Esophagogastric junction outflow obstruction

Abstract

In the Chicago Classification version 4.0 (CCv4), esophagogastric junction outflow obstruction (EGJOO) is manometrically defined as an elevated median integrated relaxation pressure (IRP) and elevated intrabolus pressure (IBP) during supine wet swallows, and persistently elevated median IRP in the upright position. A clinically relevant conclusive diagnosis of EGJOO requires a manometric diagnosis of EGJOO and associated symptoms such as dysphagia and/or chest pain with at least one of the following supportive investigations (pharmacologic provocation, timed barium esophagogram, and/or endoflip). The Chicago Classification is intended for diagnosis of primary esophageal motor disorders, and thus history and endoscopic evaluation are important to exclude conditions (eg, previous surgery, strictures, or masses) that can secondarily generate the EGJOO pattern on HRM. While a manometric finding of EGJOO is often made and can be an early sign of achalasia, more often it is a manometric finding without clinical implications. The proposed changes in CC4.0 have attempted to make the diagnosis more specific, in order to reduce the number of clinically irrelevant diagnoses and avoid confusion by patients and physicians alike.

Is EGJOO a Purely Manometric Diagnosis?

“…More commonly, in the setting of a hiatal hernia the EGJ barrier is more commonly weakened and an elevation in IRP is highly suspicious for artifact and that can be ignored unless additional testing can support obstruction at the level of the LES. 3 Opioid use has also been found in research studies to be associated with EGJOO and other esophageal motility disorders. In these studies, patients with EGJOO had higher rates of narcotic prescriptions compared to non-EGJOO controls (28% vs 9%).…”

“…The finding of EGJOO is identified in 5% to 24% of patients referred for HRM under the CC v3.0 definition. 3 Dysphagia is the most reported symptom among t hese patients. Other common presenting symptoms include regurgitation, heartburn, chest pain, and globus sensation.…”

“…Some experts recommend cross-sectional imaging and EUS for certain cases; however, the specific circumstances in which additional testing may be of value is still unclear. 3,16 Functional Luminal Imaging Probe FLIP is a balloon catheter-based device used at the time of endoscopic evaluation. It can be placed under direct endoscopic visualization or blindly.…”

Diagnostik von Motilitätsstörungen des Ösophagus – Bedeutung der neuen Chicago-Klassifikation v4.0

“…Daher ist bei unauffälligem endoskopischem Befund eine Endosonografie oder Computertomografie zu erwägen [32]. Andererseits handelt es sich bei dem Befund einer EGJOO häufiger um einen manometrischen Befund ohne klinisches Korrelat, daher soll mit der CC4.0 die Zahl der klinisch irrelevanten Diagnosen reduziert werden, um eine Übertherapie zu vermeiden [30,33,34].…”

“…Da die primäre Dysfunktion, die gestörte Schluckrelaxation des UÖS bei der Achalasie und der EGJOO gleich sind, sind Symptome und Behandlungsformen oft sehr ähnlich. Allerdings haben einige Patienten mit einem EGJOO-Muster in der Manometrie keine oder nur geringe Symptome und können auch ohne Therapie beschwerdefrei werden [29,33,36].…”