Rare case of upper gastrointestinal bleeding in achalasia

INTRODUCTION

Achalasia is the prototypic esophageal motility disorder characterized by a hypertensive lower esophageal sphincter with incomplete relaxation upon swallowing, accompanied by aperistalsis of the esophageal body[1]. Patients with achalasia are at risk for developing complications such as aspiration-pneumonia, esophagitis, esophageal ulcers and bleeding, esophageal-tracheal fistula, spontaneous rupture of the esophagus, and squamous cell carcinoma[2]. The prevalence is 10 per 100000 in the United States, involving an equal distribution of men and women of all ages and from all ethnicities[3]. We report a rare case of upper gastrointestinal bleeding in a patient with achalasia that was associated with an esophageal stone, ulcer formation and Mallory-Weiss syndrome.

CASE REPORT

A 61-year-old woman who complained of vomiting blood for six hours was admitted to our department. She experienced dizziness, palpitations, sweating, and fatigue, but did not present with fever, rash or jaundice. Her medical history revealed achalasia that had been present for 30 years, for which she had declined any treatment. When questioned, she reported ingesting 1 kg hawthorn within the past 3 d.

A physical examination indicated that the patient had severe anemia due to pale conjunctiva and nail beds, and mild palpitation in the upper abdomen. Routine blood tests showed: red blood cell count, 1.34 × 10¹²/L; hemoglobin, 41 g/L; white blood cell count, 11.25 × 10⁹/L; platelet count, 150 × 10⁹/L; blood urea nitrogen, 15.99 mmol/L; and creatinine, 98 μmol/L. Lower esophageal dilatation and esophageal wall thickening were revealed upon CT examination (Figure 1A). An emergency upper endoscopy was performed revealing substantial expansion of the esophagus by a dark round stone (Figure 1B), multiple ulcers on the esophageal wall (Figure 1C), and a slit in the cardiac mucosa with a large clot attached (Figure 1D). Endoscopic sprinkling hemostasis and injection of 2.5% sodium bicarbonate were applied to cease the bleeding and dissolve the stone.

DISCUSSION

In achalasia, injury to the lower esophageal sphincter neurons and the loss of the main functional inhibitory neurotransmitter result in a hypertensive sphincter that loses its ability to relax, leading to stenosis of cardia and lower esophagus expansion. Occasionally, patients will present with persistent food retention, and esophageal stone formation can occur in those who have ingested foods rich in tannins, such as hawthorn and persimmon. The pressure of stones can cause multiple ulcers and even upper gastrointestinal bleeding. The discomfort when swallowing and frequent nausea and vomiting can then lead to the development of Mallory-Weiss syndrome.

Currently, there are no curative treatments for achalasia cardia, rather palliative measures are provided, such as oral nitrates or calcium channel blockers, endoscopic pneumatic dilation, injection of sclerosant substances, or surgery[4-6]. However, complications such as bleeding and rupture can be prevented by avoiding excessive ingestion of tannins.

COMMENTS