In a patient with dysphagia and manometry showing diffuse esophageal spasm or ineffective motility plus positive pH study, how long should GERD be treated before reconsidering the diagnosis of achalasia, and what additional testing should be pursued?

In this case, optimal treatment for GERD (twice daily PPI) should continue for 8 weeks. If symptoms persist, I would first consider repeat reflux testing on PPI to ensure that reflux is well-controlled on optimized therapy. If not, escalation of reflux treatment may be needed. On the other hand, if ...

I agree with the previous answer. Ultimately, if there is still concern for achalasia despite esophageal manometry, one can obtain a timed-barium swallow to assess esophageal emptying, or EndoFLIP to evaluate the LES/EGJ distensibility.