Achalasia Type II on High-Resolution Manometry MCQ — NEET PG Practice Question | NEETPGAI
Achalasia Type II on High-Resolution Manometry
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stethoscope Medicine
A 45-year-old man from rural India presents with a 2-year history of progressive dysphagia to both solids and liquids, nocturnal regurgitation of undigested food, and a 6 kg weight loss. Upper endoscopy shows a dilated esophagus with retained food and a puckered lower esophageal sphincter (LES), with biopsies excluding malignancy. High-resolution manometry (HRM) is performed and the pattern marked **B** in the diagram is identified: 100% failed peristalsis with ≥20% of swallows demonstrating uniform pressurization spanning from the upper esophageal sphincter to the LES at ≥30 mmHg.
Based on this HRM finding, which of the following therapeutic approaches is most likely to yield the BEST long-term response in this patient?
A. Nifedipine and isosorbide dinitrate sublingual before meals
B. Botulinum toxin injection into the LES with planned repeat injections
C. Pneumatic dilation with graded balloon series (30–40 mm)
D. Laparoscopic Heller myotomy with partial fundoplication or POEM (peroral endoscopic myotomy)
Explanation
Why Laparoscopic Heller myotomy with partial fundoplication or POEM is right
The HRM pattern marked B defines Type II achalasia (pan-esophageal pressurization), which is the MOST COMMON and MOST RESPONSIVE-TO-TREATMENT subtype according to the Chicago Classification V4.0. Type II achalasia achieves ~90–95% success with all invasive modalities. Both laparoscopic Heller myotomy with fundoplication (Dor anterior or Toupet posterior) and POEM are first-line, durable surgical options with excellent long-term outcomes in Type II disease. These are the gold standard approaches that provide definitive relief of LES obstruction by dividing the circular muscle fibers and restoring esophageal emptying.
Why each distractor is wrong
Pneumatic dilation with graded balloon series: While effective, pneumatic dilation requires multiple sessions, carries a 1–2% perforation risk, and provides less durable relief than myotomy. Although it is a first-line option for Type II, it is not the BEST long-term response compared to surgical myotomy or POEM, which offer single-procedure definitive outcomes.
Nifedipine and isosorbide dinitrate sublingual: Pharmacologic therapy (calcium channel blockers and nitrates) has limited efficacy and is reserved only for patients who refuse invasive options. These agents do not address the underlying pathophysiology (loss of inhibitory neurons in the myenteric plexus) and are not appropriate first-line therapy for a symptomatic patient with confirmed Type II achalasia.
Botulinum toxin injection into the LES: Botulinum toxin provides only temporary relief (3–12 months) and requires repeated injections. It is used as a bridge therapy for poor surgical candidates or those refusing invasive procedures, not as the primary treatment for a fit patient with Type II achalasia who has excellent prognosis with myotomy.
High-YieldNEET PG
Type II achalasia (≥20% pan-esophageal pressurization on HRM) is the earliest stage with the BEST response to all therapies (~90–95% success); laparoscopic Heller myotomy or POEM are durable first-line options, while pneumatic dilation and botulinum toxin are reserved for specific clinical scenarios.
Chicago Classification V4.0; ACG Guidelines on Achalasia 2020
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