S4289 When Swallowing Stops: A Rare Case of Achalasia Presenting With Pulmonary Abscesses in an Elderly Patient

Introduction: Achalasia is a rare esophageal motility disorder defined by impaired lower esophageal sphincter relaxation and loss of peristalsis, leading to dysphagia, regurgitation, and weight loss. Though typically diagnosed between ages 25–60, achalasia can present in elderly patients, where symptoms may be misattributed to more common conditions like gastroesophageal reflux disease, delaying diagnosis and increasing risk for complications such as aspiration or malnutrition. Long-standing disease may result in esophageal dilation and stasis, which predispose to aspiration pneumonia and, in rare cases, pulmonary abscesses. Diagnosis is confirmed with manometry, while computed tomography and endoscopy help evaluate structural and infectious complications. Case Description/Methods: An 80-year-old man with known achalasia and spondylitis presented with progressive dysphagia, vomiting of saliva, and weakness over 2 weeks. He reported complete intolerance to solids and liquids. Physical exam showed signs of dehydration and malnutrition. A contrast-enhanced computed tomography of the chest, abdomen, and pelvis revealed a markedly dilated esophagus filled with food debris and multiple right middle lobe fluid collections concerning for pulmonary abscesses. Empiric intravenous antibiotics were initiated. Esophagogastroduodenoscopy demonstrated a severely dilated esophagus with retained food and a fibrotic but traversable stricture at the lower esophageal sphincter. Balloon dilation was performed. Post-procedure imaging confirmed improvement in esophageal decompression. The patient gradually improved clinically and biochemically, with resolution of fever and decreasing leukocytosis. Upon stabilization, he was referred to a tertiary center for peroral endoscopic myotomy evaluation. Discussion: This case highlights the severe complications of untreated achalasia, particularly in elderly patients. Esophageal dilation with retained contents can lead to chronic aspiration, which predisposes to pneumonia, and in rare cases, pulmonary abscess formation. In 1 review, up to 37% of achalasia patients had pulmonary complications, though pulmonary abscesses specifically remain rare (<2%) and are primarily reported in isolated case series. The multidisciplinary approach in this case—combining endoscopic dilation, antibiotic therapy, thoracentesis, and nutritional support—was key to recovery and stabilization.