Esophageal Achalasia and Perforated Stercoral Ulcer Secondary to Immune Checkpoint Inhibitor–Induced Enteric Neuropathy

Immune checkpoint inhibitors (ICIs) are effective cancer therapies known to cause immune-related adverse events (irAEs). We present a 70-year-old man with acute-onset severe constipation, dysphagia, and failure to thrive following nivolumab and ipilimumab therapy. Given the clinical course, ICI-induced enteric neuropathy was suspected. Esophageal manometry revealed type II achalasia. Despite high-dose corticosteroids, botulinum toxin injection to the lower esophageal sphincter, intravenous immunoglobulin, and plasmapheresis, severe dysphagia persisted, ultimately requiring myotomy. Concurrent progression of constipation resulted in a perforated stercoral ulcer requiring sigmoidectomy. This case highlights a rare gastrointestinal irAE and underscores the potential for rapid progression with significant complications.