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. Topics covered 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 Key decisions A normal IRP keeps you out of achalasia and points into the body Distal latency under 4.5 seconds on a fifth of swallows defines spasm DCI over 8000 on a fifth of swallows defines the hypercontractile jackhammer pattern Premature contraction with an elevated IRP is type three achalasia, not spasm Opioids raise DCI and shorten latency, so stop the drug and restudy before any procedure Endoscopy with biopsies comes first to exclude EoE and mechanical obstruction For the full chapter with MCQs, tables, and primary-guideline references, visit www.boardpearls.com. Questions or feedback: [email protected]. (00:00) - The too-much body (00:47) - Same costume, check the IRP (01:24) - Spasm and distal latency (02:04) - Jackhammer and the DCI bar (02:44) - Symptoms required to count (03:20) - The type three achalasia trap (04:20) - Clear the secondary mimics (05:29) - Stepwise treatment logic

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“What did the council decide on item 42?” — answered with the speaker and the moment.

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