From the Guidelines
Manometry is still required for achalasia diagnosis, even with suggestive barium swallow results.
Diagnostic Approach
- A comprehensive diagnostic workup, including clinical history, upper endoscopy, timed barium esophagram, and high-resolution manometry, is essential for patients being evaluated for achalasia treatment, such as per-oral endoscopic myotomy (POEM) 1.
- While barium swallow studies can suggest achalasia, high-resolution manometry (HRM) remains the gold standard for diagnosis and is necessary to confirm the diagnosis and define the subtype of achalasia according to the Chicago classification system 1.
- The sensitivity of videofluoroscopy, including barium studies, for diagnosing esophageal motility disorders like achalasia is around 80-89%, but manometry may still be necessary to further elucidate the nature of the functional motility disorder 1.
- The American Gastroenterological Association recommends that manometry is indicated when achalasia is suspected, and more common esophageal disorders should be excluded with barium radiographs or endoscopy before manometric evaluation 1.
Key Points
- A suggestive barium swallow result is not sufficient for a definitive diagnosis of achalasia.
- HRM is necessary to confirm the diagnosis and define the subtype of achalasia.
- Manometry is essential for guiding treatment decisions and ensuring optimal patient outcomes.
From the Research
Diagnosis of Achalasia
- The diagnosis of achalasia is typically suggested by barium swallow and endoscopy, and confirmed by manometry 2.
- Barium swallow may have higher sensitivity than endoscopy for detecting subtle strictures, but has lower overall accuracy than high-resolution manometry for diagnosing achalasia 3.
- A study found that contrast radiography lacks sensitivity in the diagnosis of achalasia, with characteristic radiological features present in only 50% of cases 4.
Role of Manometry
- Manometry is considered the gold standard for the diagnosis of achalasia 4, 2.
- However, a study found that in patients with typical radiographic findings of achalasia, the barium study can be used to guide treatment without a need for manometry 5.
- If radiographic findings are equivocal, however, manometry may be required for a more certain diagnosis 5.
- Barium swallow can help secure the diagnosis in cases of equivocal manometry 3.
Diagnostic Accuracy
- Characteristic findings on chest CT and barium swallow tests were observed in more than 80% of achalasia patients, but in less than 10% of non-achalasia patients 6.
- Conventional characteristic findings of upper gastrointestinal endoscopy were seen in only 40-70% of achalasia patients 6.
- A study found that intra-esophageal food debris or resistance at the esophagogastric junction on upper gastrointestinal endoscopy will be positive in only about half of patients with achalasia 6.