When Two Roads Intersect: Coexisting Achalasia Cardia and Oesophageal Varices as a Therapeutic Dilemma

Achalasia is a rare cause of oesophageal dysmotility. This disorder causes impaired relaxation of the lower oesophageal sphincter (LOS), impacting peristalsis and the normal movement of food through the digestive tract, resulting in worsening swallowing difficulty, known as dysphagia. Although various effective treatments are available, like pneumatic dilation, laparoscopic Heller myotomy, and peroral endoscopic myotomy (POEM), patients with portal hypertension may develop oesophageal varices, which complicates treatment due to the heightened risk of severe bleeding. We present the case of a 45-year-old man with a history of cirrhosis and chronic hepatitis C who developed progressively worsening dysphagia over four months, which led to significant weight loss over this period and prompted further investigation. An oesophagogastroduodenoscopy (OGD) showed a dilated oesophagus with retained food contents and grade II oesophageal varices without any endoscopic red signs. Additionally, a barium swallow and high-resolution manometry were done, which led to the confirmation of the diagnosis of achalasia cardia. Given the high risk of bleeding associated with conventional therapies in the presence of varices, a safer, minimally invasive approach was chosen. Botulinum toxin was carefully injected into the LOS under endoscopic ultrasound (EUS) guidance to avoid the variceal sites and negate the risk of bleeding. This approach allowed targeted treatment of achalasia while minimising the risk of variceal bleeding. The patient experienced significant improvement in dysphagia without complications. This case highlights the rare and challenging coexistence of achalasia and oesophageal varices. It highlights the need for considering individualised treatment strategies in high-risk individuals.