High-Resolution Esophageal Manometry is Required to Confirm Achalasia
High-resolution esophageal manometry is the gold standard and necessary test to definitively confirm achalasia in this patient. 1
Why Manometry is Essential
Achalasia is defined by specific manometric criteria that cannot be established by any other test: incomplete lower esophageal sphincter (LES) relaxation with an elevated 4-second integrated relaxation pressure (IRP) and absent or abnormal esophageal peristalsis. 1, 2, 3
The British Society of Gastroenterology guidelines explicitly state that esophageal manometry must be performed to confirm the diagnosis of achalasia after clinical features and endoscopic or barium swallow findings suggest it. 1
High-resolution manometry (HRM) provides critical prognostic information by identifying achalasia subtypes (Type I, II, or III), which predict treatment response—Type II responds best to any therapy, while Type III (spastic achalasia) has poorer outcomes. 1
Why the Other Options Are Insufficient
Repeat EGD (Option A)
- A repeat endoscopy is not necessary to confirm achalasia because the prior EGD 6 months ago already excluded masses and Barrett esophagus. 1
- Endoscopy's role in suspected achalasia is to exclude mechanical obstruction and pseudoachalasia (malignancy at the gastroesophageal junction), not to diagnose the motility disorder itself. 1
Barium Esophagography (Option B)
- Barium swallow can suggest achalasia by showing a dilated esophagus with a "bird's beak" narrowing at the LES, but it cannot confirm the diagnosis because it does not measure LES relaxation or esophageal contractility. 1
- The British Society of Gastroenterology recommends barium swallow as complementary to manometry, useful for anatomical detail in complex strictures or when endoscopy is not possible, but manometry remains mandatory for diagnosis. 1
Endoscopic Esophageal Ultrasonography (Option C)
- Endoscopic ultrasound (EUS) is indicated when pseudoachalasia from occult malignancy is suspected, particularly if there are red flags such as age >60, symptom duration <1 year, or significant weight loss. 1
- This patient's 6-month-old negative EGD and chronic GERD history make pseudoachalasia unlikely, so EUS is not the next diagnostic step. 1
Esophageal pH Test (Option E)
- pH monitoring diagnoses gastroesophageal reflux disease, not achalasia. 1, 4
- The American Gastroenterological Association explicitly states that manometry is not indicated for confirming GERD but is indicated to establish the diagnosis of dysphagia when obstruction cannot be found, particularly if achalasia is suspected. 1
Clinical Context Supporting Achalasia
This patient's symptom evolution—initial heartburn responsive to PPI followed by progressive regurgitation and postprandial chest pain—is classic for achalasia, which is frequently misdiagnosed initially as GERD. 2, 3, 5, 6
Regurgitation of undigested food and liquids with dysphagia to both solids and liquids (implied by "worsening" symptoms despite PPI) strongly suggests a motility disorder rather than reflux. 2, 3, 5
The American Gastroenterological Association guidelines state that manometry is indicated for preoperative assessment if there is any question of an alternative diagnosis, especially achalasia, before considering antireflux surgery in a patient presumed to have GERD. 1
Critical Pitfalls to Avoid
Do not assume PPI failure equals refractory GERD—achalasia commonly mimics GERD and may initially respond to acid suppression because stasis causes fermentation and secondary esophagitis. 2, 5, 6
Do not proceed to antireflux surgery without manometry—performing fundoplication on undiagnosed achalasia leads to catastrophic outcomes with worsened dysphagia. 1
Do not rely on barium swallow alone—while it may show suggestive findings, only manometry can definitively confirm absent LES relaxation and absent peristalsis required for diagnosis. 1