Achalasia-induced catastrophe in pregnancy: Empyema, esophageopleural fistula, septic shock, fetomaternal survival, multidisciplinary management, and literature review. A case report.

INTRODUCTION AND IMPORTANCE: Esophageal achalasia is a rare motility disorder characterized by impaired relaxation of the lower esophageal sphincter and absent peristalsis. Its occurrence during pregnancy is uncommon but can result in life-threatening complications. We present a clinically significant case highlighting the diagnostic and management challenges of achalasia in late pregnancy.

CASE PRESENTATION: A 30-year-old gravida 4, para 3 woman at 33 weeks' gestation presented with worsening cough, chest pain, vomiting, and signs of sepsis. Imaging showed right-sided empyema, cavitary lung lesions, and a markedly dilated esophagus consistent with achalasia. Chest tube drainage revealed purulent fluid mixed with gastric contents, raising suspicion of TEF and lastly EPF was confirmed via endoscopy and intraoperatively. She underwent right thoracotomy with decortication, esophageal perforation repair, and Heller myotomy. During ICU care, she delivered a healthy neonate vaginally. Follow-up CT at 10 days showed significant radiologic improvement and no ongoing fistula. The patient was discharged after one month with favorable maternal and neonatal outcomes.

CLINICAL DISCUSSION: Achalasia-related complications such as esophageal perforation, tracheoesophageal(TEF), and EPF during pregnancy are extremely rare and pose diagnostic and management challenges. Pregnancy-related physiological changes can exacerbate achalasia symptoms and increase risk of severe outcomes. Timely surgical intervention combined with critical care and obstetric management is essential to optimize fetomaternal survival.

CONCLUSION: This case highlights a rare and life-threatening complication of achalasia in pregnancy. Early diagnosis and a multidisciplinary approach are crucial for successful management and favorable fetomaternal outcomes.