Yes manometry is a must before treatment for Achalasia as it is the only confirmative test to diagnose achalasia. Because of its sensitivity, esophageal manometry (esophageal motility study) is considered the key test for establishing the diagnosis of achalasia.We frequently see patients coming with recurrence of symptoms after surgery or endoscopic dilatation and with incomplete workup before treatment. In many such patients there is a doubt about the diagnosis of achalasia. Manometry after surgery or dilatation is difficult to interpret and may not give adequate information required. A reverse scenario, there are many patients with difficulty in swallowing but normal endoscopy and barium study and are counselled to have no disease. Such scenario can arise in early achalasia and is always picked up on manometry. So all patients with difficulty in swallowing and normal endoscopy should certainly get an esophageal manometry done.