Endoscopic injection therapy for achalasia and other esophageal motility disorders

Sabine Roman, David A. Katzka

Research output: Contribution to journalReview articlepeer-review


Botulinum toxin (BT) injections have been proposed to treat achalasia and hypertensive esophageal motility disorders. They affect lower esophageal sphincter (LES) and esophageal muscle function by inhibiting acetylcholine release and thus preventing neuromuscular conduction. BT injection in the LES is effective to treat achalasia but the improvement is limited to few months. As a consequence, recent guidelines recommend BT in achalasia patients who are not good candidates for more definitive therapy with pneumatic dilation or myotomy. BT might be a good option for patients with esophago-gastric junction obstruction without a firm diagnosis of achalasia. However, response to BT injection is not predictive of response to a more invasive therapy. BT injection in both the LES and the esophageal body might have a short-term efficacy to relieve dysphagia in patients with diffuse esophageal spasm or nutcracker esophagus. Usually BT is administrated as 1 cc aliquots with 20 units of toxin per milliliter into the LES and/or the esophageal body for a total dose of 100 unit international. BT injections are usually safe. Moderate chest pain might be reported following the injection. Three cases of death were reported due to acute mediastinitis and pseudoaneurysm. Finally, there is a theoretical risk of increased difficulty to perform esophageal myotomy in patients who previously received BT therapy due to the potential risk of fibrosis.

Original languageEnglish (US)
Pages (from-to)130-134
Number of pages5
JournalTechniques in Gastrointestinal Endoscopy
Issue number3
StatePublished - Jul 2018


  • Achalasia
  • Botulinum toxin injection
  • Chest pain
  • Distal esophageal spasm
  • Jackhammer esophagus

ASJC Scopus subject areas

  • Radiology Nuclear Medicine and imaging
  • Gastroenterology


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