Achalasia Investigation Diagnosis Suspect achalasia in patients with dysphagia to solids and liquids, and in patients with regurgitation unresponsive to an adequate trial of PPI therapy. B Upper gastrointestinal endoscopy ACG Q Does the patient have suspected achalasia? Yes Obtain endoscopic assessment of the GEJ and gastric cardia to rule out pseudoachalasia. B No Evaluate for alternative diagnoses as clinically appropriate. Esophageal manometry ACG Q Does upper gastrointestinal endoscopy show mechanical obstruction? Yes Obtain further assessment for the cause of obstruction as clinically appropriate. No Obtain esophageal manometry in all patients with suspected achalasia without evidence of mechanical obstruction on endoscopy or esophagram. B Diagnostic criteria for achalasia (esophageal motility testing) Esophageal manometry shows an integrated relaxation pressure above the ULN Esophageal manometry shows 100% failed peristalsis or spasm