P1.014. Gastroesophageal Intussusception After Myotomy for Achalasia

Abstract

Abstract Topic Benign Disease: Esophageal Function and Motility Case Submission Gastroesophageal intussusception (GEI) is a rare condition in adults, defined by telescoping of the stomach into the oesophagus. Its presentation is often nonspecific—manifesting as dysphagia, vomiting, epigastric or chest pain—which can delay diagnosis. While most adult intussusceptions involve the small bowel, GEI is uncommon and frequently associated with structural or motility disorders of the gastroesophageal junction, particularly achalasia. Peroral endoscopic myotomy (POEM) is an effective minimally invasive treatment for achalasia, but post-procedural anatomical and functional changes may predispose patients to complications such as GEI. The reported case involves a 43-year-old man with achalasia previously treated with balloon dilatation, POEM, and jejunostomy tube placement. He presented with a two-week history of worsening upper abdominal pain and haematemesis. On admission, he was tachycardic and hypotensive, with marked leucocytosis, acute kidney injury, and elevated lactate, suggesting systemic compromise. Imaging with non-contrast CT demonstrated a markedly distended oesophagus with most of the stomach intussuscepted into the thoracic oesophagus, consistent with gastric intussusception. Initial endoscopy revealed swollen but viable gastric mucosa; however, endoscopic reduction was unsuccessful. Surgical exploration via laparoscopy showed significant gastric displacement and oedema, necessitating conversion to laparotomy. The stomach was successfully reduced, oedematous fluid drained, and gastric viability confirmed endoscopically. Preventive measures included hiatal repair and gastropexy. The patient recovered well postoperatively, with normalization of laboratory abnormalities and gradual advancement of diet. He was discharged on postoperative day seven. One month later, the patient re-presented with coffee-ground emesis and was diagnosed with candidal esophagitis, which responded to antifungal therapy. At follow-up, he remained clinically stable and later underwent an elective McKeown oesophagectomy with good recovery. Adult intussusception accounts for only about 5% of cases overall, and GEI is particularly rare, with evidence largely limited to case reports. Proposed predisposing factors include a shortened oesophagus, hiatal hernia, motility disorders, increased intra-abdominal pressure, prior foregut surgery, and eating disorders. In this case, achalasia, oesophageal dilation, vomiting, and prior myotomy likely contributed. Notably, only a handful of GEI cases have been reported in patients with achalasia following myotomy, reinforcing this association. Prompt recognition of GEI is critical to prevent complications such as ischaemia or perforation. Computed tomography is the diagnostic modality of choice, while endoscopy can assist in diagnosis and attempted reduction. Definitive management is usually surgical, with the approach individualized based on patient stability and surgeon expertise. Hiatal repair and gastropexy are recommended to reduce recurrence risk. In conclusion, GEI should be considered in patients with achalasia, especially after myotomy, who present with acute obstructive or upper gastrointestinal symptoms. Early imaging and timely surgical intervention are essential, and further research is needed to clarify pathophysiology and optimize management strategies.