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SUMMARY Patterns of lower oesophageal sphincter (LOS) function associated with the onset of 644 reflux episodes were recorded and analysed in 67 patients referred for evalution of gastrooesophageal reflux (GOR). Patients were studied recumbent, for one hour before and four hours after a standard meal. Transient LOS relaxation was the most prevalent mechanism and overall accounted for 82% of reflux episodes. With increasing severity of oesophagitis, absent basal LOS pressure became a progressively more common mechanism, accounting for 23% of episodes in the patients with severe oesophagitis. Patients commonly exhibited more than one mechanism. The timing of most (69%) LOS relaxations associated with reflux was not compatible with triggering by swallowing. Prolonged transient LOS relaxations were associated with inhibition of oesophageal peristalsis suggesting that this response is produced by neural inhibition. This study suggests the primary importance of transient LOS relaxations as the cause of GOR across the spectrum of severity of reflux disease.For many years gastrooesophageal reflux (GOR) was generally believed to result from lower oesophageal sphincter (LOS) incompetence caused by defective basal LOS tone.'`This concept, however, fails to account for the substantial proportion of patients with reflux disease in whom resting LOS pressure is normal.7 A recent study has shown that GOR in normal subjects occurs almost exclusively as a result of transient LOS relaxation, rather than from defective basal LOS pressure.8 In a subsequent study of 10 selected patients with erosive peptic oesophagitis, transient LOS relaxation accounted for 65% of reflux episodes, the remainder of reflux episodes occurring during prolonged periods of absent or low basal LOS pressure.9 The aims of the present study were to: (a) investigate possible variation in the mechanisms of GOR within a large group of patients exhibiting a spectrum of severity of reflux disease: and (b) analyse in detail, patterns of oeso-

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Achalasia is a relatively rare primary motor esophageal disorder, characterized by absence of relaxations of the lower esophageal sphincter and of peristalsis along the esophageal body. As a result, patients typically present with dysphagia, regurgitation and occasionally chest pain, pulmonary complication and malnutrition. New diagnostic methodologies and therapeutic techniques have been recently added to the armamentarium for treating achalasia. With the aim to offer clinicians and patients an up-to-date framework for making informed decisions on the management of this disease, the International Society for Diseases of the Esophagus Guidelines proposed and endorsed the Esophageal Achalasia Guidelines (I-GOAL). The guidelines were prepared according the Appraisal of Guidelines for Research and Evaluation (AGREE-REX) tool, accredited for guideline production by NICE UK. A systematic literature search was performed and the quality of evidence and the strength of recommendations were graded according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Given the relative rarity of this disease and the paucity of high-level evidence in the literature, this process was integrated with a three-step process of anonymous voting on each statement (DELPHI). Only statements with an approval rate >80% were accepted in the guidelines. Fifty-one experts from 11 countries and 3 representatives from patient support associations participated to the preparations of the guidelines. These guidelines deal specifically with the following achalasia issues: Diagnostic workup, Definition of the disease, Severity of presentation, Medical treatment, Botulinum Toxin injection, Pneumatic dilatation, POEM, Other endoscopic treatments, Laparoscopic myotomy, Definition of recurrence, Follow up and risk of cancer, Management of end stage achalasia, Treatment options for failure, Achalasia in children, Achalasia secondary to Chagas' disease.