Esophageal Motility

• Audio chapter
  Single-voice audio, listen on the commute.
• ABIM-format MCQs
  5-option vignettes with full wrong-answer teaching.
• Study guide
  Tables, decision trees, primary sources.
• AI tutor
  Chapter-grounded, answers the question you're stuck on.

What this chapter covers

• Section 2.1: Manometry fundamentals and Chicago v4.0 framework

  High-resolution manometry is the test that converts a swallow into numbers, and the Chicago Classification version 4.0 is the algorithm that converts those numbers into a diagnosis.

• Section 2.2: Achalasia subtypes and management

  Achalasia is the prototypical disorder of EGJ outflow obstruction with absent peristalsis, and the mechanism explains everything that follows on the manometry tracing, on the barium esophagram, and at the time of treatment selection.

• Section 2.3: Distal esophageal spasm and hypercontractile disorders

  Distal esophageal spasm and hypercontractile (jackhammer) esophagus are the disorders of preserved sphincter relaxation but disordered body contraction, and they sit together in the algorithm because both occur on a normal IRP and both produce a chest pain and dysphagia phenotype that often arrives in the GI clinic after a negative cardiac workup.

• Section 2.4: Hypotensive LES, scleroderma, and absent contractility

  Ineffective esophageal motility, absent contractility, and scleroderma esophagus sit together because all three are disorders of failed peristalsis on a normal or low IRP, and they share a downstream consequence of impaired esophageal acid clearance.

• Section 2.5: EGJ outflow obstruction and adjunctive testing with FLIP

  EGJ outflow obstruction (EGJOO) is the heterogeneous bucket that contains every patient with an elevated IRP and some preserved peristalsis, and the v4.0 changes to the diagnostic criteria reflect the recognition that the bucket contains many false positives and that a manometric abnormality alone is not enough to call a disease.

Podcast episodes

1. 01

   Manometry Principles

   Manometry from first principles: every swallow the esophagus has two jobs, the sphincter must open and the body must squeeze in a top-to-bottom wave, and every number the test reports measures one of those two jobs. This episode teaches the order you read them in, sphincter first then body, because that sequence decides which half of the differential you are even in. Master the three numbers here and every motility diagnosis in the chapter becomes a specific pairing of two answers.

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2. 02

   Achalasia

   Achalasia is where the manometry numbers point most often, and every strange feature of the disease falls out of one lesion: loss of the inhibitory nerves that relax the sphincter and time the wave. The sphincter clamps but never releases, the body loses its wave, and what the body does on those failed swallows names the subtype. Subtype picks treatment because it changes what the procedure has to accomplish.

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3. 03

   Spasm and Hypercontractile

   Once achalasia is off the table, a normal IRP sends you into the body of the esophagus, which can only fail two ways: too much or too little. This episode is the too-much side: distal esophageal spasm and hypercontractile jackhammer. Both hinge on a normal IRP, both require symptoms to count, and both must clear secondary causes before earning the word diagnosis.

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4. 04

   Weak Pump Scleroderma Obstruction

   The fourth and final Esophageal Motility episode covers the weak-body disorders on a normal IRP: ineffective motility, absent contractility, and scleroderma, then the one diagnosis you are required to distrust, outflow obstruction with an elevated IRP but peristalsis still firing. The weak-body tracings resolve into three different diseases depending on two numbers: what the body is doing and what the LES is doing. Obstruction is never a manometry diagnosis alone; it needs pattern, symptoms, and a confirmatory test.

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Key topics

• ·The two jobs of every swallow: sphincter opening and the peristaltic wave
• ·Why you read the sphincter before the body, always
• ·The manometry catheter and the standard ten supine, five upright protocol
• ·IRP: how completely the sphincter relaxes, not resting tone
• ·DCI bands: failed, weak, normal, and hypercontractile swallows
• ·Distal latency and premature contraction as the signature of spasm
• ·Fragmentation and ineffective motility
• ·The recurring trap: same body tracing, two opposite diseases
• ·One lesion: inhibitory nerve loss, excitatory nerves spared
• ·Dysphagia to solids and liquids from the start
• ·Three subtypes as three ways a wave-less body behaves
• ·EGD first as a rule-out, not a rule-in
• ·Bird-beak on barium, IRP and subtype on manometry
• ·No treatment fixes the muscle: all lower sphincter pressure
• ·Botox, dilation, Heller, POEM tradeoffs
• ·Opioids and pseudoachalasia as framework-breaking traps
• ·Normal IRP moves the problem into the esophageal body
• ·Distal esophageal spasm: short distal latency under 4.5 seconds
• ·Jackhammer: DCI over 8000 on a fifth of swallows
• ·Symptoms required or the pattern is inconclusive
• ·Type three achalasia as the mirror-image trap
• ·Secondary mimics: opioids, reflux, EoE, mechanical obstruction
• ·Stepwise treatment: smooth muscle relaxants then neuromodulators
• ·Ineffective esophageal motility: strict criteria, common pattern, rare disease
• ·Multiple rapid swallows: probing pump reserve before fundoplication
• ·Absent contractility versus type one achalasia on the IRP
• ·Scleroderma esophagus: failed pump plus hypotensive LES together
• ·Twice-daily PPI, not a Nissen, in scleroderma reflux
• ·Elevated IRP outflow obstruction and its defensive criteria
• ·FLIP distensibility index and the Dallas Consensus line of 2.0