Esophageal motility disorders often present with chest pain and dysphagia. Achalasia is a disorder of the lower esophageal sphincter and the smooth muscle fibers of the esophagus. In achalasia, the lower esophageal sphincter usually does not relax with swallowing and the esophagus is not peristaltic. In contrast to spastic disorders of the esophagus, achalasia can be progressive and cause severe morbidity.

Esophageal spastic disorders, such as diffuse esophageal spasm (DOS) and oesophageal sphincter (OK) are benign and non-progressive, with similar findings in esophageal manometry. Although the exact cause remains unknown, these disorders may represent a manifestation of gastroesophageal reflux disease.

Dysphagia and chest pain are common symptoms in general medical practice. When episodes of chest pain are accompanied by dysphagia and cardiac sources of pain are officially ruled out, the esophagus often becomes the main focus of research. Gastroesophageal reflux disease (GERD) can sometimes be implicated as the cause of such symptoms, but spastic disorders of the esophagus or lower esophageal sphincter (LES) should be included in the differential diagnosis.

How they are classified

Classification is based on high-resolution manometry, under the Chicago Classification version 4.0. The metrics that matter are the integrated relaxation pressure (IRP), which reflects whether the lower esophageal sphincter relaxes, the distal latency (DL), which shows whether a contraction is premature, and the distal contractile integral (DCI), which measures contraction vigour.

  • Achalasia. Failed relaxation of the sphincter with absent peristalsis. Three subtypes, and the subtype guides treatment. Unlike the other disorders it is progressive.
  • Esophagogastric junction outflow obstruction. Impaired relaxation with preserved peristalsis. Requires exclusion of a mechanical cause.
  • Distal esophageal spasm and hypercontractile esophagus. Spastic disorders, benign and non-progressive, presenting mainly with chest pain. Covered in detail on the page for nutcracker esophagus and diffuse esophageal spasm.
  • Ineffective esophageal motility. Weak or fragmented peristalsis, often associated with reflux disease.

Diagnostic sequence

Endoscopy first, in every case of dysphagia, to exclude a tumour, a stricture and eosinophilic esophagitis, which frequently mimics a motility disorder. High-resolution manometry then establishes the diagnosis and the subtype. Barium swallow demonstrates delayed emptying and the bird beak appearance in achalasia. CT is added when pseudoachalasia from an infiltrating tumour is suspected.

Treatment

For achalasia the established options are pneumatic dilation, peroral endoscopic myotomy (POEM) and surgical myotomy. POEM is performed entirely endoscopically through a submucosal tunnel, with the length of the myotomy tailored to the subtype.

For spastic disorders management is more conservative, and European guidance advises caution in extending POEM beyond achalasia, since the evidence base remains limited.

Key figures: Under Chicago Classification version 4.0, distal oesophageal spasm requires at least 20 percent of swallows with a distal latency below 4.5 seconds. Hypercontractile oesophagus is defined by a DCI of 8,000 mmHg·s·cm or above.

The principal entities are achalasia and distal oesophageal spasm. Before manometry, gastroscopy excludes a mechanical cause.

Frequently asked questions

How is an esophageal motility disorder diagnosed?

High-resolution manometry is the reference standard and the only test that establishes the diagnosis and its subtype. Endoscopy comes first in every case of dysphagia, to exclude a tumour, a stricture or eosinophilic esophagitis. A barium swallow may show delayed emptying or the bird beak appearance in achalasia, but a normal study does not exclude a motility disorder.

Is achalasia different from esophageal spasm?

Yes, in an important way. Achalasia is progressive: the sphincter fails to relax, peristalsis is absent, and without treatment the esophagus dilates and morbidity increases. Spastic disorders such as distal esophageal spasm are benign and non-progressive, presenting mainly with chest pain rather than worsening obstruction.

Is POEM suitable for all motility disorders?

It is an established treatment for achalasia. Outside achalasia, European Society of Gastrointestinal Endoscopy guidance advises caution, because the evidence in spastic disorders is limited compared with achalasia. The decision is individualised after manometric subtyping.

Sources

Content last updated: September 2026 (14/09/2026).