Key Complaints to Monitor in Patients with Achalasia
Patients with a history of achalasia should be monitored primarily for dysphagia (especially if rapidly progressive), weight loss, and regurgitation, as these may indicate disease progression or complications requiring intervention. 1
Primary Complaints to Monitor
1. Dysphagia
- Rapidly progressive dysphagia requires urgent evaluation as it may indicate:
- Disease progression
- Development of esophageal stricture
- Possible malignancy (patients with achalasia have a 5-fold higher risk of esophageal cancer) 1
- Failure of previous treatment
2. Weight Loss
- Significant or unintentional weight loss may indicate:
- Worsening obstruction
- Inadequate nutritional intake due to difficulty swallowing
- Possible development of malignancy
- Need for treatment adjustment or intervention
3. Regurgitation
- Particularly concerning when:
- Occurs at night (risk of aspiration)
- Contains undigested food from previous meals
- Associated with respiratory symptoms
Additional Important Complaints
4. Chest Pain
- May indicate:
- Esophageal spasm
- Food impaction
- Esophagitis
- Need to differentiate from cardiac causes
5. Respiratory Symptoms
- Monitor for:
- Cough (especially nocturnal)
- Recurrent pneumonia
- Aspiration events
- Voice changes
6. GERD Symptoms
- Post-treatment reflux is common (41-56% of patients develop abnormal acid exposure after POEM) 1
- Monitor for:
- Heartburn
- Regurgitation
- Esophagitis (may be asymptomatic in 25% of cases)
Monitoring Algorithm
Regular Follow-up Schedule:
- Endoscopic surveillance should be performed to monitor for disease progression and complications of GERD 1
- Consider alternating esophagram and endoscopy to monitor structural changes and mucosal condition
Immediate Evaluation Required For:
- Rapidly progressive dysphagia
- Significant weight loss
- Food impaction
- Respiratory complications (aspiration, pneumonia)
Diagnostic Testing When Symptoms Change:
- Esophagogastroduodenoscopy to rule out malignancy and assess for esophagitis
- Timed barium esophagram to evaluate esophageal emptying
- High-resolution manometry if symptoms suggest treatment failure
- pH monitoring (6-12 months after treatment) to evaluate for pathologic acid exposure 1
Important Caveats
- Cancer Risk: Patients with achalasia have a significantly higher risk of esophageal cancer (HR 4.6) compared to the general population 1
- Silent GERD: One-quarter of patients with post-treatment GERD are asymptomatic, making objective evaluation necessary 1
- Symptom Interpretation: Reflux-like symptoms after treatment may not necessarily indicate acid reflux but could represent food stasis, fermentation, or visceral hypersensitivity 1
- Medication Management: Patients who have undergone myotomy procedures should be considered for prophylactic acid suppression therapy for at least 3-6 months 1
By systematically monitoring these key complaints, clinicians can detect complications early and intervene appropriately to improve outcomes in patients with achalasia.