A 43-Year-Old Female with Dysphagia: What Is Your Diagnosis by High-Resolution Manometric Finding?

Abstract

A 43-year-old female was admitted to our hospital with dysphagia for both liquids and solid foods for 2 months. A high-resolution manometry (HRM; version 2.1; Manoscan; Sierra Scientific Instruments Inc., Los Angeles, CA) was performed (Fig. 1). The resting esophagogastric junction (EGJ) pressure in expiration and inspiration were 69 mmHg and 54 mmHg, respectively. The mean integrated relaxation pressure (IRP) with 10 swallows of 5 mL was 40.7 mmHg. This pattern of deglutitive pressure topography was very unswerving during 10 water swallows. The black isobaric contour was set at 30 mmHg in the presented topography. What is your diagnosis with this high-resolution manometry finding? This HRM finding of one swallow shows impaired EGJ relaxation with 57.8 mmHg of IRP, absent peristalsis, and pan-esophageal pressurization from the upper esophageal sphincter (UES) to the EGJ. It was consistent with achalasia and associated esophageal compression based on the Chicago classification of distal esophageal motility disorders.1 Incomplete deglutitive EGJ relaxation with mean IRP and/or mean intrabolus pressure ≥15 mmHg is an essential feature in the diagnosis of achalasia. However, there is no significant pressurization within the body of the esophagus in classic achalasia with impaired EGJ relaxation. In achalasia with esophageal compression as in this case, there is a rapid pan-esophageal pressurization from the UES to the EGJ with >30 mmHg intrabolus pressure in ≥20% of swallows. In spastic achalasia, there is a rapidly propagated pressurization attributable to spastic contractions in which the contractile front velocity is >8 cm/sec in ≥20% of swallows.1,2