What's the next step for an 84-year-old female with suspected achalasia and significant weight loss?

Management of Suspected Achalasia in an 84-Year-Old Female with Weight Loss

The next step for this 84-year-old female with suspected achalasia should be high-resolution manometry (HRM) to confirm the diagnosis and determine the achalasia subtype, followed by endoscopy to exclude malignancy. 1

Diagnostic Confirmation Process

1. High-Resolution Manometry (HRM)

   • Gold standard for confirming achalasia diagnosis 1
   • Allows classification into achalasia subtypes (I, II, or III)
   • Provides prognostic information that guides treatment selection 1
   • Essential for distinguishing true achalasia from other causes of dysphagia

2. Upper Endoscopy

   • Must be performed to exclude pseudoachalasia (malignancy at GE junction) 1
   • Particularly important in elderly patients with weight loss
   • Allows for biopsy of any suspicious areas
   • Can assess for esophageal dilation and food retention

3. Additional Testing

   • CT scan or endoscopic ultrasound may be needed if malignancy is suspected 1
   • Careful endoscopic assessment of the gastroesophageal junction is critical 1

Clinical Considerations in This Patient

Age and Weight Loss Concerns

• The combination of advanced age (84) and weight loss raises concern for malignancy
• Pseudoachalasia (cancer mimicking achalasia) must be excluded before proceeding with treatment
• Weight loss indicates significant impairment in nutrition that requires prompt intervention

Barium Findings Interpretation

• Smooth tapering at GE junction with marked contrast stasis strongly suggests achalasia
• However, these radiographic findings alone are insufficient for definitive diagnosis 1
• The absence of hiatal hernia or reflux is consistent with achalasia

Treatment Planning (After Diagnosis Confirmation)

Once achalasia is confirmed and malignancy excluded, treatment options include:

1. For Type I or II Achalasia:

   • Pneumatic dilation (PD) - Often preferred in elderly patients due to lower morbidity 1
   • Laparoscopic Heller myotomy (LHM) - More invasive but highly effective 1

2. For Type III Achalasia:

   • Per-oral endoscopic myotomy (POEM) is preferred if expertise is available 1
   • Extended myotomy may be required to address the spastic component

3. For Frail Elderly Patients:

   • Botulinum toxin injection may be considered as a temporizing measure 2
   • Less effective long-term but lower procedural risk

Important Caveats

• Patient preparation for procedures requires special attention in achalasia:

  • Prolonged fasting or esophageal lavage may be needed due to esophageal stasis 1
  • Higher risk of aspiration during procedures

• Post-treatment monitoring is essential:

  • POEM patients have high risk of reflux esophagitis (may require PPI therapy) 1
  • Nutritional rehabilitation will be important given the weight loss

• Procedure selection should consider the patient's overall health status and life expectancy, particularly given her advanced age

Conclusion

The diagnostic approach must be systematic and thorough before initiating treatment. HRM is essential to confirm the diagnosis and guide therapy selection, while endoscopy is critical to exclude malignancy in this elderly patient with weight loss.