Clinical Characteristics and Response to Therapy in Patients With Esophagogastric Junction Outflow Obstruction (EGJOO)

Abstract

Introduction: EGJOO is a new manometric diagnosis in Chicago Classification (CC) v3.0. Data regarding patient characteristics, clinical features, and response to treatment are limited. Our aim is to describe these features in patients meeting EGJOO criteria. Methods: HRM database was used to identify patients that met CCv3.0 EJGOO criteria (median 4 sec IRP > 15mmHg) on HRM. Esophageal pressure topography plots were prospectively analyzed to exclude patients with achalasia or otherwise not meeting CC3.0 criteria. Consecutive adult patients between 1/2012 and 12/2014 were included. Solid state catheter with 36 pressure sensors spaced 1-m apart with 10 single 5ml swallows was used to perform HRM, analyzed with Manoview software (Covidien, Duluth, GA). Mean lower esophageal resting pressure (LESP) and distal contractile interval (DCI) was estimated, Median 4-sec integrated relaxation pressure (IRP) and intrabolus pressure (IBP) were also calculated. Clinical variables were collected from the electronic medical records. Response to treatment was defined as either partial or complete resolution of primary symptom on at least 6 month followup. Statistical analysis used 2 tail t-test for continous variables. Results: 79 met inclusion criteria with mean (SD) age 58 (16) years and 68% female. Most common primary symptom was dysphagia 47% (37/79), heartburn 23% (17/75), chest pain 18% (14/79) and others 14% (11/79). EGD was completed in 90% (71) with findings of PUD in 25% hiatal hernia 25%, and rings/strictures in 13%. Common associated conditions were previous fundoplication 17%, narcotic use 14% and autoimmune disorders 11%. Mean LESP was 41. 38% (30/79) had LESP >43mmHg. Mean DCI was 2756 mmHg-cm-s. Average Median-IRP was 25. Mean IBP was 19. 63% (50/79) patients had IBP > 17mmHg. 9% (7/79) met HRM criteria for jackhammer esophagus. Patients with EGJOO and fundoplication were compared with EGJOO without fundoplication. HRM characteristics were significantly different between them (Table 2). Nonpharmacological interventions were noted in 33 patients. 45% (15/33) had Botox injected in esophagus, 24% (8/33) had dilation. 27% (9/33) underwent fundoplication. Follow up was found for 64% (21/33) of these patient. 90% had a favorable response.Table 2: HREM characteristics of patients with EGJOO and fundoplication compared to EGJOO without fundoplicationConclusion: EGJOO is not an uncommon HRM diagnosis and should be differentiated from achalasia. Common associations include GERD, narcotics and autoimmune disorders. Various interventions may improve symptoms but prospective outcome studies are needed.Table 1: HREM characteristics of patients meeting Chicago Classification v 3.0 criteria for esophagogastric junction outlet obstructionFigure 1