Anaesthesia, 1992, Volume 47, pages 38-40 CASE REPORT

Oesophageal achalasia causing respiratory obstruction

J . L. WESTBROOK

Summary A patient with complete respiratory obstruction due to massive oesophageul dilatation is described. Immediate reliyf'of'syniptoms and disappearance of the oesophageal swelling occurred a f e r administration of sublingual glyceryl trinitrate. Nitrates cause u reduetion in the lower oesophageal sphincter pressure in patients with oesophageal achalasia and in this cuse ii is presumed ihat spasm of the lower oesophageal sphincter had been a major factor preventing decompression of the dilated oesophagus.

Keywords Airway; obstruction. Gasirointestinal traci; oesophagus, achalasia. Pharmacology; glyceryl trinitrate.

Acute airway obstruction due to massive oesophageal dilatation is a rare complication of achalasia of the oesophagus. It is well described in the literature, but relatively few reports have been published in anaesthetic journals [I]. Emergency treatment previously described has included tracheostomy under local anaesthesia [2], passage of a nasogastric tube [3], tracheal intubation [4], transcutaneous needle puncture [S]and rigid oesophagoscopy [6]. A patient with achalasia of the oesophagus is described, whose acute airway obstruction was relieved by simpler measures.

Case history A 90-year-old woman was referred to hospital by her general practitioner with a provisional diagnosis of congestive cardiac failure, which was based on a history of increasing shortness of breath of recent onset. She was very dyspnoeic on arrival and the ambulance crew reported that she had become cyanosed during the journey, but that this was relieved by oxygen given through a Hudson mask. The patient was unable to give any history because she was too breathless to speak and on examination she was cyanosed despite supplementary oxygen. Her pulse rate was 90 beat.min-' and regular, blood pressure 130/85 mmHg, the jugular venous pulse was not visible and the heart sounds were normal. There was slight pitting oedema of the ankles. Her chest expansion was poor but both sides moved equally, and the percussion note was

resonant. On auscultation the breath sounds were reduced but vesicular, with no crackles or wheezes. In her neck there was a soft midline swelling about 7 cm in diameter which expanded on inspiration. It bulged over the suprasternal notch, was nonpulsatile and could be transilluminated. Her cyanosis resolved with an increased oxygen flow via the facemask and therefore an urgent chest X ray and soft tissue X rays of the neck were arranged (Figs 1 and 2). The swelling was shown to be a massively dilated oesophagus which was compressing the trachea against the posterior aspect of the manubrium. The patient's condition then deteriorated, she became cyanosed again and showed signs of upper airway obstruction. The dilatation of the oesophagus was thought to be due to acute lower oesophageal sphincter spasm and so the patient was given glyceryl trinitrate (GTN) 500 pg sublingually. Within 2 min the cervical swelling collapsed and the patient's dyspnoea was immediately relieved. After the patient had recovered it was possible to take a more complete history. She had been investigated for symptoms of gastric reflux some months previously and barium studies performed at that time had shown a dilatedoesophagus with reduced peristaltic movements. She gained symptomatic relief from an H, receptor antagonist and the condition was not investigated any further. The chest X ray taken soon after the administration of the G T N shows a marked reduction in the size of the

J.L. Westbrook, MB, BS, MRCP, FCAnaes, Registrar, Nuffield Department of Anaesthetics, John Radcliffe Hospital Headington, Oxford OX3 9DU. Accepted 23 April 1991. 0003-2409/92/010038 +03 $03.00/0

@ 1992 The Association of Anaesthetists of G t Britain and Ireland

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Oesophageal achalasia

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Fig. 3. PA chest X ray showing the reduced size of the oesophagus following treatment. Fig. 1. PA chest X ray showing a massively dilated oesophagus extending up into the neck.

oesophagus (Fig. 3). The patient declined any further investigation or intervention and she was subsequently discharged with a supply of glyceryl trinitrate.

Discussion

Fig. 2. Lateral soft tissue x ray of the neck. This shows increased anterior/posterior diameter of the oesophagus with a fold of oesophagus. at the level of the third cervical vertebra, preventing air from escaping to atmosphere. The trachea is seen compressed against the posterior aspect of the manubrium.

We believe that this patient could not relieve pressure within her oesophagus because the tortuous folds acted as valves, preventing air that had entered the oesophagus from leaving it again. The oesophagus could not decompress into the stomach because the lower oesophageal sphincter was in spasm. The massively dilated oesophagus caused direct compression of the trachea against the manubrium sterni, resulting in acute respiratory distress due to airway obstruction. In the absence of follow-up oesophagoscopy, oesophageal manometry or barium studies it is not possible to be certain about the underlying pathology. Malignancy is unlikely because of the long history and the patient is now known to have survived these events by 2 years. The two conditions that could cause this degree of oesophageal dilatation are achalasia of the oesophagus and a benign oesophageal stricture secondary to reflux oesophagitis. In view of the sequence of events, a lower oesophageal stricture is unlikely, since a significant scarring would be necessary to produce massive dilatation of the oesophagus and this would not be relieved by smooth muscle relaxants. However, spasm is a well recognised component of achalasia and its relief by the nitrates and calcium antagonists is well documented [7]. Gelfond et ul. [7] demonstrated that nitrates afford prompt reduction in lower oesophageal sphincter pressure and confirmed the consequent emptying of the oesophagus with studies. Nitrates have a role in the management Of achalasia [8] but oesophageal dilatation and surgical myotomy remain the standard treatment,

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J.L. Westbrook

because of the side effects of chronic nitrate therapy. Gelfond et al. [9] studied the response of 24 patients with achalasia to isosorbide dinitrate and found that a mean lower oesophageal sphincter (LOS) pressure of 46.3 mmHg decreased to a mean of 15.3 mmHg after the nitrate. In this case it appears that the reduction in lower oesophageal sphincter tone by glyceryl trinitrate was enough to allow decompression of the critically dilated oesophagus. This produced dramatic relief of symptoms and avoided the use of more invasive procedures.

[2] BARRGD, MACDONALD 1. Management of achalasia and [3] [4] [5]

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Acknowledgment

I thank Dr M.D. Hellier FRCP for his kind permission to report this case.

[7]

[8]

References [ I ] TRAVISKW, SAINIVK, O'SULLIVAN PT. Upper-airway

obstruction and achalasia of the oesophagus. Anesthesiology 1981; 54: 87-8.

laryngo-tracheal compression. Journal of Larvngology and Otology 1989; 103: 713-4. ZIKKD, RAPOPORT Y, HALPERIN D, PAPOJ, HIMELFARB MZ. Acute airway obstruction and achalasia of the esophagus. Annals of Otology, Rhinology and Laryngology 1989; 98: 641-3. BECKERDJ, CASTELL DO. Acute airway obstruction in achalasia. Possible role of defective belch reflex. Gastroenterology 1989; 97: 1323-6. EVANS CR, CAWOODR, DRONFIELU MW, MUNGALLIPF. Achalasia: presentation with stridor and a new form of treatment. British Medical Journal 1982; 285: 1704. CARLSSON-NORLANDER B. Acute upper airway obstruction in a patient with achalasia. Archives of Otokrryngology ~ n H d i d and Neck Surgery 1987; 113: 885-7. GELFOND M, ROZENP, GILATT. lsosorbide dinitrate and nifedipine treatment of achalasia: A clinical, manometric and radionuclide evaluation. Gastroenterology 1982; 83: 963-9. TRAUBE M, MCCALLUM R.W. Primary oesophageal motility disorders. Current therapeutic concepts. Drrrgs 1985; 30;

66-77. [9] GELFOND M, ROZEN P, KERENS. GILAT T. Effect of nitrates on

LOS pressure in achalasia: a potential therapeutic aid. Cur 1981; 22: 312-8.

Oesophageal achalasia causing respiratory obstruction.

A patient with complete respiratory obstruction due to massive oesophageal dilatation is described. Immediate relief of symptoms and disappearance of ...
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