Key Complaints to Monitor in Patients with Achalasia History
Patients with a history of achalasia should be carefully monitored for dysphagia, regurgitation, chest pain, weight loss, and respiratory symptoms as these indicate potential disease progression or complications requiring intervention. 1
Primary Symptoms to Monitor
Dysphagia
- Progressive difficulty swallowing both solids and liquids
- Worsening of previously controlled dysphagia, which may indicate:
- Disease recurrence after treatment
- Development of strictures
- Incomplete myotomy (if previously treated)
- Food getting "stuck" sensation, especially with solid foods
Regurgitation
- Undigested food regurgitation, particularly when lying down
- Nocturnal regurgitation and aspiration
- Morning regurgitation of undigested food consumed the previous day
- Halitosis (bad breath) due to food retention
Chest Pain
- Retrosternal discomfort during or after meals
- Spasm-like pain, especially in Type III achalasia patients
- Pain that mimics cardiac symptoms
Weight Loss
- Unintentional weight loss
- Nutritional deficiencies
- Avoidance of eating due to discomfort
Respiratory Complications
Aspiration-Related Symptoms
- Chronic cough, particularly at night or after meals
- Recurrent pneumonia or bronchitis
- Wheezing or asthma-like symptoms
- Sleep disturbances due to aspiration
Post-Treatment Complications
Reflux Symptoms
- Heartburn
- Regurgitation of acidic content
- Particularly important after POEM (Per-Oral Endoscopic Myotomy) as 41-56% of patients develop abnormal acid exposure 2
Treatment-Specific Complications
- After pneumatic dilation: acute chest pain may indicate perforation 1
- After myotomy: new-onset reflux symptoms 1
- After botulinum toxin injection: diminishing effect over time requiring retreatment 3
Surveillance Recommendations
Regular Follow-up Schedule
- Assessment at 1 month and 6 months after treatment
- Annual follow-up thereafter
- More frequent monitoring for patients with:
- Incomplete symptom resolution
- Type III achalasia (more difficult to treat)
- Elderly patients with higher aspiration risk
Diagnostic Testing
- Timed barium esophagram to evaluate esophageal emptying
- pH monitoring if reflux symptoms develop
- Repeat endoscopy to assess for:
- Esophagitis
- Strictures
- Barrett's esophagus
- Esophageal cancer (patients with achalasia have 5-fold higher risk) 2
Special Considerations
Achalasia Subtypes
- Type I (classic): Monitor for progressive esophageal dilation
- Type II: Generally best treatment response, but still requires monitoring
- Type III (spastic): Higher risk of persistent symptoms, requires closer follow-up 1
Complications of Untreated/Undertreated Disease
- Esophageal dilation and sigmoid-shaped esophagus
- Food retention leading to bacterial overgrowth
- Esophageal candidiasis
- Squamous cell carcinoma risk (increased with disease duration)
Clinical Pitfalls to Avoid
- Mistaking reflux symptoms for recurrent achalasia
- Failing to recognize aspiration as a cause of respiratory symptoms
- Overlooking nutritional deficiencies in patients with longstanding disease
- Delaying endoscopic evaluation in patients with new or worsening symptoms
By systematically monitoring these key complaints, clinicians can detect complications early and optimize management strategies for patients with achalasia, ultimately improving morbidity, mortality, and quality of life outcomes.