We describe a rare case of symptomatic achalasia associated with multiple esophageal
diverticula, and report a successful clinical improvement after botulinum toxin injection.
A 66-year-old man had a 2-year history of worsening dysphagia to solids and liquids.
In the previous 2 months, the patient had experienced episodes of immediate regurgitation
of swallowed food and fluids. Since the onset of dysphagia, he had been treated irregularly
with antacids.
Barium esophagogram demonstrated three right-sided esophageal diverticula along the
mid to distal esophagus ([Fig. 1]). Endoscopy revealed three diverticula in the esophagus ([Fig. 2 a]). Esophageal manometry was performed and showed that there was no peristalsis in
the esophageal body. Each swallow resulted in simultaneous contractions ([Fig. 3])
Botulinum toxin was injected at four sites ([Fig. 2 b]). Following the injection therapy, the symptomatic response was accompanied by a
decrease in the lower esophageal sphincter pressure and the patient was discharged.
After 6 months, he had no dysphagia or vomiting.
Although esophageal diverticula have accompanied a variety of esophageal motility
disorders, achalasia-associated multiple esophageal diverticula are extremely rare.
Treatment of patients with achalasia with esophageal diverticula has the risk of iatrogenic
esophageal perforation during pneumatic balloon dilatation [1]. Botulinum toxin injection could be recommended as an alternative treatment, especially
in older patients with either an increased risk for dilation or who have failed to
respond to other treatment modalities [2].
Fig. 1 View of barium esophagogram showing multiple diverticula.
Fig. 2 Endoscopic view of esophageal diverticula. b View of botulinum toxin injection treatment.
Fig. 3 Manometric view of aperistalsis in the esophageal body.
Endoscopy_UCTN_Code_CCL_1AB_2AC_3AF
Endoscopy_UCTN_Code_CCL_1AB_2AC_3AH
