What complaints should be monitored in a patient with a history of achalasia?

Monitoring Complaints in Patients with Achalasia History

The most important symptom to monitor in patients with a history of achalasia is dysphagia, as it may indicate disease recurrence, progression, or development of complications including malignancy. 1

Key Symptoms to Monitor

Primary Concerns

• Dysphagia - Most critical symptom requiring vigilance:

  • Rapidly progressive dysphagia
  • Worsening after previous successful treatment
  • Changes in character from baseline symptoms 1

• Weight Loss - Requires prompt evaluation as it may indicate:

  • Disease progression
  • Treatment failure
  • Development of complications
  • Possible malignant transformation 1, 2

Secondary Concerns

• Regurgitation - Especially undigested food and bland regurgitation unresponsive to PPI therapy 2
• Chest pain - Common in achalasia patients, may indicate disease progression 2
• Signs of aspiration - May lead to respiratory complications including chest infections 3

Evaluation of Concerning Symptoms

When patients with achalasia history present with concerning symptoms, the following diagnostic approach is recommended:

1. Endoscopy with biopsy:

   • Rule out malignancy
   • Assess for esophageal dilation
   • Exclude eosinophilic esophagitis 1, 4

2. Barium swallow:

   • Assess esophageal dilation
   • Evaluate for bird's beak appearance
   • Identify potential structural abnormalities 1, 4

3. High-resolution manometry (HRM):

   • Determine achalasia subtype
   • Evaluate treatment response
   • Guide management decisions 4, 1

Achalasia Subtypes and Specific Monitoring Considerations

HRM allows classification into three subtypes with different monitoring considerations:

• Type I (Non-compression subtype):

  • Dilated, decompensated esophagus
  • Higher risk of food retention and aspiration
  • Patients require monitoring for nutritional deficiencies 4, 1

• Type II (Pan-esophageal compression):

  • Best response to treatments
  • Still require monitoring for symptom recurrence 4, 1

• Type III (Spastic variant):

  • Poorest response to standard treatments
  • More likely to have persistent symptoms
  • May require alternative treatment approaches 4, 1

Common Pitfalls and Caveats

• Delayed diagnosis: Achalasia can remain undiagnosed for years due to slow, initially oligosymptomatic progression 5

• Perforation risk: Patients undergoing dilatation procedures are at risk of perforation (2.6% overall rate) and should be monitored for signs including pain, breathlessness, fever, or tachycardia 4

• Secondary achalasia: Consider infectious and inflammatory causes of secondary achalasia during evaluation, including recent COVID infections, risks for Chagas disease, and symptoms of eosinophilic disease 4

• Cancer risk: Patients with achalasia are at increased risk of esophageal cancer and require appropriate surveillance 1

In summary, while all three symptoms mentioned (chest infection, dysphagia, and weight loss) can occur in achalasia patients, dysphagia is the cardinal symptom that requires closest monitoring, followed by significant weight loss as an indicator of disease progression or complications.