Progression of Jackhammer Esophagus to Achalasia

TO THE EDITOR: Abdallah and Fass recently reported an interesting case of a patient with dysphagia who was initially diagnosed with Jackhammer esophagus (JE) and progressed to type 2 achalasia over the course of approximately 2 years. We read this report with great interest as our group has studied the natural course of JE and has also found progression of JE to achalasia, which we reported previously in 2014. In our case series, the single most important risk factor for progression of JE to achalasia was an elevated integrated relaxation pressure (IRP) on the initial manometry. Though the reported patient’s initial manometry showed a normal IRP a barium swallow at the time displayed a narrowed gastroesophageal junction. One common pitfall in measuring the IRP in JE is an upward displacement of the lower esophageal sphincter (LES) due to esophageal shortening caused by vigorous contractions after swallows. Therefore, during swallows, the LES does not remain at the same level of resting pressure measurement and adjustments must be made in order to accurately calculate the IRP. An example of this phenomenon is shown in Figures 1 and 2. On further evaluation of Figure 2 by Abdallah and Fass, we believe that the IRP may have been indeed elevated on the initial manometry. It appears that the IRP was measured below the actual location of the LES at the time of swallow, thereby artificially lowering the