Esophageal achalasia with severe malnutrition and liver enzyme elevation

A 70-year-old woman presented dysphagia and postprandial vomiting, and weight loss of about 15 kg in one year. She was markedly emaciated with a body mass index of 12.4 kg/m² and had difficulty in movement. Esophagogastroduodenoscopy and computed tomography revealed stenosis of the esophagogastric junction (EGJ) with no malignant findings. Additionally, based on the findings of the esophagogram and high-resolution manometry, the patient was diagnosed with esophageal achalasia. The patient also had an elevation in liver enzymes but was ruled out alcoholic, drug-induced, viral, or other hepatitis. It was considered that malnutrition caused by esophageal achalasia led to a rise in liver enzymes. After the onset of nutritional therapy, the liver enzyme elevation deteriorated, electrolyte abnormalities and hypoglycemic attacks occurred frequently. She had developed the refeeding syndrome, thus feeding was reduced, but the condition deteriorated further and the liver enzymes reached a peak. These findings were assumed to be due to persistent malnutrition, and normalized with gradually increased nutrition. After improving the general condition, per-oral endoscopic myotomy (POEM) was performed. After POEM, her dysphagia disappeared and nutritional state completely improved. Careful nutritional therapy improved her general condition, and POEM improved gastrointestinal symptoms and prevented the recurrence of malnutrition.