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28-03-2024 | Achalasia

Esophagogastric Junction Outflow Obstruction (EGJOO): A Manometric Phenomenon or Clinically Impactful Problem

Authors: Laura Bach, Marcelo F. Vela

Published in: Current Gastroenterology Reports

Abstract

Purpose of Review

Esophagogastric junction outflow obstruction (EGJOO), defined manometrically by impaired esophagogastric junction relaxation (EGJ) with preserved peristalsis, can be artifactual, due to secondary etiologies (mechanical, medication-induced), or a true motility disorder. The purpose of this review is to go over the evolving approach to diagnosing and treating clinically relevant EGJOO.

Recent Findings

Timed barium esophagram (TBE) and the functional lumen imaging probe (FLIP) are useful to identify clinically relevant EGJOO that merits lower esophageal sphincter (LES) directed therapies. There are no randomized controlled trials evaluating EJGOO treatment. Uncontrolled trials show effectiveness for pneumatic dilation and peroral endoscopic myotomy to treat confirmed EGJOO; Botox and Heller myotomy may also be considered but data for confirmed EGJOO is more limited.

Summary

Diagnosis of clinically relevant idiopathic EGJOO requires symptoms, exclusion of mechanical and medication-related etiologies, and confirmation of EGJ obstruction by TBE or FLIP. Botox LES injection has limited durability, it can be used in patients who are not candidates for other treatments. PD and POEM are effective in confirmed EGJOO, Heller myotomy may also be considered but data for confirmed EGJOO is limited. Randomized controlled trials are needed to clarify optimal management of EGJOO.

Yadlapati R, Kahrilas PJ, Fox MR, Bredenoord AJ, PrakashGyawali C, Roman S, et al. Esophageal motility disorders on high-resolution manometry: Chicago classification version 4.0(©). Neurogastroenterol Motil. 2021;33(1):e14058. https://doi.org/10.1111/nmo.14058.CrossRefPubMedPubMedCentral

Kahrilas PJ, Bredenoord AJ, Fox M, Gyawali CP, Roman S, Smout AJ, et al. The Chicago Classification of esophageal motility disorders v3.0. Neurogastroenterol Motil. 2015;27(2):160–74. https://doi.org/10.1111/nmo.12477.CrossRefPubMed

Beveridge CA, Triggs JR, Thanawala SU, Ahuja NK, Falk GW, Benitez AJ, et al. Can FLIP guide therapy in idiopathic esophagogastric junction outflow obstruction? Dis Esophagus. 2022;35(4):doab077. https://doi.org/10.1093/dote/doab077.

Beveridge C, Lynch K. Diagnosis and Management of Esophagogastric Junction Outflow Obstruction. Gastroenterol Hepatol (N Y). 2020;16(3):131–8.PubMed

Patel DA, Yadlapati R, Vaezi MF. Esophageal Motility Disorders: Current Approach to Diagnostics and Therapeutics. Gastroenterology. 2022;162(6):1617–34. https://doi.org/10.1053/j.gastro.2021.12.289.CrossRefPubMed

Bredenoord AJ, Babaei A, Carlson D, Omari T, Akiyama J, Yadlapati R, et al. Esophagogastric junction outflow obstruction. Neurogastroenterol Motil. 2021;33(9): e14193. https://doi.org/10.1111/nmo.14193.CrossRefPubMed

Zikos TA, Triadafilopoulos G, Clarke JO. Esophagogastric Junction Outflow Obstruction: Current Approach to Diagnosis and Management. Curr Gastroenterol Rep. 2020;22(2):9. https://doi.org/10.1007/s11894-020-0743-0.CrossRefPubMed

Liu A, Woo M, Nasser Y, Gupta M, Buresi MC, Curley M, et al. Esophagogastric junction outflow obstruction on manometry: Outcomes and lack of benefit from CT and EUS. Neurogastroenterol Motil. 2019;31(12): e13712. https://doi.org/10.1111/nmo.13712.CrossRefPubMed

Snyder DL, Vela MF. Impact of opioids on esophageal motility. Neurogastroenterol Motil. 2023;35(5): e14587. https://doi.org/10.1111/nmo.14587.CrossRefPubMed

10.

Misselwitz B, Hollenstein M, Bütikofer S, Ang D, Heinrich H, Fox M. Prospective serial diagnostic study: the effects of position and provocative tests on the diagnosis of oesophageal motility disorders by high-resolution manometry. Aliment Pharmacol Ther. 2020;51(7):706–18. https://doi.org/10.1111/apt.15658.CrossRefPubMed

11.

Triggs JR, Carlson DA, Beveridge C, Jain A, Tye MY, Kahrilas PJ, et al. Upright Integrated Relaxation Pressure Facilitates Characterization of Esophagogastric Junction Outflow Obstruction. Clin Gastroenterol Hepatol. 2019;17(11):2218-26.e2. https://doi.org/10.1016/j.cgh.2019.01.024.CrossRefPubMedPubMedCentral

12.

Kahrilas PJ, Carlson DA, Pandolfino JE. Advances in the Diagnosis and Management of Achalasia and Achalasia-Like Syndromes: Insights From HRM and FLIP. Gastro Hep Adv. 2023;2(5):701–10. https://doi.org/10.1016/j.gastha.2023.02.001.CrossRefPubMedPubMedCentral

13.

de Oliveira JM, Birgisson S, Doinoff C, Einstein D, Herts B, Davros W, et al. Timed barium swallow: a simple technique for evaluating esophageal emptying in patients with achalasia. AJR Am J Roentgenol. 1997;169(2):473–9. https://doi.org/10.2214/ajr.169.2.9242756.CrossRefPubMed

14.

Blonski W, Kumar A, Feldman J, Richter JE. Timed Barium Swallow: Diagnostic Role and Predictive Value in Untreated Achalasia, Esophagogastric Junction Outflow Obstruction, and Non-Achalasia Dysphagia. Am J Gastroenterol. 2018;113(2):196–203. https://doi.org/10.1038/ajg.2017.370.CrossRefPubMed

15.

Clayton SB, Shin CM, Ewing A, Blonski W, Richter J. Pneumatic dilation improves esophageal emptying and symptoms in patients with idiopathic esophago-gastric junction outflow obstruction. Neurogastroenterol Motil. 2019;31(3): e13522. https://doi.org/10.1111/nmo.13522.CrossRefPubMed

16.

Savarino E, di Pietro M, Bredenoord AJ, Carlson DA, Clarke JO, Khan A, et al. Use of the Functional Lumen Imaging Probe in Clinical Esophagology. Am J Gastroenterol. 2020;115(11):1786–96. https://doi.org/10.14309/ajg.0000000000000773.CrossRefPubMedPubMedCentral

17.

Triggs JR, Carlson DA, Beveridge C, Kou W, Kahrilas PJ, Pandolfino JE. Functional Luminal Imaging Probe Panometry Identifies Achalasia-Type Esophagogastric Junction Outflow Obstruction. Clin Gastroenterol Hepatol. 2020;18(10):2209–17. https://doi.org/10.1016/j.cgh.2019.11.037.CrossRefPubMed

18.

Carlson DA, Schauer JM, Kou W, Kahrilas PJ, Pandolfino JE. Functional Lumen Imaging Probe Panometry Helps Identify Clinically Relevant Esophagogastric Junction Outflow Obstruction per Chicago Classification v4.0. Am J Gastroenterol. 2023;118(1):77–86. https://doi.org/10.14309/ajg.0000000000001980.CrossRefPubMed

19.

Khashab MA, Familiari P, Draganov PV, Aridi HD, Cho JY, Ujiki M, et al. Peroral endoscopic myotomy is effective and safe in non-achalasia esophageal motility disorders: an international multicenter study. Endosc Int Open. 2018;6(8):E1031–6. https://doi.org/10.1055/a-0625-6288.CrossRefPubMedPubMedCentral

20.

Marin I, Serra J. Patterns of esophageal pressure responses to a rapid drink challenge test in patients with esophageal motility disorders. Neurogastroenterol Motil. 2016;28(4):543–53. https://doi.org/10.1111/nmo.12749.CrossRefPubMed

21.

Krause AJ, Su H, Triggs JR, Beveridge C, Baumann AJ, Donnan E, et al. Multiple rapid swallows and rapid drink challenge in patients with esophagogastric junction outflow obstruction on high-resolution manometry. Neurogastroenterol Motil. 2021;33(3): e14000. https://doi.org/10.1111/nmo.14000.CrossRefPubMed

22.

Shaker A, Stoikes N, Drapekin J, Kushnir V, Brunt LM, Gyawali CP. Multiple rapid swallow responses during esophageal high-resolution manometry reflect esophageal body peristaltic reserve. Am J Gastroenterol. 2013;108(11):1706–12. https://doi.org/10.1038/ajg.2013.289.CrossRefPubMedPubMedCentral

23.

Dodds WJ, Stewart ET, Kishk SM, Kahrilas PJ, Hogan WJ. Radiologic amyl nitrite test for distinguishing pseudoachalasia from idiopathic achalasia. AJR Am J Roentgenol. 1986;146(1):21–3. https://doi.org/10.2214/ajr.146.1.21.CrossRefPubMed

24.

Mayrand S, Diamant NE. Measurement of human esophageal tone in vivo. Gastroenterology. 1993;105(5):1411–20. https://doi.org/10.1016/0016-5085(93)90146-4.CrossRefPubMed

25.

González M, Mearin F, Vasconez C, Armengol JR, Malagelada JR. Oesophageal tone in patients with achalasia. Gut. 1997;41(3):291–6. https://doi.org/10.1136/gut.41.3.291.CrossRefPubMedPubMedCentral

26.

Babaei A, Shad S, Szabo A, Massey BT. Pharmacologic interrogation of patients with esophagogastric junction outflow obstruction using amyl nitrite. Neurogastroenterol Motil. 2019;31(9): e13668. https://doi.org/10.1111/nmo.13668.CrossRefPubMedPubMedCentral

27.

Babaei A, Szabo A, Shad S, Massey BT. Chronic daily opioid exposure is associated with dysphagia, esophageal outflow obstruction, and disordered peristalsis. Neurogastroenterol Motil. 2019;31(7): e13601. https://doi.org/10.1111/nmo.13601.CrossRefPubMedPubMedCentral

28.

Snyder DL, Vela MF. Opioid-induced esophageal dysfunction. Curr Opin Gastroenterol. 2020;36(4):344–50. https://doi.org/10.1097/mog.0000000000000648.CrossRefPubMed

29.

Ravi K, Murray JA, Geno DM, Katzka DA. Achalasia and chronic opioid use: innocent bystanders or associated conditions? Dis Esophagus. 2016;29(1):15–21. https://doi.org/10.1111/dote.12291.CrossRefPubMed

30.

Jacobs CC, Al-Haddad M, Stainko S, Perkins A, DeWitt JM. Prevalence and impact of opioid use in patients undergoing peroral endoscopic myotomy. Gastrointest Endosc. 2023;97(4):655-63.e2. https://doi.org/10.1016/j.gie.2022.12.006.CrossRefPubMed

31.

Lynch KL, Yang YX, Metz DC, Falk GW. Clinical presentation and disease course of patients with esophagogastric junction outflow obstruction. Dis Esophagus. 2017;30(6):1–6. https://doi.org/10.1093/dote/dox004.CrossRefPubMed

32.

Garbarino S, von Isenburg M, Fisher DA, Leiman DA. Management of Functional Esophagogastric Junction Outflow Obstruction: A Systematic Review. J Clin Gastroenterol. 2020;54(1):35–42. https://doi.org/10.1097/mcg.0000000000001156.CrossRefPubMed

33.

Scherer JR, Kwiatek MA, Soper NJ, Pandolfino JE, Kahrilas PJ. Functional esophagogastric junction obstruction with intact peristalsis: a heterogeneous syndrome sometimes akin to achalasia. J Gastrointest Surg. 2009;13(12):2219–25. https://doi.org/10.1007/s11605-009-0975-7.CrossRefPubMedPubMedCentral

34.

Salvador R, Provenzano L, Nezi G, Capovilla G, Nicoletti L, Pierobon ES, et al. Laparoscopic Heller-Dor Is an Effective Treatment for Esophageal-Gastric Junction Outflow Obstruction. J Gastrointest Surg. 2021;25(9):2201–7. https://doi.org/10.1007/s11605-021-05021-1.CrossRefPubMedPubMedCentral

35.

Clayton SB, Patel R, Richter JE. Functional and Anatomic Esophagogastic Junction Outflow Obstruction: Manometry, Timed Barium Esophagram Findings, and Treatment Outcomes. Clin Gastroenterol Hepatol. 2016;14(6):907–11. https://doi.org/10.1016/j.cgh.2015.12.041.CrossRefPubMed

36.

Pérez-Fernández MT, Santander C, Marinero A, Burgos-Santamaría D, Chavarría-Herbozo C. Characterization and follow-up of esophagogastric junction outflow obstruction detected by high resolution manometry. Neurogastroenterol Motil. 2016;28(1):116–26. https://doi.org/10.1111/nmo.12708.CrossRefPubMed

37.

Desai N, Kline M, Duncan D, Godiers M, Patel V, Keilin S, et al. Expanding the role of pneumatic dilation for nonachalasia patients: a comparative study. Gastrointest Endosc. 2023;97(2):251–9. https://doi.org/10.1016/j.gie.2022.09.032.CrossRefPubMed

38.

Okeke FC, Raja S, Lynch KL, Dhalla S, Nandwani M, Stein EM, et al. What is the clinical significance of esophagogastric junction outflow obstruction? evaluation of 60 patients at a tertiary referral center. Neurogastroenterol Motil. 2017;29(6). https://doi.org/10.1111/nmo.13061.

39.

Ichkhanian Y, Sanaei O, Canakis A, Vosoughi K, Almazan E, Ghandour B, et al. Esophageal peroral endoscopic myotomy (POEM) for treatment of esophagogastric junction outflow obstruction: results from the first prospective trial. Endosc Int Open. 2020;8(9):E1137–43. https://doi.org/10.1055/a-1198-4643.CrossRefPubMedPubMedCentral

40.

Sanaka M, Kumar P, Mohammed A, Sudarshan M, Murthy S, Raja S. Efficacy of Peroral Endoscopic Myotomy for the Treatment of Functional Esophagogastric Junction Outflow Obstruction. iGIE. 2023;2(4):467–71. https://doi.org/10.1016/j.igie.2023.08.003.

Title: Esophagogastric Junction Outflow Obstruction (EGJOO): A Manometric Phenomenon or Clinically Impactful Problem
Authors: Laura Bach
Marcelo F. Vela
Publication date: 28-03-2024
Publisher: Springer US
Keywords: Achalasia
Botulinum Toxin
Opioids
Opioids
Dysphagia
Dysphagia
Dysphagia
Motility Disorder
Motility Disorder
Published in: Current Gastroenterology Reports
Print ISSN: 1522-8037
Electronic ISSN: 1534-312X
DOI: https://doi.org/10.1007/s11894-024-00928-6

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