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

Monitoring Complaints in Patients with Achalasia History

Patients with a history of achalasia should be primarily monitored for dysphagia and weight loss, as these are the most significant symptoms that may indicate disease recurrence, progression, or development of complications including malignancy. 1

Key Complaints to Monitor

Primary Concerns

• Dysphagia - Most important symptom to monitor, especially if rapidly progressive 1, 2
• Weight loss - Significant weight loss may indicate disease progression or complications 1, 3
• Regurgitation - Particularly undigested food and bland regurgitation unresponsive to PPI therapy 3

Secondary Concerns

• Chest pain - Common complaint in achalasia patients 2, 3
• Signs of aspiration - Particularly in Type I achalasia (non-compression subtype) 1
• Nutritional deficiencies - More common in Type I achalasia with food retention 1

Monitoring Based on Achalasia Subtype

Different subtypes require specific monitoring approaches:

Subtype	Characteristics	Key Monitoring Focus
Type I	Non-compression, dilated esophagus	Higher risk of food retention, aspiration, nutritional deficiencies [1]
Type II	Pan-esophageal compression	Best treatment response, monitor for symptom recurrence [1]
Type III	Spastic variant	Poorest response to standard treatments, more likely to have persistent symptoms [1]

Complications to Watch For

• Esophageal cancer - Patients with achalasia have increased risk and require appropriate surveillance 1
• Perforation - Particularly in patients who have undergone dilatation procedures (2.6% risk) 1
• Signs of perforation include: Pain, breathlessness, fever, tachycardia 1
• Malnutrition - Due to persistent dysphagia and poor food intake 3, 4
• Aspiration pneumonia - Due to regurgitation of undigested food 4

Diagnostic Approach for Recurrent Symptoms

When patients with achalasia history present with concerning symptoms:

1. Endoscopy with biopsy - To rule out malignancy, assess esophageal dilation, exclude eosinophilic esophagitis 1
2. Barium swallow - To evaluate esophageal dilation and identify structural abnormalities 1
3. High-resolution manometry (HRM) - To evaluate treatment response and guide management decisions 1

Treatment Considerations for Recurrent Symptoms

• Recurrent dysphagia may require repeat interventions 1
• Treatment options include pneumatic dilation, botulinum toxin, or surgical myotomy 1, 2
• First-line treatment depends on achalasia subtype, patient preference, and local expertise 2

Clinical Pearls

• Rapidly progressive dysphagia should raise concern for malignancy (pseudoachalasia) 1, 5
• Consider secondary achalasia during evaluation, including infectious causes (e.g., Chagas disease) and recent COVID infections 1
• Recurrent foreign body impaction warrants evaluation for other esophageal disorders 1
• Although achalasia cannot be permanently cured, excellent outcomes are achieved in over 90% of properly treated patients 3

Based on the evidence, the answer to the question is B. Dysphagia, as this is the most significant complaint to monitor in patients with achalasia history according to the American Gastroenterological Association guidelines 1.