Successful Treatment of Achalasia With Endoscopic Ultrasound-Guided Botulinum Injection in Setting of Esophageal Varices

Achalasia in a patient with liver cirrhosis decompensated by esophageal varices is an extremely rare presentation with complex management implications. We describe a case of achalasia and malnutrition in a male patient with esophageal varices treated by endoscopic ultrasound-guided botulinum toxin injection. After treatment, the patient's dysphagia dramatically improved, and his weight loss stabilized, which allowed an important window to remove the barrier of nutritional status for transplant candidacy. Endoscopic ultrasound-guided botulinum toxin injection to avoid varices is potentially a safer method for delivering botulinum toxin injection to the lower esophageal sphincter in a patient with esophageal varices.