Synopsis
Confirm impaired oesophagogastric-junction relaxation with high-resolution manometry, exclude malignant pseudoachalasia, and select dilation, surgical myotomy or POEM through specialist multidisciplinary care.
- Achalasia combines absent or abnormal peristalsis with impaired lower-sphincter relaxation, causing liquid and solid dysphagia, regurgitation and weight loss.
- Endoscopy with careful junction inspection and biopsy precedes manometry to exclude cancer and structural obstruction.
- High-resolution manometry confirms the physiological diagnosis and subtype; a barium study quantifies morphology and emptying.
Key red flags
Rapid weight loss, short symptom history, older age or difficult scope passage at the junction suggests pseudoachalasia from malignancy.
Nocturnal regurgitation, cough and recurrent pneumonia indicate clinically important oesophageal retention and aspiration risk.
Short rapidly progressive history, disproportionate weight loss or a resistant irregular junction requires renewed cancer exclusion.
Investigation priorities
Exclude obstructing tumour and mucosal mimics before physiological classification.
Management branches
A fit 46-year-old has liquid and solid dysphagia with chest pain; endoscopy and biopsies exclude a junctional lesion.
- High-resolution manometry tests both supine and upright positions. The primary-position median IRP is above the laboratory’s validated normal limit, with no normal peristalsis and premature contractions in 40% of test swallows: a conclusive Chicago v4.0 type III pattern rather than type I, type II or the stricter inconclusive outflow-obstruction category.
- Timed barium swallow confirms impaired emptying with a retained column at five minutes and maps oesophageal morphology, while the endoscopy and imaging record is rechecked for structural obstruction.