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Treatment of Achalasia with Intrasphincteric Injection of Botulinum Toxin: A Pilot Trial

Pankaj J. Pasricha, MD; William J. Ravich, MD; Thomas R. Hendrix, MD; Samuel Sostre, MD; Bronwyn Jones, MD; and Anthony N. Kalloo, MD
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From Johns Hopkins Hospital, Baltimore, Maryland.\\\Requests for Reprints: Pankaj J. Pasricha, MD, Johns Hopkins Hospital, 600 North Wolfe Street, Blalock 4, Baltimore, MD 21287-4461.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1994;121(8):590-591. doi:10.7326/0003-4819-121-8-199410150-00006
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Achalasia is a disorder characterized by a failure of the lower esophageal sphincter to relax with swallowing and by a lack of esophageal peristalsis. The sphincteric abnormalities in achalasia are thought to be caused by a selective loss of inhibitory neurons in the myenteric plexus, resulting in the relatively unopposed excitation of the smooth muscle by acetylcholine and other mediators. Our previous studies in animals [1] have shown that locally injected botulinum toxin, a potent inhibitor of acetylcholine release, can reduce lower esophageal sphincter tone. We report our initial experience with this agent for the treatment of achalasia in humans.

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Figure 1.
The change in esophageal clearance in one patient in response to injections of botulinum toxin.

The four graphs show the percentage of ingested radioactivity (vertical axis) remaining in the esophagus at several points in time after ingestion of the test meal (horizontal axis). A. Baseline esophageal clearance was markedly abnormal, with a 5-minute retention of 56.1%. B. One week after botulinum toxin injection, the patient had normal esophageal clearance, with a 5-minute retention of 5%. The patient remained asymptomatic for about 1 year, then dysphagia gradually recurred. C. Esophageal clearance measured at this time was again grossly abnormal, with a 5-minute retention of 74.8%. This patient then had a second injection of botulinum toxin, and symptoms completely resolved. D. The patient's esophageal clearance then returned to normal, again with a 5-minute retention of 5.6%.

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