401 EGJ Outflow Obstruction in Setting of Opiate Use Is Associated With Esophageal Spasticity and Hypercontractility

Abstract

INTRODUCTION: Esophagogastric junction outflow obstruction (EGJOO) is an increasingly diagnosed motility disorder defined by an elevated integrated relaxation pressure without meeting criteria for achalasia subtypes per the Chicago Classification v3.0. Various mechanisms may contribute to an EGJOO motility pattern such as effect from opiates, hiatal hernia, or normal physiology. We hypothesize that esophageal motility patterns differ across mechanisms of EGJOO. The aim of this study was to compare physiologic factors across sub-groups of patients with EGJOO. METHODS: This was a retrospective study of adult patients who underwent high-resolution manometry at a single academic center over 59 months (1/2014-11/2018). Demographics, medical/surgical history, medications, and manometry results were collected from the electronic health record. Patients diagnosed with EGJOO and without prior foregut surgery were included in the analysis. Patients were further classified according to whether they had a hiatal hernia and/or opiate use. Fisher’s exact test and a Wald test from linear regression was used to compare EGJOO sub-groups for categorical and continuous variables, respectively. RESULTS: Of 912 patients who underwent manometry over 59 months, 114 (13%) had EGJOO; 26 were excluded due to history of foregut disease. Therefore, 88 patients with EGJOO are included in this analysis: 29 (33%) male, mean age 59.1 years (SD 13.6), mean body mass index 26.4 kg/m2 (SD 5.7) [Table 1]. The 88 patients were sub-grouped as: EGJOO + Hernia 25 (28%), EGJOO + Opiate 18 (21%), and EGJOO without hernia or opiate use 45 (51%). Patients with EGJOO + Opiate had a significantly higher distal contractile integral than EGJOO + Hernia (4132 (SD 2079) vs 2147 (SD 2166) mmHg-s-cm; P = 0.03) and a greater proportion of hypercontractile swallows than those with EGJOO + Hernia or EGJOO without hernia or opiate use (P = 0.06). Additionally, EGJOO + Opiate use had a shorter mean distal latency than those with EGJOO + Hernia or EGJOO without hernia or opiate use (P = 0.17) [Table 2]. CONCLUSION: In this study of 88 patients with EGJOO, patients with EGJOO and opiate use exhibited increased esophageal contractility and spasticity compared to those without opiate use. These results support the notion that mechanisms of EGJOO vary, and that spasticity may explain EGJOO in patients using opiates. Further research should assess the efficacy of treatments targeting esophageal spasticity in patients with EGJOO that are unable to stop opiates.