P1397 - “Everything Is Not What It Seems”: Reversible Achalasia

Marisa-Nicole Zayat, BS¹, Zeina-Christina Zayat, BS², Estephan Zayat, MD^2
1University of Kansas Medical Center, Kansas City, KS; ²University of Kansas School of Medicine, Wichita, KS

Introduction: Achalasia is a rare irreversible motility disorder of the esophagus characterized by aperistalsis and failure of lower esophageal sphincter (LES) relaxation. It is characterized by difficulty swallowing liquids and/or solids.

Case Description/Methods: A 58-year-old female presented with severe, mixed dysphagia. EGD and CT were unremarkable. An esophageal manometry disclosed a high resting LES pressure with inadequate relaxation and high amplitude, simultaneous esophageal body contractions compatible with achalasia (Figure A). Nitrates, calcium channel blockers, and botulinum toxin injections did not result in significant benefit. She was lost to follow up but re-presented one year later with vague upper abdominal discomfort. Her swallowing difficulty had improved since she completed a self-initiated opioid-dependence rehabilitation program. Prior to this, we were not aware of her opiate use. Repeat study revealed a slightly elevated LES pressure with appropriate LES relaxation, peristaltic esophageal contractions in 100% of the swallows, and complete bolus clearance in 90% of the swallows (Figure B).

Discussion: Opiates activate opiate receptors, which interrupt the typical motor activity and are associated with impaired LES pressure and other manometric abnormalities that can mimic achalasia. Given the widespread use of opiates, care must be exercised to exclude opiate-induced esophageal dysfunction (OIED) before a firm diagnosis of dysmotility and achalasia can be reliably made. For these reasons, a robust, explorative patient history with direct questions on opiate usage and repeat testing off-opiates are critical in diagnosing and treating patients with suspected achalasia. As our case demonstrates, OIED can be completely resolved upon discontinuation of opioids.


Figure: Figure A represents manometric findings on opioids and was initially diagnosed as type III achalasia. Figure B represents repeat testing off opioids and demonstrates a significant improvement in esophageal motility.

	Figure A	Figure B
LES Pressure (mmHg)	53.7	49.1
Residual LES Pressure (mmHg)	32.9	14.4
% Relaxation	23	73
Esophageal body
Peristaltic	10	100
Simultaneous	90	0
Amplitude (mmHg)	128.6	166.1
Distal Contractile Integral (mean) (mmHg-cm-s)	2402.5	3785.1

Table: Manometric findings both on (Figure A) and off (Figure B) opioids signifying a reversal of achalasia.


Disclosures:
Marisa-Nicole Zayat indicated no relevant financial relationships.
Zeina-Christina Zayat indicated no relevant financial relationships.
Estephan Zayat indicated no relevant financial relationships.


Marisa-Nicole Zayat, BS¹, Zeina-Christina Zayat, BS², Estephan Zayat, MD². P1397 - “Everything Is Not What It Seems”: Reversible Achalasia, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.