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Case Reports
. 2025 Aug 1;17(8):e89206.
doi: 10.7759/cureus.89206. eCollection 2025 Aug.

Misinterpretation of High-Resolution Manometry Leading to Inappropriate Treatment of Achalasia: A Diagnostic Challenge

Kyle Schneider  1 , David S Braun  1 , Prashant Kedia  2
Affiliations
Case Reports

Misinterpretation of High-Resolution Manometry Leading to Inappropriate Treatment of Achalasia: A Diagnostic Challenge

Kyle Schneider et al. Cureus. .

Abstract

Achalasia is a motility disorder of the esophagogastric junction outflow, characterized by impaired lower esophageal sphincter (LES) relaxation and loss of normal peristalsis of the esophageal smooth muscle. The common clinical manifestations of achalasia include dysphagia of both solids and liquids, regurgitation of undigested food and saliva, and chest pain. It shares symptoms with gastroesophageal reflux disease (GERD), such as a retrosternal burning sensation and dysphagia, which can delay the diagnosis. Several modalities are useful in establishing the diagnosis of achalasia, including high-resolution manometry (HRM), barium esophagram (BE), and upper endoscopy. Despite potential issues with HRM, it remains the gold standard for diagnosing achalasia, underscoring the importance of proper technique and interpretation. Improper probe placement can lead to inaccurate diagnoses. Here, we present the case of a patient with achalasia who was misdiagnosed with GERD and underwent an inappropriate Toupet fundoplication, who eventually required peroral endoscopic myotomy (POEM) as a salvage treatment to relieve their symptoms.

Keywords: achalasia; endoflip; gastroenterology; high-resolution manometry; poem.

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Conflict of interest statement

Human subjects: Informed consent for treatment and open access publication was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Figures

Figure 1
Figure 1. High-resolution manometry (10-swallow composite) showing ineffective esophageal motility with integrated relaxation pressure of 3.1.
Figure 2
Figure 2. Timed barium esophagram showing a dilated esophagus tapering to a “bird’s beak”-type point, with a significant amount of retained contrast in the esophagus. Frame A is the beginning of study, B is the middle, and C is the end of the study.
Figure 3
Figure 3. Endoscopic images of (A) copious fluid in the esophagus; (B) a dilated esophagus with puckered appearance of lower esophageal sphincter; (C) retroflexed view of stomach with evidence of prior fundoplication; (D) submucosal dissection prior to myotomy; (E) the myotomy site; (F) endoscopic suturing after myotomy.
Figure 4
Figure 4. Summary timeline of events from misdiagnosis to resolution of symptoms.
GERD: gastroesophageal reflux disease; HRM: high-resolution manometry; EndoFLIP: endoluminal functional lumen imaging probe; LES: lower esophageal sphincter; POEM: peroral endoscopic myotomy
See this image and copyright information in PMC

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