Anesthesia Considerations for Patients With Severe Achalasia

Aspiration, the inadvertent introduction of fluids or solids into the trachea, is a severe risk in patients with achalasia, presenting major challenges for anesthesia providers. Achalasia is an autoimmune reaction resulting in decreased lower esophageal peristalsis and the inability of the lower esophageal sphincter to relax, preventing the passage of food and liquids. A 47-yearold woman with a history of achalasia presented to the endoscopy suite for esophagogastroduodenoscopy. The patient was admitted with complaints of dysphagia and the inability to tolerate solids and liquids. Despite the recommendation from the gastroenterology team for monitored anesthesia care, the anesthesia care team advocated for general anesthesia with rapid sequence induction to protect the airway. On introduction of the video laryngoscope (GlideScope, Verathon Inc), a pool of saliva and food particles were observed in the posterior oropharynx. This case study examines a severe case of achalasia requiring unconventional treatment. This case illustrates the need for maintaining a high index of suspicion for aspiration risk in patients with achalasia during their precarious and stressful course of management, and the importance of collaboration between the anesthesia and the gastroenterology care teams in safely managing these patients.