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Difficulty: Very hardGastroenterology and Hepatology

High-resolution manometry (HRM) is the gold standard for diagnosing esophageal motility disorders. According to the Chicago Classification v4.0, match the following esophageal motility disorders with their precise defining manometric criteria.

  • Type I AchalasiaElevated IRP, 100% failed peristalsis, and absence of panesophageal pressurization
  • Type II AchalasiaElevated IRP, 100% failed peristalsis, and panesophageal pressurization in 20% or more of swallows
  • Type III AchalasiaElevated IRP and premature (spastic) contractions in 20% or more of swallows
  • Distal Esophageal SpasmNormal IRP and premature (spastic) contractions in 20% or more of swallows
  • Hypercontractile (Jackhammer) EsophagusNormal IRP and at least 20% of swallows with a Distal Contractile Integral (DCI) > 8,000 mmHg·s·cm

Answer

Type I Achalasia matches with elevated IRP, 100% failed peristalsis, and no pressurization. Type II Achalasia matches with elevated IRP, 100% failed peristalsis, and pan-esophageal pressurization. Type III Achalasia matches with elevated IRP and premature contractions. Distal Esophageal Spasm matches with normal IRP and premature contractions. Hypercontractile Esophagus matches with normal IRP and a DCI > 8,000 mmHg·s·cm.
The correct matches strictly follow the Chicago Classification algorithm for esophageal motility disorders. The first critical metric is the IRP. Achalasia requires an elevated IRP, while DES and Jackhammer require a normal IRP. Once IRP is established, the contractility pattern (failed, pressurized, premature, or hypercontractile) differentiates the specific subtype.

Step-by-Step Solution

1
Evaluate the Integrated Relaxation Pressure (IRP) to determine lower esophageal sphincter (LES) function.
An elevated IRP indicates impaired LES relaxation (defining achalasia), while a normal IRP rules out achalasia.
This primary branching point separates achalasia (Types I, II, and III) from other motility disorders (DES, Jackhammer).
2
Assess the contractility pattern in the esophageal body for cases with an elevated IRP.
100% failed peristalsis without pressurization is Type I. 100% failed peristalsis with pan-esophageal pressurization is Type II. Premature contractions indicate Type III.
The distinct contractility patterns dictate the achalasia subtype, which influences the choice of therapy (e.g., Type II responds best to pneumatic dilation or myotomy, while Type III often requires a longer myotomy).
3
Assess the contractility pattern in cases with a normal IRP.
Premature contractions with normal IRP define Distal Esophageal Spasm. Extremely high vigor contractions (DCI > 8,000) with normal IRP define Hypercontractile (Jackhammer) Esophagus.
Separating these prevents inappropriate achalasia treatments for patients with functioning LES relaxation.

Key Concept

Diagnosis and classification of esophageal motility disorders using high-resolution manometry criteria.
Estimated Time:2m 0s
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Topics

Gastroenterology and Hepatology

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