A 45-year-old man reports episodic severe substernal chest pain with dysphagia, unrelieved by nitrates. Barium swallow shows a corkscrew or rosary bead appearance of the oesophagus. Which manometric finding confirms the diagnosis?

• A Absent peristalsis with impaired lower oesophageal sphincter relaxation
• B Failure of relaxation of the upper oesophageal sphincter with cricopharyngeal bar
• C Hypotensive lower oesophageal sphincter with free reflux on impedance studies
• D Simultaneous premature contractions of preserved amplitude interspersed with normal peristalsis, with normal sphincter relaxation ✓

Explanation

Diffuse (distal) oesophageal spasm shows the corkscrew oesophagus on barium and manometrically shows intermittent simultaneous, often high-amplitude premature contractions alternating with normal peristalsis, while sphincter relaxation remains intact. Option A describes achalasia, where peristalsis is uniformly absent and sphincter relaxation fails, which distinguishes it from the key both radiologically and manometrically.

Reference: Sabiston Textbook of Surgery, 21st ed.

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