{"type":"rich","version":"1.0","provider_name":"Transistor","provider_url":"https://transistor.fm","author_name":"Board Pearls","title":"Chapter 2, Ep 1 of 2: Manometry and Achalasia","html":"<iframe width=\"100%\" height=\"180\" frameborder=\"no\" scrolling=\"no\" seamless src=\"https://share.transistor.fm/e/7c6feb89\"></iframe>","width":"100%","height":180,"duration":1327,"description":"High-resolution manometry is the gateway physiologic test after a clean endoscopy in esophageal\ndysphagia or pre-fundoplication evaluation. The Chicago Classification version 4.0 reduces the\nreport to four numbers read in a fixed hierarchy: relaxation first, propagation second. Once you\nhold that order, every diagnosis falls out. This episode walks the framework and applies it to\nachalasia, where elevated IRP plus body pressurization pattern picks the subtype and the therapy.\n \nThe case. A patient with progressive solids-and-liquids dysphagia. Manometry reports an IRP of 22, a DCI of\n300, and a distal latency of 4.0 seconds. Which achalasia subtype, and which definitive therapy?\n \nTopics covered\n\nCatheter, sensors, and the Clouse plot: 36 solid-state sensors at 1 cm spacing; pressure topography by position vs time\nThe two-job reading: relaxation at the EGJ first, propagation along the body second\nStandardized v4.0 protocol: 10 supine swallows, 5 upright, multiple rapid swallow, rapid drink challenge\nIntegrated relaxation pressure (IRP): catheter-specific thresholds, why upright matters\nDistal contractile integral (DCI): failed, weak, normal, hypercontractile bins\nDistal latency (DL) under 4.5 seconds defines premature contraction; CFV retired in v4.0\nContraction pattern and the v4.0 IEM definition: ≥70% ineffective or ≥50% failed\nAchalasia phenotype: elevated IRP plus 100% failed peristalsis\nSubtype assignment: type 1 silent body, type 2 panesophageal pressurization, type 3 premature spastic\nPseudoachalasia red flags: age over 55, symptom duration under 6 months, disproportionate weight loss, non-traversable junction\nAchalasia therapies: pneumatic dilation, Heller with partial wrap, POEM, botulinum toxin for non-procedural patients\nSubtype-driven therapy choice: type 1 to dilation, type 2 to any modality, type 3 preferentially to POEM\n\n \nKey decisions\n\nDCI of 300 with elevated IRP is failed peristalsis against a closed junction (achalasia); DCI of 300 with normal...","thumbnail_url":"https://img.transistorcdn.com/-FuAdDBcPDLhEoUmroZKtOBRvuBn_FHPpYlh41hOnU4/rs:fill:0:0:1/w:400/h:400/q:60/mb:500000/aHR0cHM6Ly9pbWct/dXBsb2FkLXByb2R1/Y3Rpb24udHJhbnNp/c3Rvci5mbS9iNzlh/ZTU4Y2MzNWExMjQ5/MjA5OWMwMmI3ZTk5/NGFiZS5wbmc.webp","thumbnail_width":300,"thumbnail_height":300}