A man with progressive dysphagia

ENDOSCOPIC THERAPY

8. What endoscopic therapies are appropriate for patients with esophageal spasm that does not respond to medication?

• Bougie dilation
• Balloon dilation
• Onabotulinum toxin injection
• Expandable mesh stent placement
• Mucosal sclerotherapy

Onabotulinum toxin injections have been shown to improve dysphagia when given in a linear pattern.²³

Endoscopic dilation has not been shown to be beneficial in this setting, as a study found no difference in efficacy between therapeutic (54-French) and sham (24-French) bougie dilation.²⁴

Our patient received 100 units of onabotulinum toxin (10 units every centimeter in the distal 10 cm of the esophagus). Afterward, he experienced resolution of dysphagia, with only mild intermittent chest pain, which was controlled by taking peppermint extract as needed. The symptoms returned approximately 1 year later but responded to repeat endoscopy with onabotulinum toxin injections.^23,25

Peroral endoscopic myotomy

Another relatively new endoscopic treatment for esophageal motility disorders is peroral endoscopic myotomy (Figure 5). During this procedure a tiny incision is made in the esophageal mucosa, permitting the endoscope to tunnel within the lining. The smooth muscle of the distal esophagus and lower esophageal sphincter is then cut, thereby freeing either the spastic muscle (in distal esophageal spasm) or the hyperactive lower esophageal sphincter (in achalasia).^26,27

In an open trial, after undergoing peroral endoscopic myotomy for esophageal spasm and hypercontractile esophagus, 89% of patients had complete relief of dysphagia, and 92% had palliation of chest pain.²⁸ Of note, the rate of relief of dysphagia was higher for patients with achalasia (98%) than for nonachalasia patients (71%).