Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with progressive dysphagia to both solids and liquids, regurgitation of undigested food, and retrosternal chest pain. Symptoms are chronic, associated with nocturnal cough and unintentional weight loss. No history of GERD or response to PPI therapy.
Clinical Examination Findings
General appearance: Patient appears thin/malnourished. HEENT: No cervical lymphadenopathy. Chest: Clear to auscultation, no wheezing. Abdomen: Soft, non-tender, non-distended, no palpable masses. Neurological: Intact.
Treatment Protocol
Surgical intervention indicated: Laparoscopic Heller Myotomy with Dor fundoplication. Pre-operative optimization includes nutritional support and pulmonary clearance. Post-operative plan: Clear liquid diet, gradual advancement, PPI prophylaxis, and follow-up manometry.