Idiopathic achalasia is an inflammatory disease of unknown etiology characterized by esophageal aperistalsis and failure of LES relaxation due to loss of inhibitory nitrinergic neurons in the esophageal myenteric plexus. Proposed causes of achalasia include gastroesophageal junction obstruction, neuronal degeneration, viral infection, genetic inheritance, and autoimmune disease. Current evidence suggests that the initial insult to the esophagus, perhaps a viral infection or some other environmental factor, results in myenteric plexus inflammation. The inflammation then leads to an autoimmune response in a susceptible population who may be genetically predisposed. Subsequently, chronic inflammation leads to destruction of the inhibitory myenteric ganglion cells resulting in the clinical syndrome of idiopathic achalasia. Further studies are needed to better understand the etiology and pathogenesis of achalasia-such an understanding will be important in developing safe, effective, and possibly curative therapy for achalasia.

BID PPI appears to be more effective than QD PPI in achieving clinical symptom response in suspected LPR. More response was achieved at 4 months compared with 2 months. Therefore, aggressive acid suppression with BID PPI for at least 4 months is warranted for treatment of LPR.

Multichannel intraluminal impedance (MII) is a new technique available for the evaluation of esophageal bolus transit and reflux similar to barium swallow, but without the hazards of radiation exposure. Combined MII and pH monitoring (MII-pH) allows evaluation of the nature and pH of the refluxate and the proximal extent of a reflux event. Thus, MII-pH is useful in evaluation of nonacid reflux in patients with persistent typical or atypical symptoms of gastroesophageal reflux disease that are refractory to acid suppression therapy. Additionally, combined MII and esophageal manometry (MII-EM) affords concurrent assessment of esophageal function (bolus transit) and motility. Therefore, it provides a more complete esophageal function test than esophageal manometry alone. The few limitations of impedance monitoring include the complexity of interpreting the tracings and the lack of data in the diseased population. However, continued improvements in the software and increasing studies in different patient populations will aid in overcoming these limitations.

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