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Background High-resolution esophageal manometry (HREM) is the gold standard for evaluating esophageal motility disorders. Population-specific data from the Middle East remain limited. This study aimed to characterize manometric patterns and their clinical correlations in a Saudi cohort presenting with refractory gastroesophageal reflux disease (GERD) and/or dysphagia.Methods A retrospective analysis was conducted of 382 consecutive patients who underwent HREM between October 2023 and September 2025 at King Abdullah Medical City (KAMC), Makkah, Saudi Arabia. Demographic data, body mass index (BMI), comorbidities, medication history, and prior bariatric surgery were reviewed. Manometric findings were interpreted according to the Chicago Classification version 4.0. ( IDDF2026-ABS-0460 Table 1)Results The mean age was 42.1 ± 14.2 years; 59% were female. Presenting symptoms included refractory GERD (62.8%), dysphagia (21.2%), and overlapping symptoms (16%). Proton pump inhibitor (PPI) use was reported in 91% of patients. Ineffective esophageal motility (IEM) was the most common disorder (36.9%), followed by normal motility (30.4%), absent contractility (12.8%), and achalasia (11.2%). Obesity was significantly associated with IEM (p = 0.018), bariatric surgery with absent contractility (p = 0.025), and NSAID/steroid use with lower esophageal sphincter dysfunction (p = 0.019). Older age and comorbidities correlated with abnormal motility patterns. Dysphagia showed a strong association with achalasia and IEM (p = 0.001). ( IDDF2026-ABS-0460 Table 2)Conclusions HREM revealed a diverse spectrum of esophageal motility abnormalities in patients with refractory GERD and dysphagia. Significant clinical associations underscore the diagnostic value of HREM in guiding personalized management. These findings contribute essential regional data and support the routine incorporation of manometry in evaluating refractory esophageal symptoms.Abstract IDDF2026-ABS-0460 Table 1Baseline characteristics of the study population (n = 382)VariableValue% / SDMean age (years)42.1±14.2Female sex22659.2%Presenting symptomGERD24062.8%Dysphagia8121.2%Both6116.0%PPI use34891.0%Obesity (BMI ≥30 kg/m2)16844.0%History of bariatric surgery5614.7%Abstract IDDF2026-ABS-0460 Table 2Manometric findings and significant clinical associationsManometric DiagnosisPrevalence (%)Significant Associationp-valueIneffective Esophageal Motility (IEM)36.9Obesity0.018Normal motility30.4——Absent contractility12.8Bariatric surgery0.025Achalasia11.2Dysphagia0.001LES dysfunction8.7NSAID/steroid use0.019