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(a) An esophagogram showing the dilated esophagus (labeled “E”). The distal esophagus forms a “bird's beak” at the lower esophageal sphincter and contains a column of barium that could not pass into the stomach. (b) Lateral view of dilated esophagus with barium column.
Source publication
Background. The optimal treatment for management of esophageal achalasia in pregnancy is controversial. Little information exists about pregnancy outcome after successful myotomy. Case. Achalasia in pregnancy was diagnosed when a patient presented with pneumomediastinum from microrupture of the overdistended esophagus. An attempt at surgical correc...
Citations
... Several studies reported that achalasia symptoms may be exacerbated with elevation of the diaphragm by the fetus during pregnancy [13,14]. Additionally, increasing the concentration of progesterone during pregnancy can lead to a decrease in smooth muscle motility and tension, gastric acid reflux into the esophagus can cause esophagitis [15]. In our series, pregnancy caused relapse of the same preoperative symptoms in all 3 patients, even though the symptoms improved after surgery. ...
Background
The aggravation of symptoms in female patients with esophageal achalasia has been sporadically reported to be associated with pregnancy. However, the relationship between symptoms recurrence and postoperative pregnancy after radical surgery remains unclear.
Case presentation
There were 3 female achalasia patients who became pregnant after surgery between 1994 and 2018. Patient #1, #2 and #3 were 32, 27 and 25 years old, respectively. The main symptom was vomiting in #1, chest pain in #2, dysphagia in #3, the Eckardt score was 12, 9 and 7, respectively. The classification of achalasia was St grade Ⅱ in #1-2, St grade Ⅲ in #3. Laparoscopic Heller-Dor was underwent in all patients, there were no intraoperative and postoperative complications, and the symptoms improved in these patients. The Eckardt scores decreased to 2, 3 and 1, respectively. Each patient became pregnant 36, 24 and 46 months after surgery, and symptoms recurred during pregnancy in all patients. The Eckardt scores increased to 4, 5 and 4. These patients were followed without oral administration due to the risk of teratogenicity, and the pregnancies progressed smoothly. Healthy babies were delivered vaginally at 38-41weeks. The symptoms in all patients were immediately improved after delivery, and there was no recurrence of symptoms thereafter.
Conclusions
This case report showed that female patients who became pregnant after achalasia surgery had temporary symptom relapse during pregnancy. It was possible to continue pregnancy and deliver without treatment, and symptoms spontaneously improved immediately after delivery.
... The increased progesterone levels during pregnancy cause a reduction in the motility and tonus of the smooth muscle, which could lead to a symptom relief, but subsequently to an increased reflux of gastric acid into the esophagus and esophagitis. This can be a possible trigger for symptoms of achalasia [14]. Even increased mental stress can aggravate the symptoms of achalasia during pregnancy [11]. ...
Introduction:
Little is known concerning the interaction of achalasia and pregnancy and about an optimal time and type for treatment. Achalatic women of our collective of patients with at least one pregnancy in their history resulting in confinement or miscarriage were invited for a structured interview.
Materials and methods:
43 of 109 female patients were included. Questionnaire contained questions on symptoms, type of symptoms, whether patients could link a specific event with outbreak of disease. Date of primary diagnosis and individual therapies were double checked against our documentation as well as duration of complaints and kind of therapy. Patients were asked about their obstetric history, whether and how symptoms had changed, and during which pregnancy week symptoms have occurred. Temporal correlation of the diagnosis of achalasia and pregnancy was investigated.
Results:
There was no relationship between pregnancy and onset of achalasia. Risk of subfertility, undernourishment, premature birth, or miscarriage does not seem to be increased in achalasia. Health condition often worsened significantly during pregnancy, mainly in the first trimester and particularly in the untreated patients.
Conclusions:
It is advisable to clarify the diagnosis if symptoms suspicious of an achalasia are present before a planned pregnancy. In case of manifest achalasia, surgical treatment should be performed before pregnancy and the improvement in the state of health should be anticipated, as, otherwise, a considerable deterioration of the symptoms during pregnancy may occur. Scientific impact of our observations is very limited and prospective clinical trials are required.
... Risikoen ved nye svangerskap belyses av en kvinne med gjennomgått myotomi som i påfølgende svangerskap ble innlagt med svaer mediastinal herniering av ventrikkel/ tarm. Et slikt brokk kan gi akutt dyspné ved kompresjon og akuttkirurgi kan bli nødvendig, uavhengig av svangerskapsalder (22). ...
A diaphragmatic hernia is a rare condition during pregnancy, but the symptomatic form carries high maternal and especially fetal mortality. Nonspecific symptoms are commonly attributed to other diseases, especially because clinicians are reluctant to use plain chest X-ray, which is often diagnostic. The use of thoracic sonography and thoracic MRI add to an earlier and more accurate diagnosis. In most cases, present immediately after labor and abdominal or thoracic CT can be performed with high diagnostic accuracy. For a symptomatic patient, treatment is surgical, mostly at the time of presentation. A treatment algorithm is less straightforward for asymptomatic patients detected during pregnancy. Some recommend surgical treatment to prevent complications during labor when increased intra-abdominal pressure occurs, while others operate when symptoms develop. The type of delivery is also not solved completely. Some recommend Cesarean section at 34 weeks with simultaneous diaphragmatic hernia repair. Others claim that vaginal delivery is safe with laparoscopic diaphragmatic hernia repair postpartum.
Fewer than 40 cases of achalasia occurring in pregnant woman have been reported in the literature. Given the rarity of achalasia during pregnancy, and the numerous treatment options that are available for achalasia in general, no guidelines exist for the management of achalasia during pregnancy. Diagnosis of new cases may be difficult as symptoms and physiological changes that occur during pregnancy may obscure the clinical presentation of achalasia. The management of achalasia in pregnancy is also challenging. Treatment decisions should be individualized for each case, considering both the welfare of the mother and the fetus. Since pregnant women suffering from achalasia represent a diagnostic and therapeutic challenge with complex maternal-fetal aspects to consider, we have reviewed the available literature on the subject and summarized current diagnostic and therapeutic options. Additionally, we present a management algorithm as a means to guide treatment of future cases. We recommend that a conservative approach should be adopted with bridging therapies performed until after delivery when definitive treatment of achalasia can be more safely performed.
A diaphragmatic hernia is a rare condition during pregnancy, but symptomatic form carries high maternal and especially fetal mortality. Nonspecific symptoms are commonly attributed to other diseases especially because clinicians are reluctant to use plain chest X-ray which is often diagnostic. Fortunately, the use of thoracic sonography and thoracic MRI adds to earlier and more accurate diagnosis. As many cases present immediately after labor, abdominal and/or thoracic CT can be performed and is also diagnostic. If the patient is symptomatic, treatment is surgical mostly at the time of presentation. A treatment algorithm is less straightforward for asymptomatic patients detected during pregnancy. Some recommend surgical treatment to prevent complications during labor when increased intra-abdominal pressure occurs, while others operate only when symptoms develop. Type of the delivery is also not solved completely. While some recommend Cesarean section with simultaneous diaphragmatic hernia repair, others claim that vaginal delivery is safe with laparoscopic diaphragmatic hernia repair at a later date.
Peroral endoscopic myotomy (POEM) is a newly developed, less invasive treatment for esophageal achalasia that requires general anesthesia under positive pressure ventilation. In this retrospective case series, we describe the anesthetic management of 28 consecutive patients who underwent POEM for esophageal achalasia. Anesthesia was maintained with sevoflurane and remifentanil under positive pressure ventilation through a tracheal tube. Retained contents in the esophagus were evacuated just before anesthesia induction to prevent regurgitation into the trachea. The POEM procedure was performed using an orally inserted flexible fiberscope. Elevation of end-tidal carbon dioxide after initiating esophageal carbon dioxide insufflation was observed in all patients and was treated by minute adjustments to the ventilation volume. Scopolamine butylbromide-induced tachycardia in one patient was treated with landiolol hydrochloride, which is a short-acting beta 1-selective blocker. Minor subcutaneous emphysema around the neck was observed in one patient. POEM was successfully completed, and tracheas were extubated immediately after the procedure in all patients. Our findings suggest that prevention of aspiration pneumonia during anesthesia induction, preparation for carbon dioxide insufflation-related complications, and treatment of scopolamine butylbromide-induced tachycardia play important roles in safe anesthesia management of POEM for esophageal achalasia.
