Endoscopic Controlled Radial Expansion Balloon Dilatation in Infantile Achalasia: A Case Series of Four Infants

Achalasia cardia is an uncommon esophageal motility disorder that is often misdiagnosed as gastroesophageal reflux disease (GERD). Although rare in infancy, it presents unique diagnostic and therapeutic challenges compared to adults. We describe four infants who presented with early-onset vomiting and feeding difficulties and were diagnosed with achalasia cardia based on characteristic findings on timed barium esophagogram (TBE). None of our patients had features of Allgrove (Triple-A) syndrome, which is characterized by achalasia, alacrimia, and adrenal insufficiency. Serial controlled radial expansion (CRE) balloon dilatation was performed under direct endoscopic vision to relieve lower esophageal sphincter (LES) obstruction. The procedure was uneventful, and three (75%) infants showed marked clinical improvement, remaining symptom-free at a median follow-up of 4.5 months. Congenital esophageal stenosis, an important differential diagnosis in this age group, was carefully excluded based on characteristic endoscopic and radiologic findings. Infantile achalasia is diagnostically challenging because of symptom overlap with GERD and difficulty in performing manometry, limited cooperation for functional studies, and the requirement for specialized pediatric endoscopic equipment due to the small caliber of the esophagus. Timed barium esophagogram remains the most useful diagnostic tool, while CRE balloon dilatation provides a safe and minimally invasive alternative to surgery. Endoscopic CRE balloon dilatation appears to be an effective treatment option for infantile achalasia, with sustained symptom remission and nutritional recovery highlighting its feasibility and clinical value.