Episode 1: Manometry Fundamentals — Indications, Caveats, and the Conventional FrameworkEpisode keywords: esophageal manometry indications, esophageal motility abnormalities, conventional manometry, LES pressure normal values, manometry before Nissen fundoplication, five manometry caveatsEpisode SummaryBefore interpreting any manometric tracing, you need the philosophical framework: what the study can and cannot tell you. This episode covers the three core indications for esophageal manometry, five critical interpretive caveats that govern every motility diagnosis, and the conventional four-bucket framework that predates the Chicago Classification. Whether you are reading a board question or ordering a study on a post-EGD dysphagia consult, these principles govern everything downstream.Key TopicsWhen to order esophageal manometry: Three indications — unexplained dysphagia after normal EGD, chest pain after cardiac clearance, and pre-operative evaluation before antireflux surgery. The third indication is the most commonly missed on boards.The five interpretive caveats: (1) Cause of most motility abnormalities is unknown. (2) Abnormalities do not always have physiologic consequences. (3) Symptoms may not respond when the manometric abnormality is corrected. (4) Meeting diagnostic criteria does not establish clinical importance. (5) Diagnosis requires integration of clinical AND manometric data.Conventional four-bucket framework: Inadequate LES relaxation (achalasia), uncoordinated contraction (diffuse esophageal spasm), hypercontraction (nutcracker esophagus), and hypocontraction (ineffective esophageal motility).Normal values: LES basal pressure 10–45 mmHg; LES relaxation residual pressure <8 mmHg above gastric; peristaltic velocity 2–6 cm/sec; distal amplitude 30–180 mmHg.Board PearlsBoard trap: Asymptomatic patient with textbook DES pattern on manometry found during pre-op evaluation. The answer is NOT to treat DES — caveats two and four apply. Manometric criteria without clinical relevance do not establish a disorder.High-yield: Manometry before antireflux surgery is a classic board setup. Without it, you risk performing a Nissen on a patient with impaired peristalsis and creating a functional obstruction.

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