A 29-year-old woman reports progressive dysphagia to both solids and liquids, occasional regurgitation of undigested food, and chest discomfort. Barium swallow shows a dilated esophagus tapering to a bird-beak appearance. High-resolution manometry would show which pattern to confirm the diagnosis?

• A Weak peristalsis with a hypotensive lower esophageal sphincter
• B Hypercontractile distal esophageal pressurization with normal lower esophageal sphincter relaxation
• C Repetitive retrograde contractions with normal sphincter relaxation
• D Absent peristalsis in the distal esophagus with impaired deglutitive relaxation of the lower esophageal sphincter ✓

Explanation

Achalasia is defined manometrically by absent distal esophageal peristalsis together with failed relaxation of the lower esophageal sphincter on swallowing, reflecting loss of inhibitory myenteric neurons. Diffuse esophageal spasm shows preserved sphincter relaxation with premature contractions, and ineffective motility shows weak peristalsis with a competent or hypotensive sphincter. Both can cause chest pain but neither produces the bird-beak obstruction seen here.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.