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

Complications to Monitor in Patients with Achalasia

Patients with a history of achalasia should be monitored for perforation, pulmonary aspiration, chest infections, dysphagia, weight loss, and post-treatment reflux as these are the most significant complications affecting morbidity and mortality. 1

Primary Complications

Perforation

• Risk of perforation is 0-7% (mostly 3-4%) with pneumatic dilatation, with mortality <1% 1
• Suspect perforation when patients develop pain, breathlessness, fever, or tachycardia 1
• Perforation is more common during the first dilatation procedure 1
• Requires immediate medical attention as it is a medical emergency requiring assessment by experienced physicians and surgeons 1

Pulmonary Complications

• Pulmonary aspiration is a major complication due to food and fluid retention in the esophagus 1
• Patients with achalasia are particularly prone to esophageal stasis, increasing aspiration risk 1
• Chest infections may develop secondary to aspiration of retained esophageal contents 1
• Patients should be monitored for respiratory symptoms including cough, fever, and shortness of breath 1

Persistent or Recurrent Dysphagia

• Up to 20% of patients experience persistent dysphagia after treatment 2
• May indicate need for repeat dilatation or alternative treatment 1
• Dysphagia to both solids and liquids is characteristic of achalasia 3
• Recurrent dysphagia may require additional interventions or different treatment approach 1

Nutritional Issues

• Weight loss is common due to reduced oral intake from dysphagia 4
• Monitor nutritional status, BMI, and albumin levels 3
• May require nutritional supplementation in severe cases 5

Post-Treatment Complications

Post-Treatment Reflux

• Approximately 30% of patients develop symptoms of gastroesophageal reflux after treatment 2
• Usually mild and readily controlled with acid suppression 1
• Can lead to reflux esophagitis and stricture formation if untreated 1

Bleeding

• Rare complication following dilatation procedures 1
• Study of 504 balloon dilations in achalasia patients showed 1.7% asymptomatic hematomas but no clinically significant hemorrhage 1

Monitoring Recommendations

Post-Procedure Monitoring

• Close observation after dilatation procedures with regular measurement of pulse, blood pressure, and temperature 1
• Chest x-ray and contrast study should be performed urgently if patients develop pain, breathlessness, fever, or tachycardia 1
• Patients should receive written information about warning signs requiring immediate medical attention 1

Long-Term Surveillance

• Regular follow-up to assess symptom control and nutritional status 1
• Endoscopic surveillance may be necessary due to slightly increased risk of esophageal cancer in long-standing achalasia 6
• Repeat treatments may be required as the disease is rarely "cured" with a single procedure 3

Special Considerations

Elderly Patients

• Higher risk of complications from treatment procedures 1
• May require more conservative management approaches 5

Patients on Anticoagulants

• Consider discontinuation of anticoagulants prior to dilatation procedures to reduce bleeding risk 1
• For high-risk patients, bridging therapy with heparin may be necessary 1

Patients with Comorbidities

• ASA grades III-V patients are at higher risk of cardiorespiratory events during procedures 1
• May require alternative treatment approaches like botulinum toxin injection 5