P2848 - A Rare Cause of Nausea and Vomiting in Pregnancy: Achalasia

Sean Sullivan, DO¹, Stephanie Tzarnas, MD¹, Shyam Patel, MD²
1Jefferson Einstein Hospital/ Thomas Jefferson University, Philadelphia, PA; 2Jefferson Einstein Hospital/Thomas Jefferson University, Philadelphia, PA

Introduction: Nausea and vomiting of pregnancy (NVP) is an extremely common problem during pregnancy affecting an estimated 50-90% of women. There are numerous underlying etiologies but most self-resolve. Here we present a case of a rare underlying disease process leading to a common complaint.

Case Description/

Methods: Our patient is a 30-year-old G2P1 female, currently 22 weeks and 4 days pregnant, with a medical history of asthma and hyperemesis gravidarum who presented with an inability to tolerate solids and liquids for approximately 2 weeks. She reported a 10-pound weight loss during this time. Earlier in her pregnancy she did have significant nausea and vomiting but this resolved. Her social and surgical history was negative. On admission she was hypotensive with blood pressure 80/46 but otherwise her vitals were within normal limits. On physical exam she had signs of dehydration including chelitis. Her admission labs were hemoconcentrated and her urinalysis was significant for an elevated specific gravity and 4+ ketones. She was given intravenous fluids, metoclopramide, famotidine, diphenhydramine, ondansetron, famotidine, pantoprazole and prochlorperazine with minimal improvement. Esophagogastroduodenoscopy (EGD) was considered but unfortunately the patient left against medical advice. She returned a few weeks later with continued symptoms, weight loss and decreased fetal movement. Absence of fetal heart tones were confirmed. She later underwent EGD and was found to have a significantly dilated esophagus and candida esophagitis. She was treated with fluconazole and underwent outpatient high resolution manometry. This was significant for an elevated integrated relaxation pressure and panesophageal pressurization confirmed the diagnosis of achalasia type II.

Discussion: Achalasia is a relatively rare condition affecting approximately 1 in 100,000 people. The symptoms can be easily confused with other causes of NVP and therefore the diagnosis may be delayed. It is uncommon for achalasia to manifest during pregnancy. The exact cause is not known but it is hypothesized that symptoms may be made worse by increased abdominal pressure during pregnancy from the growing gravid uterus. This patient had very common symptoms but a rare diagnosis and an extremely unfortunate outcome. It is therefore of the utmost importance to always keep a broad differential when assessing pregnant females with common complaints.

Disclosures:
Sean Sullivan indicated no relevant financial relationships.
Stephanie Tzarnas indicated no relevant financial relationships.
Shyam Patel indicated no relevant financial relationships.

Sean Sullivan, DO¹, Stephanie Tzarnas, MD¹, Shyam Patel, MD². P2848 - A Rare Cause of Nausea and Vomiting in Pregnancy: Achalasia, ACG 2025 Annual Scientific Meeting Abstracts. Phoenix, AZ: American College of Gastroenterology.