Untoward effects of esophageal botulinum toxin injection in the treatment of achalasia

Injection of botulinum toxin in the lower esophagus has been reported as a safer alternative in the treatment of achalasia. Although the efficacy of this treatment as compared to dilation or myotomy is presently being studied and debated, few complications of botulinum toxin injection have been reported. We began to study botulinum toxin injection in the treatment of high-risk patients with achalasia and report a case of untoward complications of injection. The patient selected botulinum toxin injection due to its reported safety and because of his heart disease and the associated risks of surgery. This patient developed severe ulcerative esophagitis, with biopsy and 24-hr pH monitor evidence of reflux. Due to his lack of clinical improvement, the patient subsequently chose to undergo myotomy. At the time of surgery, he was found to have extraluminal distal esophageal inflammation with adhesions and loss of tissue planes, making dissection more difficult. Thus, he developed several complications after botulinum toxin injection, and this prompts us to be cautious until more is known regarding this treatment option.