Timed barium swallow: Esophageal stasis varies markedly across subtypes of esophagogastric junction obstruction.

Abstract

Timed barium swallow (TBS) is a recommended ancillary investigation in evaluation of esophagogastric junction (EGJ) obstruction, yet there are little data comparing esophageal stasis across subtypes. A retrospective cohort study was performed. All type III achalasia diagnosed between November 2016 and November 2020 were included, along with matched numbers of consecutive types I and II and conclusive EGJOO cases with concurrent TBS evaluation. Co-primary outcomes were TBS retention at 1 and 5min. Secondary outcomes were symptoms and manometric metrics of EGJ function and peristaltic integrity. One hundred patients were included (25 each of types I-III and conclusive EGJOO). TBS retention measured by height and width at 1 and 5min differed significantly across the four subtypes (p<0.0001 all comparisons), with esophageal stasis tending to be significantly greater for types I and II achalasia (88% and 84% with >5cm column at 5min) compared to type III and EGJOO (24% and 8% with >5cm column; p<0.0001). Eckardt symptom severity was similar across subtypes (p=0.30). Magnitude of esophageal stasis and integrated relaxation pressure (IRP) were uncorrelated (R=0.21). In EGJOO, the number of swallows with intact peristalsis inversely correlated with barium column height (R=-0.49) and those with disordered peristalsis were more likely to have any residual barium at 5min compared to those without disordered peristalsis (43% vs. 0%; p=0.02). Timed barium swallow findings differed markedly with significantly less esophageal stasis in type III achalasia and EGJOO, despite similar symptom severity and no correlation between degree of emptying and IRP. Preservation of peristalsis may underlie this finding in EGJOO.