Botulinum Toxin (Botox®) Injection for Achalasia

Botulinum toxin is a naturally occurring protein produced by the bacterium Clostridium botulinum. Injection of botulinum toxin into muscles causes temporary paralysis of the specific muscle, which lasts for months to over one year. In gastroenterology, botulinum toxin is used primarily to treat achalasia. Botulinum toxin is injected into the muscle of the lower esophageal sphincter.

How is botulinum toxin injection performed?

During an outpatient upper endoscopy, the endoscopist will pass a catheter with a small needle through the endoscope and inject the toxin under the lining of the esophagus into the muscle of the lower esophageal sphincter. From the patient’s perspective, undergoing botulinum toxin injection is exactly similar to the experience of undergoing upper endoscopy.

Who needs botulinum toxin injection?

Patients with difficulty swallowing due to achalasia may be treated with botulinum toxin injection. Alternative treatments include peroral endoscopic myotomy (POEM), Heller myotomy (a traditional surgery), and pneumatic dilation.

Botulinum toxin may also be injected into the upper esophageal sphincter to treat other types of difficulty swallowing, into the pylorus muscle of the stomach to treat gastroparesis, and into the anal sphincter to treat anal fissures.

What are the potential complications of botulinum toxin injection?

Botulinum toxin injection is generally a very safe procedure. Very rare complications include bleeding and infection. If you notice blood in your stool, black stool, fever, chills, vomiting, chest pain, stomach pain, or shortness of breath, contact your doctor as instructed on your discharge papers.

What do I need to do before botulinum toxin injection?

Preparation for botulinum toxin injection for achalasia is similar to preparation for upper endoscopy, except you should limit your diet to liquids for at least 24 hours before the procedure. You must have a licensed driver who is 18 years or older accompany you to your appointment and drive you home, as the sedatives or anesthesia will make you drowsy. 

What happens after botulinum toxin injection?

After the botulinum toxin injection, you will be taken to a recovery room where your driver can join you. The doctor who performed the procedure will explain the preliminary results to you. You will receive detailed recommendations for diet, medicines, and follow-up. The results of the procedure will be communicated to your referring physician(s). It can take a few days to a week before you notice the effects of botulinum toxin. The effects are not permanent, so re-injections are typically needed months later.