Extremely High Panesophageal Pressurization in Type II Achalasia

CC This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons. org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Figure 1. Endoscopic findings. (A) Es-ophagoscopy reveals a tightly narrowed distal esophagus at 40 cm from the upper incisor, even with full aeration. It was very hard to advance an endoscope through the lower third of the esophagus. (B) Retroflexion view shows that esopha-gogastric junction constricts an endo-scope tightly (arrows). A 74-year-old man came to our motility clinic with a complaint of difficulty in swallowing solid food and liquid that had seriously progressed for the past 2 months. Two years ago, he developed intermittent swallowing difficulty but maintained usual daily life without serious problems. After then, the symptom abruptly progressed for the last 2 months before visit. He was not able to swallow anything for two days before coming to our clinic. Esophagogastroscopy showed the very narrow and tight lower esophagus (Fig. 1A) and the tight esophagogastric junction constricting an endoscope strongly (Fig. 1B). Advancing an endo-scope was difficult and even needed much force. Endoscopic ul-trasonography demonstrated thickened esophageal inner circular muscle, approximately 2.5 mm, at 40 cm from upper incisor (Fig. 2A). High-resolution manometry revealed elevated mean integrated relaxation pressure of 21.8 mmHg with panesophageal pressurization in all ten swallows (Fig. 2B). The pressure of the esophageal body during swallowing was extremely high; elevated up to 150.0 mmHg at the lower esophagus (Fig. 2B). According