A patient presents with progressive dysphagia to both solids & liquids. What is the GOLD STANDARD diagnostic test for this condition?

• A. Barium swallow
• B. Esophageal manometry
• C. EGD
• D. 24 hr pH monitoring

Answer: (B)

Progressive dysphagia to both solids and liquids points to a motor problem of the esophagus rather than a fixed narrowing. The test that directly evaluates esophageal motor function is esophageal manometry, which measures the pressure waves during swallowing and how the lower esophageal sphincter relaxes. In achalasia, manometry characteristically shows absent or severely impaired peristalsis in the esophageal body along with incomplete LES relaxation and elevated LES resting pressure. This combination confirms the diagnosis, making esophageal manometry the definitive (gold standard) test.

A barium swallow can suggest achalasia by showing a dilated esophagus with a narrowed, tapering distal segment (bird-beak), but it isn’t definitive. Endoscopy (EGD) is used to rule out a mechanical obstruction or cancer. 24-hour pH monitoring is used to evaluate reflux, not motility.