The fourth and final Esophageal Motility episode covers the weak-body disorders on a normal IRP: ineffective motility, absent contractility, and scleroderma, then the one diagnosis you are required to distrust, outflow obstruction with an elevated IRP but peristalsis still firing. The weak-body tracings resolve into three different diseases depending on two numbers: what the body is doing and what the LES is doing. Obstruction is never a manometry diagnosis alone; it needs pattern, symptoms, and a confirmatory test. Topics covered Ineffective esophageal motility: strict criteria, common pattern, rare disease Multiple rapid swallows: probing pump reserve before fundoplication Absent contractility versus type one achalasia on the IRP Scleroderma esophagus: failed pump plus hypotensive LES together Twice-daily PPI, not a Nissen, in scleroderma reflux Elevated IRP outflow obstruction and its defensive criteria FLIP distensibility index and the Dallas Consensus line of 2.0 Impostor differential: opioids, EoE, hernia, malignancy, obesity Key decisions The only decision ineffective motility changes is whether the esophagus can survive a full fundoplication A flat multiple-rapid-swallow response predicts post-op dysphagia and sends you to a partial wrap (Toupet or Dor) Absent contractility on a normal IRP means the pump is guilty and the sphincter is innocent; on an elevated IRP suspect type one achalasia Scleroderma is the paired hit: absent contractility plus a resting LES below ten, driving Barrett in five to thirty-five percent Outflow obstruction requires the IRP elevated both supine and upright (upright cutoff twelve) plus elevated intrabolus pressure On manometry alone, junction outflow obstruction is always inconclusive; it needs symptoms and a confirmatory timed barium or FLIP For the full chapter with MCQs, tables, and primary-guideline references, visit www.boardpearls.com. Questions or feedback: [email protected]. (00:00) - The weak pump on a normal IRP (00:44) - Ineffective motility and the fundoplication question (02:42) - Absent contractility and the systemic hunt (03:56) - Scleroderma esophagus: two hits at once (07:04) - Outflow obstruction: the diagnosis to distrust (11:17) - The imaging probe and distensibility (14:09) - The whole weak-body and obstruction picture

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

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