On manometry, what distinguishes achalasia from distal esophageal spasm?

• A. Achalasia: absent peristalsis with incomplete LES relaxation; DES: normal or high LES relaxation with uncoordinated, spastic contractions
• B. Achalasia: normal peristalsis; DES: absent peristalsis
• C. Achalasia: increased LES relaxation; DES: decreased LES relaxation
• D. Achalasia: rapid peristalsis; DES: slow peristalsis

Answer: (B)

The key idea is what the manometry pattern tells you about both esophageal movement and LES behavior. Achalasia shows failure of the LES to relax properly and little to no coordinated movement of the esophageal body. On manometry you’d see elevated LES pressure with incomplete relaxation and absent peristalsis in the esophagus, meaning the tube can’t open well and the body isn’t propelling a bolus forward.

Distal esophageal spasm, on the other hand, keeps the LES relaxing normally but the contractions in the distal esophagus are discoordinated and often spastic. So you see normal LES relaxation combined with uncoordinated, high‑amplitude distal contractions rather than a propagated peristaltic wave.

So the distinguishing feature is peristaltic coordination in the esophageal body along with the LES relaxation pattern: achalasia has absent peristalsis with incomplete LES relaxation; DES has preserved LES relaxation with uncoordinated, spastic distal contractions.