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 disorders of normal sphincter relaxation with abnormal body contraction: both occur with 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 are all disorders of failed peristalsis with a normal or low IRP, and all three impair esophageal acid clearance.

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

  EGJ outflow obstruction (EGJOO) is a heterogeneous diagnosis that includes every patient with an elevated IRP and some preserved peristalsis, and the v4.0 criteria were tightened because many of these findings are false positives and that a manometric abnormality alone is not enough to call a disease.

Podcast episodes

1. 01

   Esophageal Motility: Achalasia and Its Mimic

   Achalasia is loss of the inhibitory neurons of the myenteric plexus, leaving a sphincter that won't relax and an esophageal body with no propagated wave. The episode follows a thirty-eight-year-old man from his history, which already points to achalasia, through endoscopy before manometry, then barium and high-resolution manometry that confirms the diagnosis and assigns a type that predicts response. It then turns to opioids and to pseudoachalasia, shown by a sixty-eight-year-old woman with the same tracing. Treatment choice by type follows: dilation, Heller with a partial wrap, POEM, and the limited roles of botulinum toxin and drugs. It closes with lifelong follow-up and the exam traps.

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2. 02

   Esophageal Motility: Outflow Obstruction

   A manometry report reading esophagogastric junction outflow obstruction is not yet a diagnosis, and on its own it is often a false positive. The episode follows a fifty-nine-year-old man on daily opioids with obesity and dysphagia. It first defines the three tracing requirements, then explains why the diagnosis is clinically inconclusive without fitting symptoms and a confirmatory test. Next it works through the imitators: opioids, obesity, hernia, eosinophilic esophagitis, cancer, prior fundoplication, and evolving achalasia. It then confirms obstruction with a timed barium esophagram or FLIP, and ends by choosing treatment according to the cause the workup finds.

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3. 03

   Esophageal Motility: Spasm and Jackhammer

   Chest pain and dysphagia from an esophagus whose sphincter opens normally but whose body squeezes too early or too hard are worked up in a fixed order. Two patients carry the episode. A woman with distal esophageal spasm shows why a negative cardiac workup leads to endoscopy with biopsies first, how a normal IRP separates spasm from type three achalasia, how distal latency defines the disease, and which contributors to exclude. Treatment then climbs from smooth muscle relaxants to neuromodulators to procedures. A man with jackhammer esophagus shows the same path, with a high contractile integral and an obstruction below it to rule out.

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4. 04

   Esophageal Motility: The Weak Esophagus

   The organizing idea is that a weak esophagus cannot push food past a wrap, so manometry comes before every fundoplication. Two patients carry the episode. The first has failed swallows with a normal IRP, which is absent contractility, and a very low sphincter pressure that points to scleroderma. The episode then covers the history and serologies that confirm it, and the reflux-directed plan that replaces surgery: lifelong PPI, head-of-bed elevation, stricture dilation, a search for gastroparesis, and Barrett surveillance. The second patient has ineffective esophageal motility with proven reflux, and multiple rapid swallows decide whether he can have a wrap and which one.

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Key topics

• ·Achalasia history and presentation
• ·Heartburn that is not acid reflux
• ·Loss of inhibitory myenteric neurons
• ·Endoscopy before manometry
• ·Barium esophagram findings
• ·High-resolution manometry and IRP
• ·Achalasia types one, two, and three
• ·Opioid effect and pseudoachalasia
• ·Dilation, Heller myotomy, and POEM
• ·Blown-out myotomy and cancer risk
• ·Outflow obstruction on high-resolution manometry
• ·Chicago version four criteria
• ·Three-part rule for clinical relevance
• ·Opioid effect and taper
• ·Obesity as a confounder
• ·Structural imitators and endoscopic workup
• ·Rapid drink challenge
• ·Timed barium esophagram
• ·FLIP and Dallas criteria
• ·Mechanism-based treatment
• ·Chest pain after a negative cardiac workup
• ·Endoscopy with biopsies before manometry
• ·PPI trial when heartburn is present
• ·Normal IRP versus type three achalasia
• ·Distal latency and Chicago version four spasm
• ·Excluding opioids, reflux, and eosinophilic esophagitis
• ·Smooth muscle relaxants and neuromodulators
• ·Botulinum toxin and POEM for refractory disease
• ·Hypercontractile (jackhammer) esophagus
• ·Board traps in workup and treatment