Diagnosis Of Esophagogastric Junction Outflow Obstruction Research Articles

Chicago Classification ver. 4.0: Diagnosis of Achalasia and Esophagogastric Junction Outflow Obstruction

Achalasia is a common esophageal motility disorder characterized by inappropriate relaxation of the lower esophageal sphincter and a loss of normal peristalsis in the esophageal body. The newly suggested Chicago Classification ver. 4.0 recommends conclusive diagnoses of types 1, 2, and 3. A conclusive diagnosis of type 3 achalasia requires no appreciable peristalsis compared to the previously used ver. 3.0. In the case of inconclusive diagnosis of achalasia, additional tests, including timed barium esophagogram (TBE) or functional lumen imaging probe (FLIP), are strongly recommended in ver. 4.0. Esophagogastric junction outflow obstruction (EGJOO) in Chicago Classification ver. 3.0 was defined as an elevated median integrated relaxation pressure (IRP) without evidence of achalasia. On the other hand, the diagnosis of EGJOO in Chicago Classification ver. 4.0 requires elevated IRP in both positions, elevated intrabolus pressure, positive clinical symptoms, and additional positive test by TBE or FLIP. The newly suggested Chicago Classification Classification ver. 4.0 will be helpful in an accurate diagnosis of esophageal motility disorders, including achalasia and EGJOO.

Management of the patient with esophagogastric junction outflow obstruction.

Esophagogastric junction outflow obstruction (EGJOO), defined as elevated integrated residual pressure (IRP) with preservation of esophageal peristalsis, is a common finding on high-resolution esophageal manometry. The recent Chicago classification version 4.0 proposes changes to the criteria for diagnosing EGJOO, making this diagnosis more restrictive to now include elevated IRP in both supine and upright positions (with preservation of esophageal peristalsis), presence of obstructive symptoms, and confirmatory tests for EGJOO, such as timed barium esophagram with barium tablet or functional lumen imaging probe. Once the diagnosis of EGJOO is established, secondary causes need to be ruled out, especially the use of opioid medications. Upper endoscopy is needed for evaluation of EGJOO patients, though cross-sectional imaging is usually not necessary. Many patients improve without intervention; thus, expectant management is recommended for patients with mild or atypical symptoms. There seems to be a limited role for medical treatment. Botox injection into the lower esophageal sphincter is often used to see if the patient improves before committing to more definitive treatments, such as pneumatic dilation, peroral endoscopic myotomy, or Heller myotomy.

S0402 Esophagogastric Junction Outflow Obstruction Is Associated with Impaired Bolus Clearance Compared to Controls

INTRODUCTION: The manometric diagnosis of esophagogastric junction outflow obstruction (EGJOO) can be ambiguous and not indicate true functional obstruction at the lower esophageal sphincter (LES). The aim of our study was to identify the presence of impaired esophageal bolus clearance in patients with EGJOO diagnosed via high-resolution manometry (HRM), and compare to a group controls (patients with normal HRM studies) who presented with dysphagia and similar symptoms. METHODS: 12 months of High-Resolution Impedance Manometry (HRIM) results at a large academic center (Wake Forest Baptist Medical Center) were reviewed. Studies diagnostic for EGJOO based on the Chicago Classification of Esophageal disorders (CCv3) were identified. In the group of patients with EGJOO, those with impaired bolus clearance were identified. Impaired bolus clearance was defined as patients with bolus clearance <80%. As a control, a group of HRIM labeled as normal studies were also identified. Incidence of impaired bolus clearance in this group was also recorded, and later compared to that of the EGJOO group. RESULTS: After reviewing the HRIM results, 121 patients were found to have HRIM consistent with the diagnosis of EGJOO. Another 121 patients were identified as having normal manometries. Using the criteria for impaired bolus clearance (<80%), each group was divided into normal vs impaired clearance. In the EGJOO group, 64 (52.9%) patients were found to have impaired clearance, vs 57 (47.1%) which had normal bolus clearance. This was compared to the normal HRIM group, where 16 (13.2%) patients were found to have impaired bolus clearance, while 105 (86.8%) patients were found to have normal bolus clearance. Using a chi square calculation, results were found to be significant (P < 0.01). Table 1 summarizes demographics. Table 2 summarizes the bolus clearance data. CONCLUSION: Patients with EGJOO diagnosed with HRIM were found to have significantly impaired bolus clearance compared to normal subjects. Abnormal liquid bolus transit on impedance analysis may be a useful measure to define clinically significant outflow obstruction. Further investigation of these patients’ subsequent studies, such as timed barium esophagrams, is warranted to fully assess esophageal emptying.Table 1.: DemographicsTable 2.: Results

S0357 Differences in Clinical Features and Treatment Outcomes Between Patients With Dysphagia-Predominant and Chest Pain-Predominant Esophagogastric Junction Outflow Obstruction (EGJOO)

INTRODUCTION: Esophagogastric junction outflow obstruction (EGJOO) is the condition in which high-resolution manometry reveals elevated integrated relaxation pressure (IRP) with some preserved peristalsis. EGJOO may be an achalasia variant, a manifestation of disorders that infiltrate or push on the esophagus, or a spurious finding. Dysphagia and/or chest pain are the typical symptoms of EGJOO, and it is not clear how presenting symptoms relate to other features of the condition. We aimed to compare clinical features, manometric findings, and treatment outcomes between EGJOO patients with dysphagia-predominant (DP) vs. chest pain-predominant (CPP) symptoms. METHODS: We searched our manometry database for patients with a diagnosis of EGJOO, and excluded those with a structural cause for EGJOO or prior foregut surgery. We collected demographic data and manometric data including median IRP, distal contractile integral (DCI), and distal latency (DL). Symptoms were evaluated using the Eckardt score and Brief Esophageal Dysphagia Questionnaire (BEDQ), both of which are obtained routinely in patients seen in our Center for Esophageal Diseases. Patients were categorized as DP or CPP based on whichever score (dysphagia or chest pain) was higher on the Eckardt questionnaire. Medical records were reviewed for treatments and response. RESULTS: Among 187 patients with EGJOO, 101 were excluded for intrinsic esophageal pathology, extrinsic esophageal compression, or prior foregut surgery. Among 86 patients with idiopathic EGJOO, 31 were DP and 13 were CPP; 23 were excluded because dysphagia and chest pain scores were equal, and 19 had neither dysphagia nor chest pain. DP patients were older (63.5 vs 45.9 years, P < 0.05) and more likely to be female (65% vs 54%, P = 0.5) than CPP patients. The groups were similar in total Eckardt score (4 in both groups) and BEDQ score (12 DP vs 11 CPP, P = 0.8). The median IRP (22.1 DP vs 20.9 CPP mmHg, P = 0.6) and mean DL (6.7 DP vs 6.2 CPP seconds, P = 0.5) were similar, but the mean DCI was higher in the DP group (3256 DP vs 1534 CPP mmHg-cm-sec, P = 0.4). DP patients were more likely to respond to balloon dilation (the most frequently used treatment) than CPP patients (42% vs 0%, P < 0.05), and were more likely to report symptom improvement on follow up than CPP patients (29% vs 3%, P = 0.05). CONCLUSION: Compared to CPP patients, DP patients with EGJOO were older and predominantly female. DP patients had a significantly higher mean DCI and better response to treatment than CPP patients.

S0430 The Effect of Hiatal Hernia on High-Resolution Esophageal Pressure Topography Measures in Patients With Esophagogastric Junction Outflow Obstruction

INTRODUCTION: High resolution esophageal pressure topography (HREPT) is used to diagnose esophagogastric junction outflow obstruction (EGJOO), a motility disorder with impairment of lower esophageal sphincter (LES) opening defined by an elevated integrated relaxation pressure (IRP) with preserved peristalsis. Many of these patients also have concomitant hiatal hernia (HH) that may independently affect LES relaxation pressures. This study aimed to evaluate the effect of HH on the diagnosis of EGJOO by comparing manometric outcomes at a single US tertiary care academic medical center. METHODS: This retrospective, observational, cohort study identified patients who had undergone HREPT between January 2017 and March 2018. Patients diagnosed with EGJOO were eligible for inclusion and further evaluated for HH via manometry. Those with obstructive dysphagia, pseudo-achalasia, or other neuromuscular disorders affecting esophageal motility were excluded. LES integrated relaxation pressures (IRP), basal pressure (BP), distal contractile integral (DCI), intrabolus pressure (IBP), and incomplete bolus transit (IBT) were collected. Student’s t- tests were used to compare groups and Chi-square analysis was used for independent variables. RESULTS: A total of 90 total patients were identified (n = 54 EGJOO without HH, n = 36 EGJOO with HH). In general, baseline characteristics were similar between groups with no significant differences in gender or age. Comparing patients with only EGJOO to those with both EGJOO and HH, there was a statistically significant difference in basal LES pressures (50.9 mmHg vs. 42.2 mmHg, P = 0.029) but no difference in IRP (22.5 mmHg vs. 20.3 mmHg, P = 0.173) between groups. Additionally there were no intergroup differences in DCI, IBP, or IBT. CONCLUSION: EGJOO is a heterogenous manometric diagnosis with many patients also experiencing anatomic defects including HH. Our study reports among the largest real-world comparisons of these groups. The observed higher basal LES pressures in patients with only EGJOO compared to those with both EGJOO and HH suggests a possible anatomic effect on LES pressures. However, this difference does not have affect other manometric measures including IRP which is currently the principal measure of outflow obstruction. Further work exploring the anatomic and physiologic components of LES pressure is needed to understand the development of EGJOO and guide therapeutic interventions.Table 1.: Outcomes

S0412 A Large Retrospective Review of Medications as Risk Factors for Esophagogastric Junction Outflow Obstruction

INTRODUCTION: The etiologies and pathogenesis of esophagogastric junction outflow obstruction (EGJOO) remain unclear in the literature, contributing to a lack of standard guidelines for management of this disorder. We performed one of the largest review studies to evaluate the potential effect of medications as causes of EGJOO. METHODS: We conducted a retrospective chart review of 100 patients diagnosed with EGJOO based on the Chicago Classification and 100 control patients with dysphagia and normal esophageal manometry findings from 2010 to 2019. Data including age, sex, body mass index, past surgeries, and medications was collected. Statistical analysis was performed, and Spearman correlation co-efficient and P-value were used to determine statistical significance. RESULTS: Of the 100 patients diagnosed with EGJOO, 65 were female and 35 were male. There were significant positive relationships between benzodiazepines and integrated relaxation pressure (IRP) (rs = 0.27588, P = 0.0055), benzodiazepines and lower esophageal sphincter mean resting pressure (LESMRP) (rs = 0.21515, P = 0.0363), antidepressants and LESMRP (rs = 0.20585, P = 0.0454), narcotics and LESMRP (rs = 0.20936, P = 0.0417), and narcotics to distal contractile integral (DCI) (rs = 0.21186, P = 0.0343). Anticonvulsants and number of swallows with complete bolus transfer (CBT) had a negative correlation (rs = -0.26578, P = 0.0310), while anticonvulsants and DCI had a positive correlation (rs = 0.19693, P = 0.0496). The differences in mean IRP, LESMRP, DCI, and CBT between the control group and the EGJOO patients with and without use of benzodiazepines, antidepressants, narcotics, and anticonvulsants were significant (P < 0.02).The mean IRP in EGJOO patients with use of benzodiazepines, narcotics, antidepressants or anticonvulsants was 24.05, 22.17, 21.32, and 25.02, respectively. The mean IRP in EGJOO patients without use of benzodiazepines, narcotics, antidepressants or anticonvulsants was 20.38, 20.72, 21.01, and 20.86, respectively. CONCLUSION: Our study demonstrates significant correlations between particular medication classes, including benzodiazepines, narcotics, antidepressants and anticonvulsants, and esophageal function metrics in patients with EGJOO. There were also higher mean IRPs in the EGJOO patients with use of the listed medications than in EGJOO patients without their use. While our study demonstrates a strong association between the diagnosis of EGJOO and these medications, further studies should be performed to confirm causality.Table 1Table 2Table 3

Elevated Intrabolus Pressure Predicts Abnormal Timed Barium Esophagram in Esophagogastric Junction Outflow Obstruction.

Background/AimsTimed barium esophagram (TBE) is used the classification of esophageal motility disorders and assessing esophageal function. Currently, there are no published studies examining the relationship between high-resolution manometry and TBE in patients with esophagogastric junction outflow obstruction (EGJOO). This study seeks to evaluate this relationship and identify manometric variables that may indicate further evaluation using TBE.MethodsRetrospective review of medical records identified patients with a diagnosis of EGJOO per the Chicago classification version 3.0. TBE was performed using standard protocol. Patients were divided into 2 groups based on complete emptying or persistence of standing barium column at 5 minutes.ResultsEleven patients were identified with EGJOO who underwent both high-resolution manometry and TBE within 3 months. Five patients had no standing barium column at 5 minutes, while 6 patients had a persistent barium column. Mean age of each group was 54.0 years and 57.8 years, respectively. Patients with abnormal TBE were found to have significantly elevated intrabolus pressure (IBP) compared with patients who had a normal TBE.ConclusionsIn our study, we found significant differences in IBP between these patient groups. These findings suggest that patients with EGJOO and elevated IBP may prompt further clinical evaluation with TBE in order to clarify clinical diagnosis and guide therapeutic intervention.

2853 Esophagogastric Junction Outflow Obstruction Association With Mood Disorders: A Retrospective Study

INTRODUCTION: Esophagogastric Junction Outflow Obstruction (EGJOO) is a manometry abnormality at the level of the lower esophageal sphincter (LES) which is associated with elevated Integrated Relaxation Pressure (IRP). This is similar to achalasia; however, EGJOO has retained peristalsis and it is largely distinguished by poor relaxation at the LES. This diagnosis is becoming increasingly prevalent as use of esophageal High-Resolution Manometry (HRM) becomes more widespread. As EGJOO’s prevalence grows, it is important to augment our knowledge. Our objective from this analysis was to find comorbid associations which may give aide in identifying at risk patients and aide with treatment modalities. Depression and anxiety were focused upon in this study. METHODS: We performed a retrospective study of patients who were diagnosed with EGJOO by HRM from 2015 to 2018 at a single tertiary care center. Patients were classified as having EGJOO by the Chicago Classification (version 3). Chart review was performed to assess for comorbid conditions. Statistical significance was performed with a Chi Square Test of Independence. RESULTS: We identified 93 patients with EGJOO and a reliable past medical history documented in their chart. Upon analysis of our patient population, it was found that previously diagnosed depression (13.98%) and anxiety (12.9%) were common comorbidities. This was significantly higher than the prevalence of depression (6.7%, P = 0.0049) and anxiety (3.1%, P = 0.0001) in the United States. CONCLUSION: Depression and anxiety appear to show increased prevalence within patients diagnosed with EGJOO. EGJOO is generally known to be associated with structural obstructions, but importantly also seen in functional obstruction. This relation to mood disorders could suggest a psychosomatic component within certain subgroups. Whether EGJOO is an incidental finding or a true contributor to symptoms is not entirely clear. These correlations could trigger practitioners to think further about a diagnosis of EGJOO in their patients with anxiety or depression if they are displaying symptoms of dysphagia with associated manometric findings. Current treatment for EGJOO is not clearly established and treatment response is highly variable. Further studies looking into the relation of mood disorders with functional obstruction could lead to potential novel therapies.

Esophagogastric Junction Outflow Obstruction: Features, Etiology, and Outcome in a Single-Center Experience - Time for Standardization?

Introduction: Esophagogastric junction outflow obstruction (EGJOO) is defined by the Chicago classification as an elevated integrated relaxation pressure of >15 mm of Hg with preserved peristalsis. This esophageal motility disorder is increasingly recognized and while suggesting obstructive physiology, it does not describe a specific diagnosis. Variant/incompletely expressed achalasia, mechanical obstruction and artifact have all been described as causes. Methods: Aim: To describe the clinical characteristics and outcomes in a cohort of patients with EGJOO. Study design: Consecutive adult patients undergoing high resolution manometry (HRM) between 1/2/17 and 12/31/17 with a diagnosis of EGJOO were identified. Records were reviewed to determine: 1. causes of EGJOO 2.treatment and outcome. Results: Of 839 HRM studies performed, 68 (8.1%) met criteria for EGJOO. Mean age of this patient cohort was 57.6 years. 38 (55.9%) had dysphagia, 12 (17.6%) regurgitation, 6 (8%) heartburn and remainder with miscellaneous symptoms (cough, chest pain). 9 patients had prior gastric/esophageal surgery. 41 patients were evaluated with barium esophagram (BS) - of these 68.3% were abnormal. 36 patients were evaluated by upper endoscopy - 61.1 % showed abnormalities including hiatal hernia, esophagitis, or evidence of prior surgery. Esophageal biopsies in 21 patients excluded eosinophilic esophagitis. 11 had surgical interventions (Refer to figure 1). All had clinical improvement on follow up. Conclusion: EGJOO is frequently found (8%) and comprises a heterogeneous group with obstructive physiology presenting most commonly with dysphagia (56%). Benign anatomic abnormalities such as hiatal hernia are the most common associated anatomic findings as detected by BS (68.3%) or endoscopy (63.2%). Surgical treatment of hiatal hernia associated EGJOO does not subsequently result in dysphagia. Treatment of EGJOO as presumed early or variant expression achalasia is uncommon (5.8%); treatment results in improved symptoms. 402 Figure 1. Evaluation and management of a cohort of patients diagnosed with EGJOO in 2017.

Achalasia Type 3 Is More Commonly Found With Opioid Use Compared to Esophagogastric Junction Outflow Obstruction: A Single Center Experience of 75 Patients

Introduction: Opioid misuse is a US health crisis with inadvertent prescription use and unwarranted diagnostic testing stemming from adverse effects. Opioids are shown to be associated with esophageal dysmotility including esophagogastric junction outflow obstruction (EGJOO) and achalasia type III. However, it is not clear what HRM pattern is more frequent manifestation of opioid use. We retrospectively analyzed esophageal high resolution manometry (HRM) studies from year 2013-2016 from a single academic center for effect of opioid use on patterns of esophageal dysmotility to determine whether EGJOO vs achalasia type III diagnosis was more common manifestation. Methods: HRM records (years 2013-2016) from university hospital were analyzed and studies with diagnosis of EGJOO and achalasia type III were extracted. Following variables were gathered: indication, gender, constipation, distal latency period (DLP: >4.5 sec or<4.5 sec), opioid use 1 month, 2 weeks and 1 week before procedure and day of procedure and final HRM diagnosis. Opioid use was evaluated for likelihood of pattern of HRM diagnosis (achalasia type III vs EGJOO) using Chi-square and logistic regression analysis. Measure of effect was odds ratio(OR) with 95% confidence interval(CI) and P-value<0.05 was considered for statistical significance. Statistical software Stata v14 (Statacorp, 2015) was used for analysis. Results: Of 75 patients, 61 were females and primary indication was dysphagia (n=53) followed by GERD (n=12). Achalasia type III was likely to be diagnosed when opioids were used in last 1 week compared to EGJOO with an OR of 7.82 (95%CI 2.24-28.3, P<0.01). Opioid use in last 1 week was significantly associated with DLP<4.5 with OR of 7.7 (95% CI 2.44-24.01, P<0.01). Dysphagia was most common indication for HRM with opioid use compared to GERD or other symptoms (OR 2.15, 95%CI 0.39-21.9, P=0.49). On logistic regression, EGJOO (OR 0.17, p 0.02) and DLP >4.5 sec (OR 0.13, P<0.01) were less likely with opioid use in last one week while gender, smoking and constipation did not have any significant association. Reciprocal results were found for opioid use in last 1 month, last 2 weeks and on day of HRM. Limitations: single center data and retrospective analysis in lack of control arm. Conclusion: Achalasia type III was much commonly found compared to EGJOO if opioids were used in last one week of esophageal manometry testing.

Esophagogastric junction outflow obstruction is often associated with coexistent abnormal esophageal body motility and abnormal bolus transit.

Currently, the diagnosis of esophageal motility disorders is in part based upon a hierarchical algorithm in which abnormalities of the esophagogastric junction (EGJ) is prioritized. An important metric in evaluating the EGJ is the integrated relaxation pressure (IRP). Patients who do not have achalasia but are found to have an elevated IRP are diagnosed with EGJ outflow obstruction. It has been our observation that a subset of these patients also has a second named motility disorder and may also have abnormal bolus transit. The aim of this study is to determine the frequency of abnormal body motility and or abnormal bolus movement in patients with EGJ outflow obstruction. Further, in an effort to evaluate the potential clinical value in measuring bolus transit as a complement to esophageal manometry, specifically in patients with EGJ outflow obstruction, we analyzed the presenting symptoms of these patients. A total of 807 patients with a mean age of 53 years completed esophageal function testing with impedance monitoring and high-resolution manometry between January 2012 and October 2016. There were 74 patients with achalasia who were excluded from the study. Of the remaining 733 patients, 138 (19%) had an elevated IRP and were given a diagnosis of EGJ outflow obstruction. Among these patients, 56 (40%) were diagnosed with an abnormal motility pattern to liquids (ineffective esophageal motility =28, distal esophageal spasm =19, Jackhammer =6), of which 44 (76%) had abnormal bolus transit to liquids, viscous, or both. In contrast, there were 82 patients with EGJ outflow obstruction and normal esophageal motility, of which 33 (40%) had abnormal bolus transit. Patients with preserved esophageal motility and EGJ outflow obstruction were then evaluated. Of the 733 patients, 299 (40%) had intact esophageal motility. Of the 299 patients with normal esophageal motility, 56 patients had an elevated IRP, of which 16 (28%) had abnormal bolus transit. There were 243 (33%) patients with intact esophageal motility and normal IRP. Of these, 56 (23%) patients had abnormal bolus transit. Among patients with abnormal bolus transit, the two most commonly presenting symptoms were dysphagia and heartburn. A substantial percentage of patients with EGJ outflow obstruction have abnormal esophageal body motility and or abnormal bolus transit. The clinical implications of EGJ outflow obstruction need to be further elucidated as current criteria do not allow for the description of other abnormalities in esophageal motility and bolus transit among patients who are given the diagnosis of EGJ outflow obstruction.

Esophagogastric junction outflow obstruction-related functional chest pain treated using robotic-assisted thoracoscopic esophageal myotomy

Elevated relaxation pressure in combination with intact or weak peristalsis characterizes esophagogastric junction (EGJ) outflow obstruction. Symptoms of EGJ outflow obstruction include dysphagia and atypical chest pain. EGJ outflow obstruction can be diagnosed using high-resolution manometry (HRM), but there is a lack of consensus regarding treatment. We present a case report of a 43-year-old man with a history of headache and mitral valve disorder who suffered from intermittent atypical chest pain for 20 years. A diagnosis of EGJ outflow obstruction was made using esophageal HRM. Due to medication intolerance, robotic-assisted esophageal myotomy and Belsey-Mark IV fundoplication were performed. The symptoms went into complete remission and no motility disorders were detected on postoperative HRM. HRM is a useful diagnostic examination for EGJ outflow obstruction. The robotic systems-assisted long segment myotomy may potentially play an important role in the treatment of EGJ outflow obstruction-related functional chest pain.

Esophagogastric Junction Outflow Obstruction: A Heterogeneous Entity of Unclear Clinical Significance

Introduction: Esophagogastric junction outflow obstruction (EGJOO), characterized by preserved peristalsis in conjunction with an elevated integrated relaxation pressure, is a topographic pattern that has recently increased in prevalence.EGJOO can result from specific anatomic variants or it may represent achalasia in evolution, but there is limited information on the clinical significance of this diagnosis. Our aim was to describe the characteristics and outcomes in our cohort of patients with EGJOO. Methods: Consecutive adult patients who had undergone high resolution esophageal manometry (HRM) between February 2013 and November 2015 with a diagnosis of EGJOO were identified. The electronic medical records were reviewed to determine: 1] secondary causes of EGJOO; 2] treatment; and 3] natural history. Improvement in symptoms noted during follow-up evaluation was considered favorable follow-up. Worsening of symptoms or no change in symptoms was considered unfavorable follow-up. Results: Of 874 HRMs performed during this time period, 83 met the criteria for EGJOO. Of these patients, 10 had secondary causes: paraesophageal hernia(4), Nissen fundoplication (2), esophageal strictures(2), prior lap band(1), and diverticulum(1). Two patients developed type II achalasia. The remaining 71 patients were categorized as primary EGJOO; presenting symptoms can be seen in Figure 1. Two of these patients had pre-operative HRMs and were asymptomatic; they were excluded from the follow-up analysis. Of the 69 primary EGJOO patients, 19 had favorable follow-up, 19 had unfavorable follow-up, and 31 were lost to follow-up. Patient characteristics are seen in Table 1. Of those with a favorable response, 6 patients underwent treatment (Figure 2). Of the 19 patients with an unfavorable response, 7 patients underwent treatment (Figure 2). The overall median follow-up time was 5 months.Figure 1Figure 2Figure 3Conclusion: This is the largest ever reported case series of EGJOO patients and their treatment response. Symptoms in patients with EGJOO do not always require treatment and treatment response is variable. The evolution of EGJOO to achalasia is rare. We believe that the challenge in managing these patients lies in distinguishing which patients will need intervention. Further studies are needed for consideration of subgrouping this syndrome or modify the categorization into clinically relevant entities.

The Natural History of Esophagogastric Junction Outflow Obstruction and Treatment Outcomes

Purpose: Esophagogastric junction outflow obstruction (EGJOO) is a diagnosis made by high resolution manometry (HRM) that represents a heterogeneous group of disorders that cause dysphagia. Potential causes of EGJOO include evolving achalasia, strictures, extrinsic compression by tumors or the aorta, and functional obstruction where no cause is found. The focus after encountering EGJOO should be in determining the cause of the obstruction, then treating the cause. Little is known about the natural history of EGJOO. Methods: We conducted a retrospective chart review and cross sectional phone survey of patients (25-92 years old) with a diagnosis of EGJOO by HRM between June 2010 to June 2012. EGJOO was defined as a minimum integrated relaxation pressure (IRP) of 15 mmHg as well as at least one normal or weak swallow on HRM. Exclusion criteria included diagnosis other than EGJOO on HRM and a history of prior surgical procedure causing the EGJOO. Chart review measures included patient demographic and clinical characteristics (documented symptoms, prior endoscopies, endoscopic ultrasound, and treatments). Patients were contacted via telephone between November 2012 and April 2013 and asked to rate specific symptoms on a severity scale both before and after diagnosis with manometry, and whether improvement in symptoms had been achieved. Results: Ninety-four patients with EGJOO based on HRM data were initially included in the analysis. 16 patients that had a surgical cause of the EGJOO were excluded, and 21 patients were unable to complete the phone survey for various reasons. Dysphagia was the predominant symptom that initiated HRM testing (46%), followed by chest pain (32%), heartburn (20%), or nausea and vomiting (19%). Of the patients contacted by phone (N=57), 61.4% reported overall improvement in their symptoms; however, many of these patients did not receive treatment for EGJOO (54.4%). There were proportionally more patients reporting improvement in symptoms who received treatment (69.2%) compared to those who did not (54.8%), but this did not reach statistical significance (P=0.115). Conclusion: Dysphagia is the most common presenting symptom in patients with a diagnosis of EGJOO, although other atypical symptoms such as heartburn, regurgitation, and nausea and vomiting may be present, likely due to the diversity of causes. The majority of patients reported improvement in symptoms over time. Future research should involve prospective, well designed studies with a greater number of patients to evaluate the effect of different treatment modalities on patient outcomes.Table: Table. Demographics, swallow characteristics, and treatmentsTable: Table. Improvement by treatment status