Abstract
Esophageal motility disorders (EMDs) form a significant part of a busy endoscopist's
practice. Endoscopy plays an all-encompassing role in the diagnosis and management
of EMDs including achalasia cardia. The focus on in-vogue third-space endoscopic procedures
such as per-oral endoscopic myotomy often digresses the important role of endoscopy.
Endoscopic evaluation forms the part of standard first-line evaluation of any dysphagia
and serves to rule out a secondary cause such as an esophagogastric junction malignancy
and eosinophilic esophagitis. Moreover, endoscopic evaluation may itself provide corroborative
evidence that may contribute to the diagnosis of the motility disorder. Achalasia
cardia may present with a wide spectrum of endoscopic findings from being entirely
normal and the well-known and pathognomonic dilated sigmoid-shaped esophagus with
food residue, to lesser-known ornate signs. The evidence on the role of endosonography
in EMDs is conflicting and largely restricted to evaluation of pseudoachalasia. High-resolution
manometry (HRM) remains the gold standard in the diagnosis of EMDs. Endoscopists must
also keep abreast of the latest iteration of the Chicago classification version 4.0,
which differs significantly from its predecessor in being more stringent in making
diagnosis of esophagogastric junction outflow obstruction and disorders of peristalsis
since these manometric findings may be seen in normal individuals and may be mimicked
by opioid use and gastroesophageal reflux. The latest rendition also includes the
use of provocative maneuvers and testing in both supine and sitting posture. Despite
being the gold standard, there are certain lacunae in the use and interpretation of
the Chicago classification of which the users should be well aware. Emerging technologies
such as functional lumen imaging probe and planimetry, and timed barium esophagogram
fill the lacuna in diagnosis of these motility disorders, which at times is beyond
the resolution of HRM.
Keywords
achalasia cardia - motor dysphagia - Chicago classification - hypercontractile esophagus
- distal esophageal spasm - esophagogastric junction obstruction
