Endoscopic ultrasound navigated application of botulinum toxin in severe esophageal motility disorder

Abstract

The use of botulinum toxin in the therapy of esophageal motility disorders is reserved for elderly and comorbid patients considered risky for endoscopic or surgical treatment. However, there is a lack of data on the treatment of motility disorders outside the Chicago classification.We present the case of a 56-year-old patient with dysphagia and non-cardial chest pain (Eckardt 8). High resolution manometry ruled out achalasia or other motility disorder, but confirmed a localized 7-cm-long spastic segment in the upper to middle third of esophagus. We considered endoscopic or surgical therapy in this location too risky, therefore we decided to apply botulinum toxin into this segment. The spasm on high resolution manometry correlated with the thickened muscularis propria layer according to the endoscopic ultrasound. We used endoscopic ultrasound for the navigation of botulinum toxin application into the muscularis propria layer. We applied 100 IU of botulinum toxin into four quadrants, 20 and 24 cm from front teeth (12.5 IU for 1 application).The therapy led to improvement of symptoms (Eckardt 3) and to restitution of propulsive peristalsis with complete elimination of spastic segment. The worsening of symptoms appeared after 2 years, with subsequent recurrence of motility disorder fulfilling criteria of type II achalasia.Presenting this case, we wanted to point at the unique use of botulinum toxin as useful treatment in selected cases of unclassified esophageal motility disorder as a bridge therapy. Moreover, endoscopic ultrasound could be used to guide precise application of botulinum toxin.

Keywords: Botulinum toxin; Endoscopic ultrasound; Motility disorder of esophagus.

Fig. 1

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

Fig. 2

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

Fig. 3

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

Fig. 4

HRM study 3 weeks after the botulinum toxin application and restoration of the propulsive peristalsis, normal LES relaxation pressure

Fig. 5

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