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Achalasia — RACP Adult Medicine MCQ

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ModerateGastroenterology & HepatologyAchalasiaRACP Adult Medicine

A 65-year-old man presents with progressive dysphagia to both solids and liquids over 6 months. Barium swallow shows a dilated oesophagus with a bird-beak tapering at the gastro-oesophageal junction. What is the most appropriate initial investigation to confirm the diagnosis?

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Correct answer: D — Oesophageal manometry

While upper GI endoscopy should be performed first to exclude malignancy (pseudoachalasia), high-resolution oesophageal manometry is the gold standard for confirming achalasia and subtyping (Chicago classification v4.0 – types I, II, III). Type II (with panesophageal pressurisation) has the best response to treatment. Management options include pneumatic dilation, peroral endoscopic myotomy (POEM), or Heller myotomy.

Reference: eTG – 2025 – Gastrointestinal; ACG – 2020 – Achalasia Guidelines