiratory or cardiorespiratory arrest have been published. The definitive treatments received by these patients were botulinum toxin injections, open Heller cardiomyotomy with Dor fundoplication and pneumatic dilatation. None of these patients suffered recurrent respiratory distress following definitive treatment. The patient currently reported was unique as he suffered cardiorespiratory arrest following an intended definitive treatment, pneumatic dilatation. As such oesophagectomy was considered the greatest risk-reduction intervention.

CONCLUSION

Oesophagectomy should be considered for patients with end-stage achalasia and mega-oesophagus causing respiratory compromise to avoid potential fatal complications such as tracheal compression and subsequent respiratory arrest.

Sudden Tracheal Collapse during EGD and Subsequent Anesthetic Management with Dexmedetomidine-Ketamine in a Patient with Achalasia and Tracheomalacia

We present a patient who experienced airway obstruction during an elective esophagogastroduodenoscopy (EGD) under anesthesia secondary to previously undiagnosed tracheomalacia. Physiology of airway obstruction with forced breathing maneuvers is discussed along with the potential advantages of dexmedetomidine-ketamine sedation for management of patients with achalasia undergoing outpatient endoscopic procedures.