S4479 Unveiling a Rare Coexistence: Achalasia Associated with Distal Esophageal and Gastric Diverticula – A Case Series

Introduction: Achalasia is an esophageal motor disorder marked by incomplete lower esophageal sphincter relaxation and impaired peristalsis, leading to esophageal dilation. Gastroesophageal conditions coexist in 3%–7% of cases and may mimic achalasia (pseudoachalasia), be unrelated (e.g., hiatal hernia, gastric volvulus), or related (e.g., esophageal diverticulum). Distal esophageal diverticulum is often linked to motility disorders, with achalasia present in over 60% of cases. In contrast, gastric diverticula (GD) are rare, with an incidence of 0.03%–0.3%, and their coexistence with achalasia is undocumented. We present 2 rare cases of achalasia with concurrent emergency department and GD. Case Description/Methods: Case 1: A 49-year-old man with a history of gastroesophageal presented with 1 year of progressive dysphagia to solids and liquids. High-resolution esophageal manometry and barium swallow confirmed type I achalasia with complete aperistalsis. Esophagogastroduodenoscopy with functional lumen imaging probe (FLIP) demonstrated a markedly dilated esophagus and a medium-sized GD located in the gastric fundus. The patient underwent successful 30 mm balloon dilation of the gastroesophageal junction (GEJ) under fluoroscopic guidance. Post-dilation FLIP showed improved GEJ distensibility with a maximum diameter of 16 mm. The patient was discharged with scheduled outpatient follow-up. Case 2: A 90-year-old woman with Sjögren’s syndrome and hypertension presented with a 10-week history of dysphagia to solids and liquids. Manometry and barium swallow confirmed type I achalasia with aperistalsis. Esophagogastroduodenoscopy with FLIP evaluation identified a mid-esophageal diverticulum along with two distal esophageal diverticula. The patient underwent 30 mm balloon dilation of the GEJ under fluoroscopic guidance. Post-procedure FLIP revealed enhanced distensibility with a maximal diameter of 30 mm. She was discharged with outpatient gastroenterology follow-up. Discussion: This case series reports 2 rare cases of achalasia coexisting with esophageal and gastric diverticula, a previously undocumented association. Advanced diagnostics, including FLIP, and targeted interventions like balloon dilation, proved effective in managing these complex presentations. These findings highlight the importance of recognizing atypical anatomical anomalies in achalasia for optimal patient care.