Elevated Integrated Relaxation Pressure Research Articles

Impaired esophagogastric junction relaxation and lung transplantation outcomes.

The implications of impaired esophagogastric junction relaxation (i.e. esophagogastric junction outflow obstruction and achalasia) in lung transplants recipients (LTRs) are unclear. Thus, we examined the prevalence and clinical outcomes of LTRs with an abnormally elevated integrated relaxation pressure (IRP) on high-resolution manometry before lung transplantation (LTx). After IRB approval, we reviewed data on LTRs who underwent LTx between January 2019 and August 2022 with a preoperative median IRP >15mmHg. Differences in overall survival and chronic lung allograft dysfunction (CLAD)-free survival between LTRs with a normalized median IRP after LTx (N-IRP) and those with persistently high IRP (PH-IRP) were assessed using Kaplan-Meier curves and the log-rank test. During the study period, 352 LTx procedures were performed; 44 (12.5%) LTRs had an elevated IRP before LTx, and 37 (84.1%) completed a postoperative manometry assessment (24 [70.6%] males; mean age, 65.2 ± 9.1years). The median IRP before and after LTx was 18.7 ± 3.8mmHg and 12 ± 5.6mmHg, respectively (P < 0.001); the median IRP normalized after LTx in 24 (64.9%) patients. Two-year overall survival trended lower in the N-IRP group than the PH-IRP group (77.2% vs. 92.3%, P =0.086), but CLAD-free survival (P =0.592) and rates of primary graft dysfunction (P =0.502) and acute cellular rejection (P =0.408) were similar. An abnormally elevated IRP was common in LTx candidates; however, it normalized in roughly two-thirds of patients after LTx. Two-year survival trended higher in the PH-IRP group, despite similar rates of primary graft dysfunction and acute cellular rejection as well as similar CLAD-free survival between the groups.

Natural history of symptoms and prognostic information of the rapid drink challenge and solid bolus swallows in esophagogastric junction outflow obstruction defined by manometry.

Esophagogastric junction outflow obstruction (EGJOO) is a condition characterized by poor relaxation of the lower esophageal sphincter (LES), which can manifest as dysphagia and chest pain. The best treatment of EGJOO is unknown as some patients improve without any specific therapy, whereas some patients undergo invasive therapy. Currently, prognostic factors are lacking. We aimed to assess the long-term prognosis and predictors of dysphagia and chest pain by the rapid drink challenge and solid bolus swallows in EGJOO. We retrospectively assessed high-resolution esophageal manometries (HRM) performed at our center between 2015 and 2018. The patients completed a dysphagia and chest pain questionnaire a median of 34 months after the HRM/baseline assessment, including the Impaction dysphagia questionnaire-10 (IDQ-10) complemented with questions regarding chest pain and esophageal treatments. Symptoms were compared with HRM findings. In all, 980 HRMs were analyzed and 66 (6.5%) were identified as having HRM findings compatible with EGJOO. Of these, 27 patients with EGJOO (41%) completed the follow-up questionnaires and had no exclusion criteria, and 70% of these patients had dysphagia and 44% chest pain at least once a week. Dysphagia at follow-up was more common in patients with elevated integrated relaxation pressure (IRP) on all three HRM metrics (water swallows, solid bolus swallows, and rapid drink challenge) (p = 0.03, odds ratio: 8.4 (95% CI: 1.2-56.0)), but this was not seen for chest pain (p = 0.45). Abnormal motility patterns on rapid drink challenge or solid bolus swallows were not associated with dysphagia or chest pain at follow-up. Having a high IRP on three HRM metrics-water swallows, solid bolus swallows, and rapid drink challenge-is associated with a worse prognosis in patients with EGJOO and could potentially be used to select candidates suitable for invasive procedures.

The integrated relaxation pressure may not be an appropriate gold standard for deglutitive relaxation due to reliance on a single intragastric reference sensor.

Integrated relaxation pressure (IRP) calculation depends on the selection of a single gastric reference sensor. Variable gastric pressure readings due to sensor selection can lead to diagnostic uncertainty. This study aimed to examine the effect of gastric reference sensor selection on IRP measurement and diagnosis. We identified high-resolution manometry (HRM) conducted between January and November 2017 with at least six intragastric reference sensors. IRP measurements and Chicago Classification 3.0 (CCv3) diagnoses were obtained for each of six gastric reference sensors. Studies were categorized as "stable" (no change in diagnosis) or "variable" (change in diagnosis with gastric reference selection). Variable diagnoses were further divided into "variable normal/dysmotility" (≥1 normal IRP measurement and ≥1 CCv3 diagnosis), or "variable dysmotility" (≥1 CCv3 diagnosis, only elevated IRP measurements). Bland-Altman plots were used to compare IRP measurements within HRM studies. The analysis included 100 HRM studies, among which 18% had variable normal/dysmotility, and 10% had variable dysmotility. The average IRP difference between reference sensors was 6.7 mmHg for variable normal/dysmotility and 5.9 mmHg for variable dysmotility. The average difference between the proximal-most and distal-most sensors was -1.52 mmHg (lower limit of agreement -10.03 mmHg, upper limit of agreement 7.00 mmHg). IRP values can vary greatly depending on the reference sensor used, leading to inconsistent diagnoses in 28% of HRM studies. Choosing the correct gastric reference sensor is crucial for accurate test results and avoiding misdiagnosis. Standardization of reference sensor selection or supportive testing for uncertain results should be considered.

Changes in the esophagogastric junction outflow obstruction manometric feature based on the Chicago Classification updates.

BACKGROUNDThe critical diagnostic criteria for esophagogastric junction outflow obstruction (EGJOO) were published in the latest Chicago Classification version 4.0 (CCv4.0). In addition to the previous criterion [elevated integrated relaxation pressure (IRP) in supine position], manometric diagnosis of EGJOO requires meeting the criteria of elevated median-IRP during upright wet swallows and elevated intrabolus pressure. However, with the diagnostic criteria modification, the change in manometric features of EGJOO remained unclear.AIMTo evaluate the esophageal motility characteristics of patients with EGJOO and select valuable parameters for confirming the diagnosis of EGJOO.METHODSWe performed a retrospective analysis of 370 patients who underwent high-resolution manometry with 5 mL water swallows × 10 in supine, × 5 in upright position and the rapid drink challenge (RDC) with 200 mL water from November 2016 to November 2021 at Peking University First Hospital. Fifty-one patients with elevated integrated supine IRP and evidence of peristalsis were enrolled, with 24 patients meeting the updated manometric EGJOO diagnosis (CCv4.0) as the EGJOO group and 27 patients not meeting the updated EGJOO criteria as the isolated supine IRP elevated group (either normal median IRP in upright position or less than 20% of supine swallows with elevated IBP). Forty-six patients with normal manometric features were collected as the normal high-resolution manometry (HRM) group. Upper esophageal sphincter (UES), esophageal body, and lower esophageal sphincter (LES) parameters were compared between groups.RESULTSCompared with the normal HRM group, patients with EGJOO (CCv4.0) had significantly lower proximal esophageal contractile integral (PECI) and proximal esophageal length (PEL), with elevated IRP on RDC (P < 0.05 for each comparison), while isolated supine IRP elevated patients had no such feature. Patients with EGJOO also had more significant abnormalities in the esophagogastric junction than isolated supine IRP elevated patients, including higher LES resting pressure (LESP), intrabolus pressure, median supine IRP, median upright IRP, and IRP on RDC (P < 0.05 for each comparison). Patients with dysphagia had significantly lower PECI and PEL than patients without dysphagia among the fifty-one with elevated supine IRP. Further multivariate analysis revealed that PEL, LESP, and IRP on RDC are factors associated with EGJOO. The receiver-operating characteristic analysis showed UES nadir pressure, PEL, PECI, LESP, and IRP on RDC are parameters supportive for confirming the diagnosis of EGJOO.CONCLUSIONBased on CCv4.0, patients with EGJOO have more severe esophagogastric junction dysfunction and are implicated in the proximal esophagus. Additionally, several parameters are supportive for confirming the diagnosis of EGJOO.

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.

Preoperative high-resolution esophageal manometry and postoperative symptoms in patients undergoing bariatric surgery: a retrospective cohort study.

The increasing incidence of obesity has led to a rise in bariatric surgeries. Obesity can be associated with various gastrointestinal symptoms as well as abnormal findings on high-resolution esophageal manometry (HRM). Bariatric procedures have variable effects on esophageal function and may contribute to postoperative symptoms. Preoperative HRM is not performed routinely on patients undergoing bariatric surgery but may identify patients likely to experience postoperative esophageal symptoms via delineation of structural or functional abnormalities. To evaluate whether prebariatric surgery HRM could predict persistent or de novo postoperative esophageal symptoms. Academic tertiary care hospital, United States. Retrospective data were collected for 20 patients undergoing HRM and 100 controls 18 years and older from May 2012 to May 2015. Propensity score matching was performed to adjust for baseline differences between the 2 groups. Preoperative and postoperative esophageal symptoms (reflux, dysphagia, nausea/vomiting, bloating, fullness, early satiety, pain, and intolerance) were compared between HRM and control patients, and associations among HRM findings, Chicago Classification, and symptoms were analyzed. All included patients had follow-up beyond 3 months postoperatively. Data were analyzed with 2-tailed Fisher's exact test, Wilcoxon rank-sum test, and odds ratio. Compared to controls, patients undergoing preoperative HRM had a higher rate of postoperative chronic intolerance (25% versus 8%, P = .041). This difference was not observed in propensity score matching analysis. Identification of elevated integrated relaxation pressure and esophagogastric junction outflow obstruction predicted chronic intolerance (odds ratio = 21.0; 95% confidence interval: 1.40-314; P = .027 for each). Preoperative HRM abnormalities were associated with postoperative symptoms in patients undergoing bariatric surgery. HRM can identify patients who are more likely to experience postoperative esophageal symptoms and may aid in discussion of suitability for surgery and selection of bariatric intervention.

S367 Adherence to Major Society Recommendations in Patients Diagnosed with Esophagogastric Outflow Obstruction in a Large Tertiary Academic Center: A Retrospective Analysis

Introduction: Patients diagnosed with esophagogastric junction outflow obstruction (EGJOO) with high resolution manometry (HRM) are recommended to be evaluated with additional imaging modalities such as barium swallow (BaSw), CT, or endoscopic ultrasound (EUS) to exclude secondary etiologies of the elevated integrated relaxation pressure central to the diagnosis of EGJOO. We retrospectively evaluated adherence and yield with these recommendations at a large tertiary referral center. Methods: Patients undergoing HRM and diagnosed with EGJOO from January 2016 to December 2019 were included in this analysis. Demographics and HRM parameters were collected and, using a central electronic medical record (EMR), patient records were examined over 1 year from the time of diagnosis of EGJOO to determine if subsequent imaging modalities were obtained and if so, whether an explanation for EGJOO was identified. Results: A total of 117/1800 (6.5%) patients were diagnosed with EGJOO. Ninety patients (76.9%) were female, 9 (7.7%) had undergone antireflux surgery prior to HRM, and 2 (1.7%) had undergone bariatric surgery prior to HRM. Narcotic use was present in 7 (6.0%) at the time of HRM. A total of 116 follow up imaging studies were ordered within 1 year of the EGJOO diagnosis and 75 patients (64.1%) completed additional imaging within 1 year, with 34 (45%) undergoing multiple studies (Table 1). 26 patients (22.2%) underwent EUS and 11 (42.3%) of these examinations explained the EGJOO. 48 patients (41.0%) underwent CT and an explanation for EGJOO was found in 8 of these patients (16.6%). Finally, 42 patients underwent BaSw with 25 (59%) of these tests demonstrating an explanation for EGJOO (Figure 1). Conclusion: Additional imaging with BaSw, CT, or EUS is recommended in patients diagnosed with EGJOO. Among 117 patients diagnosed with EGJOO at a tertiary medical center, one-third did not undergo additional imaging within 1 year of their EGJOO diagnosis. Among patients who did undergo additional imaging, CT and BaSw were the most commonly used modalities. When obtained, additional imaging was felt to explain EGJOO in 58.7% of patients diagnosed with EGJOO on HRM. Prospective studies evaluating the compliance and yield of additional imaging after EGJOO diagnosis are needed.Table 1.: Demographic and Clinical Characteristics of GERD Cohort During Study.Figure 1.: APT-1011 3 mg HS vs Placebo: Response Defined by >=50% reduction in dysphagia frequency with 14-day period Kaplan Meier display utilizes mid-step.

Upright Integrated Relaxation Pressure Predicts Symptom Outcome for Esophagogastric Junction Outflow Obstruction.

Background/AimsEsophagogastric junction outflow obstruction (EGJOO) is characterized by elevated integrated relaxation pressure (IRP) and preserved esophageal peristalsis. The clinical significance of EGJOO is uncertain. This study aim to describe the clinical characteristics of these patients and to find out potential parameters to predict patients’ symptom outcome.MethodsConsecutive patients who received high-resolution manometry examination in our hospital in 2013-2019 and met the diagnostic criteria of EGJOO were retrospectively included. Motility and reflux parameters as well as endoscopy and barium esophagogram results were studied and compared. Patients were also followed up to record their treatment methods and symptom outcomes.ResultsA total of 138 EGJOO (accounting for 5.2% of total patients taking high-resolution manometry examination in our hospital) patients were included. Only 2.9% of these patients had persistent dysphagia. A total of 81.8% of EGJOO patients had symptom resolution during follow-up. Patients with persistent dysphagia had significantly higher upright IRP (16.6 [10.3, 19.8] vs 7.8 [3.2, 11.5]; P = 0.026) than those without. Upright IRP can effectively distinguished patients with persistent dysphagia (area under curve 0.826; P = 0.026) using optimal cut-off value of 9.05 mmHg.ConclusionEGJOO patients with persistent dysphagia and higher upright IRP (median > 9.05 mmHg) needs further evaluation and aggressive management.

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

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.

505 SURPRISING LACK OF CORRELATION BETWEEN INTEGRATED RELAXATION PRESSURE LEVEL AND SYMPTOM SEVERITY IN PATIENTS WITH ACHALASIA

Abstract With high resolution manometry (HRM), achalasia is defined as an elevated integrated relaxation pressure (IRP) and the absence of normal esophageal peristalsis. Since achalasia symptoms are attributed in part to incomplete LES relaxation, IRP values might be expected to directly correlate with symptom severity. The aim of this study was to evaluate the relationship between IRP values and symptom severity assessed by the Eckardt score in patients with achalasia. Methods We searched the database of our Center for Esophageal Diseases for patients who had HRM showing achalasia (IRP &amp;gt; 15 mmHg and absent peristalsis) between May 2017 and August 2019. All patients with achalasia seen in our Center routinely complete the Eckardt score questionnaire evaluating the severity of achalasia symptoms in each of four categories (dysphagia, chest pain, regurgitation and weight loss). Pearson correlation coefficient was used to assess the relationship between median IRP and Eckardt score; an R2 value &amp;gt;0.5 was considered clinically meaningful. Results We identified 91 subjects with achalasia (mean age 62.9 ± 16.5 years; 39 men, 52 women; 27 Type 1, 28 Type 2, 36 Type 3). We found no clinically meaningful correlation between median IRP and the total Eckardt score (R2 = 0.043) (Figure 1). Furthermore, we found no clinically meaningful correlation between median IRP and any individual component of the Eckardt score (dysphagia R2 = 0.008, chest pain R2 = 0.001, regurgitation R2 = 0.035, weight loss R2 = 0.049). Finally, in subgroup analyses we found no clinically meaningful correlation between median IRP and Eckardt scores (total or any of its individual components) for any of the 3 achalasia subtypes. Conclusion We found no clinically meaningful correlation between IRP and total Eckardt score, or between IRP and any individual component of the Eckardt score for patients with achalasia of any type. This suggests that once the IRP value exceeds 15 mmHg, further elevations in IRP have little effect on symptoms, and that factors other than IRP such as esophageal body dysmotility and hypersensitivity might contribute to symptom perception in achalasia.

Short-term outcome after singular hydraulic EsoFLIP dilation in patients with achalasia: A feasibility study.

Achalasia is a chronic esophageal motility disorder characterized by impaired relaxation of the lower esophageal sphincter, determined by an elevated integrated relaxation pressure (IRP>15mmHg) and absent peristalsis. Goal of treatment is facilitation of flow across the EGJ but minimizing postinterventional reflux. A new advanced hydraulic dilation technology, the esophageal functional luminal imaging probe (EsoFLIP), allows dynamic monitoring of hollow organ dimensions while performing hydraulic dilation. The aim of our study was to evaluate the treatment response after single EsoFLIP dilation in achalasia patients. Dilation was performed under endoscopic control with the EsoFLIP device using a self-developed dilation algorithm. Symptom scores were assessed by the Eckardt score (ES) before and 1-4weeks after intervention. Esophageal emptying before and after intervention was recorded with timed barium esophagogram. We studied 28 consecutive untreated achalasia patients (8 female) with a median age of 43years (range 19-82years) undergoing their first dilation performed with the EsoFLIP, aiming at a maximum dilation diameter of 25mm. Total ES was significantly reduced from 7 at baseline to 2 postintervention (P<.001). The median height of the barium column after 5minutes was significantly reduced from 4.5cm at baseline to 1.7cm (P=.0087). No major complications occurred. We found good efficacy in both subjective and objective short-term treatment outcome after singular EsoFLIP dilation in treatment-naive achalasia patients. Our findings suggest that EsoFLIP is a promising dilation technology that should be further studied in a larger, controlled setting with longer follow-up.

Anticholinergic, anti-depressant and other medication use is associated with clinically relevant oesophageal manometric abnormalities.

Medications can affect gastrointestinal tract motility. However, their effects on oesophageal motility in particular are often not as widely known or may be underestimated. To review the effect of existing medication use on high-resolution oesophageal manometry (HRM) in a 'real-world' setting. Adult patients with upper gut symptoms and normal endoscopy or imaging who had HRM over a 22-month period were analysed. Achalasia and major disorders of peristalsis were excluded. All medications taken within 24hours of the procedure were prospectively recorded and compared with HRM results, controlling for age, gender and proton pump inhibitor use. A total of 502 patients (323 female, mean age 51) were recruited. Of these, 41.2% had normal oesophageal HRM, while 41.4% had ineffective oesophageal motility (IOM) and 7.6% had oesophagogastric junction outflow obstruction (OGJOO). Serotonin/norepinephrine reuptake inhibitors (SNRI) and opioids were associated with significantly higher resting lower oesophageal sphincter pressure. Benzodiazepines and opioids were associated with elevated integrated relaxation pressure. SNRI and inhaled beta-agonists were associated with increased distal contractile index, whereas calcium channel blockers were associated with a lower distal contractile index. Odds ratio of being on anticholinergics was higher in IOM patients vs normal (3.6, CI 1.2-10.8). Odds ratio for anticholinergics, inhaled beta-agonists, anticonvulsants, SNRIs and opioids (trend) were all>3 for OGJOO patients vs normal. Many medication classes are associated with abnormal HRM variables and diagnoses such as OGJOO and IOM; some of these associations are probably causal. These possible links should be taken into consideration during manometry interpretation.

Management of Functional Esophagogastric Junction Outflow Obstruction: A Systematic Review.

Awareness of functional esophagogastric junction outflow obstruction (fEGJOO) has increased, but because there is no consensus on its management, we performed a systematic review of the literature to explore treatment strategies and outcomes. EGJOO is a heterogenous disorder defined by high-resolution manometry parameters of elevated integrated relaxation pressure with preserved esophageal peristalsis. The etiology may be mechanical obstruction or idiopathic, the latter being fEGJOO. The PubMed/MEDLINE, Embase, and the Cochrane library electronic databases were searched through June 2018 for all studies of adult patients describing a treatment strategy for fEGJOO or incomplete lower esophageal sphincter relaxation. The search strategy yielded 1792 studies and 8 (0.4%) met inclusion criteria. All but one included studies were retrospective (n=184 patients). There were 5 interventions described, with botulinum toxin (Botox) injection (n=69) and expectant management (n=82) the most frequently reported, with success rates of 58% and 54%, respectively. There was substantial heterogeneity among patients and treatments were not directly compared, though reported symptom resolution was similar among all strategies with a mean follow-up time of 15 months. There are a variety of management strategies available for fEGJOO and some patients may not require any intervention. However, among 4 potential approaches aimed at disrupting lower esophageal sphincter hypertonicity, the largest existing evidence base supports either a therapeutic challenge of Botox injection or watchful waiting. Ultimately, these data indicate the need for further study with controlled trials to identify a definitive approach.

2862 Severity of EGJOO and Correlation to Elevations in IRP

INTRODUCTION: Esophagogastric Junction Outflow Obstruction (EGJOO) is an abnormality of the lower esophageal sphincter (LES) which is associated with an elevation of the Integrated Relaxation Pressure (IRP). EGJOO is part of a group of disorders associated with impaired relaxation of the LES, however it remains separate from Achalasia (types I-III) due to retained peristalsis. Delayed bolus transit is frequently impaired in EGJOO due to this collection of abnormalities within the esophagus. Our goal with this retrospective analysis was to determine if there existed a correlation between an elevated IRP and solid/viscous bolus transit in patients with EGJOO. METHODS: We performed a retrospective analysis of patients who were diagnosed with EGJOO by high resolution manometry from 2015 to 2018 at a single tertiary care center. Patients were classified as having EGJOO by the Chicago Classification (version 3). An IRP of 20 or above was the cutoff in this analysis. This analysis collected a sample size of 100 patients whose manometry studies were consistent with EGJOO. RESULTS: A linear regression analysis was performed on the 100 patients reviewed. There was a weakly negative correlation between bolus transit time and an elevation in IRP. However, overall, IRP increase did not have a statistically significant impact on liquid/viscous bolus transit. CONCLUSION: In summary, an elevated integrated residual pressure (IRP) coupled with preserved esophageal body peristalsis is required for diagnosis of EGJOO. Our data revealed no statistically significant correlation between an elevated IRP and an increase in liquid/viscous bolus transit time. As such, an increase in IRP may not indicate severity of EGJOO. Therefore, success of endoscopic intervention may not be accurately indicated by observation of IRP by HRM. More data is needed to better correlate endoscopic intervention with IRP values.

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

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.

1816 Achalasia in the Setting of Esophageal Varices Achalasia in the Setting of Achalasia in the Setting of Esophageal Varices

INTRODUCTION: Primary achalasia is an esophageal motility disorder characterized by inadequate or absent lower esophageal sphincter (LES) relaxation and loss of normal esophageal peristalsis of the esophageal body. We present an unusual case of achalasia in the context of esophageal varices, creating a challenging therapeutic dilemma. CASE DESCRIPTION/METHODS: A 63-year-old male with a history of hypertension, type II diabetes, decompensated HCV cirrhosis (status post sofosbuvir/velpatasvir and ribavirin without sustained virologic response) with hepatic encephalopathy, initially presented with a five month history of progressively worsening dysphagia, unintentional 40 lb. weight loss, and epigastric abdominal pain. He underwent an EGD with findings highly suspicious of achalasia with dilated esophagus, a large amount of retained food with associated stasis esophagitis, hypertonic LES, and no obvious esophageal varices. Esophageal manometry confirmed absence of normal contractility and elevated integrated relaxation pressure (29 mm Hg) consistent with Type I achalasia. On subsequent EGD, he was noted to have grade II esophageal varices. Treatment of achalasia was performed with botulinum toxin injections of the LES, carefully avoiding the esophageal varices. In the next 48 hours, he had significant improvement in symptoms of dysphagia, tolerated a full liquid diet, and then underwent a repeat EGD with successful decompression of his varices with placement of two bands. He was discharged from the hospital tolerating a regular diet. DISCUSSION: Achalasia is uncommon, with an annual incidence of approximately 1 in 100,000 individuals. Achalasia in combination with esophageal varices is a very rare occurrence with only 12 case reports and one retrospective study of 14 patients in the current published literature. This particular disease combination presents a therapeutic challenge as our patient was a poor candidate for surgical myotomy given his cirrhosis and bleeding risk. Our case is consistent with previously documented reports showing short-term clinical improvement with botulinum toxin injections as a well-tolerated first line therapy.

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.

High-resolution esophageal manometry in pediatrics: Effect of esophageal length on diagnostic measures.

BackgroundHigh‐resolution esophageal manometry (HREM), derived esophageal pressure topography metrics (EPT), integrated relaxation pressure (IRP), and distal latency (DL) are influenced by age and size. Combined pressure and intraluminal impedance also allow derivation of metrics that define distension pressure and bolus flow timing. We prospectively investigated the effects of esophageal length on these metrics to determine whether adjustment strategies are required for children.MethodsFifty‐five children (12.3 ± 4.5 years) referred for HREM, and 30 healthy adult volunteers (46.9 ± 3.8 years) were included. Studies were performed using the MMS system and a standardized protocol including 10 × 5 mL thin liquid bolus swallows (SBM kit, Trisco Foods) and analyzed via Swallow Gateway (http://www.swallowgateway.com). Esophageal distension pressures and swallow latencies were determined in addition to EGJ resting pressure and standard EPT metrics. Effects of esophageal length were examined using partial correlation, correcting for age. Adult‐derived upper limits were adjusted for length using the slopes of the identified linear equations.Key ResultsMean esophageal length in children was 16.8 ± 2.8 cm and correlated significantly with age (r = 0.787, P = .000). Shorter length correlated with higher EGJ resting pressure and 4‐s integrated relaxation pressures (IRP), distension pressures, and shorter contraction latencies. Ten patients had an IRP above the adult upper limit. Adjustment for esophageal length reduced the number of patients with elevated IRP to three.Conclusions & InferencesWe prospectively confirmed that certain EPT metrics, as well as potential useful adjunct pressure‐impedance measures such as distension pressure, are substantially influenced by esophageal length and require adjusted diagnostic thresholds specifically for children.

Pharmacologic interrogation of patients with esophagogastric junction outflow obstruction using amyl nitrite.

The Chicago Classification of esophageal motility includes a group of patients who show evidence of esophagogastric junction outflow obstruction (EGJOO) as demonstrated by elevated integrated relaxation pressure (IRP) and preserved peristalsis. Our aim is to classify EGJOO patients based on response to amyl nitrite (AN) during high-resolution manometry. Patients were considered to have true EGJOO if elevated IRP during supine swallow persisted in the upright position and was associated with high intrabolus pressure. The EGJ response to AN was compared between patients with achalasia type 2 (A2) and normal esophageal motility. Based on the relaxation gain (deglutitive IRP-AN IRP) value that best discriminated these two groups (10mmHg), patients with true EGJOO were categorized as being in either the AN-responsive (AN-R) or AN-unresponsive (AN-U) subgroups. In the group of 49 patients with true EGJOO, the AN response classified 27 patients (IRP=25±10mmHg) with AN-R and 22 patients (IRP=20±5mmHg) with AN-U (P=0.2). In AN-R, AN produced a relaxation gain and rebound after-contraction response at the EGJ comparable to A2 patients. AN-U patients had an elevated IRP after AN and a relaxation gain similar to normal esophageal motility patients. AN-U patients were obese and had higher prevalence of sleep apnea (P<0.05). Among patients with true EGJOO, only half have pharmacologic evidence of impaired LES relaxation. Pharmacologic interrogation of the EGJ is thus necessary to identify the subgroup of EGJOO patients who could be expected to benefit from LES ablative therapies.