A case to anchor the episodeA patient with progressive solids-and-liquids dysphagia. Manometry reports an IRP of 22, a DCI of 300, and a distal latency of 4.0 seconds. Which achalasia subtype, and which definitive therapy? High-resolution manometry is the gateway physiologic test after a clean endoscopy in esophageal dysphagia or pre-fundoplication evaluation. The Chicago Classification version 4.0 reduces the report to four numbers read in a fixed hierarchy: relaxation first, propagation second. Once you hold that order, every diagnosis falls out. This episode walks the framework and applies it to achalasia, where elevated IRP plus body pressurization pattern picks the subtype and the therapy. Topics coveredCatheter, sensors, and the Clouse plot: 36 solid-state sensors at 1 cm spacing; pressure topography by position vs timeThe two-job reading: relaxation at the EGJ first, propagation along the body secondStandardized v4.0 protocol: 10 supine swallows, 5 upright, multiple rapid swallow, rapid drink challengeIntegrated relaxation pressure (IRP): catheter-specific thresholds, why upright mattersDistal contractile integral (DCI): failed, weak, normal, hypercontractile binsDistal latency (DL) under 4.5 seconds defines premature contraction; CFV retired in v4.0Contraction pattern and the v4.0 IEM definition: ≥70% ineffective or ≥50% failedAchalasia phenotype: elevated IRP plus 100% failed peristalsisSubtype assignment: type 1 silent body, type 2 panesophageal pressurization, type 3 premature spasticPseudoachalasia red flags: age over 55, symptom duration under 6 months, disproportionate weight loss, non-traversable junctionAchalasia therapies: pneumatic dilation, Heller with partial wrap, POEM, botulinum toxin for non-procedural patientsSubtype-driven therapy choice: type 1 to dilation, type 2 to any modality, type 3 preferentially to POEM Key decisionsDCI of 300 with elevated IRP is failed peristalsis against a closed junction (achalasia); DCI of 300 with normal IRP is ineffective body peristalsis. Same number, different diseaseDistal latency under 4.5 seconds identifies a premature contraction; contraction front velocity has been removed from v4.0 and is a board trapMultiple rapid swallow augmentation vs no augmentation is the binary that decides full Nissen vs partial wrap pre-fundoplicationPseudoachalasia red-flag cluster changes the next test from manometry to CT chest plus EUS, before any treatmentSubtype 2 has the best treatment response across modalities; subtype 3 preferentially responds to POEM because the myotomy can extend to cover the spastic segmentNo therapy restores peristalsis. All therapies open the LES. Every intervention loses ground over time, so counsel patients up front that one in three need a second procedure For the full chapter with MCQs, tables, and primary-guideline references, visit www.boardpearls.com.Questions or feedback: [email protected]. (00:00) - Opening: the manometry framework as a hierarchy (01:30) - What the catheter does and the Clouse plot (03:30) - The two jobs and the Chicago algorithm order (05:30) - IRP: the gate, with catheter-specific thresholds (08:00) - DCI: contractile vigor and the four bins (11:00) - Distal latency, contraction pattern, and IEM in v4.0 (13:30) - Walking the hierarchy: IRP first, peristalsis second (16:00) - Achalasia phenotype and the three subtypes (20:30) - Pseudoachalasia red flags (23:00) - Achalasia therapy: dilation, Heller, POEM, botulinum (30:00) - Subtype-driven therapy choice and durability (33:00) - Synthesis and what's next

Ask this episode

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

Transcript

Related