Functional and Anatomic Esophagogastic Junction Outflow Obstruction: Manometry, Timed Barium Esophagram Findings, and Treatment Outcomes

Clayton, Steven; Patel, Rupal; Richter, Joel E.

doi:10.1016/j.cgh.2015.12.041

Cited by 90 publications

(107 citation statements)

References 12 publications

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“…). This was also shown by Clayton et al ., since TBE was abnormal in patients with anatomical and functional EGJ outflow obstruction without differences in height of the retained barium column.…”

Section: Achalasiasupporting

confidence: 74%

What is the role of radiological testing of lower esophageal sphincter function?

Scharitzer¹,

Pokieser

2016

Annals of the New York Academy of Sciences

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Radiological fluoroscopic evaluation remains the primary imaging modality of choice to evaluate patients with swallowing disorders, despite the increasing availability and technical advantages of nonradiological techniques and the current radiological focus on cross-sectional imaging studies, such as computed tomography and magnetic resonance imaging. The radiological swallowing evaluation should be tailored to assess the entire upper gastrointestinal tract, including the lower esophageal sphincter. Fluoroscopy enables the simultaneous assessment of esophageal motility disorders, as well as structural pathologies, including strictures, webs, rings, diverticula, and tumors. Mono- and double-contrast esophagrams and solid bolus tests together allow assessment of lower esophageal sphincter function and complement other methods, such as endoscopy, manometry, or impedance planimetry. Here we review the role of radiological studies for correct assessment of structural and functional pathologies at the level of the lower esophageal sphincter.

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Section: Achalasiasupporting

confidence: 74%

What is the role of radiological testing of lower esophageal sphincter function?

Scharitzer¹,

Pokieser

2016

Annals of the New York Academy of Sciences

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“…Furthermore, there is growing literature evidence of EGJOO patients treated with Botox progressing to achalasia. In our experience, we observed 2/14 patients with idiopathic EGJOO who were treated with Botox (14%) progress to type 3 achalasia within 20 months of treatment . There have been four patients with EGJOO treated with surgical myotomy who had positive outcomes …”

Section: Discussionmentioning

confidence: 84%

“…Table summarizes all currently published data in regards to EGJOO treatment outcomes . Somewhat surprising are the three reports (Van Hoeij, Perez‐Fernandez and Lynch) suggesting that 44%–52% improve with no therapy …”

Section: Discussionmentioning

confidence: 97%

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Pneumatic dilation improves esophageal emptying and symptoms in patients with idiopathic esophago‐gastric junction outflow obstruction

Clayton

Shin

Ewing

et al. 2018

Neurogastroenterology Motil

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Background and aims Idiopathic Esophago‐gastric outflow obstruction (EGJOO) is a new clinical entity resulting in delayed esophageal emptying secondary to a poorly relaxing lower esophageal sphincter. Little is known about treatment outcomes of idiopathic EGJOO patients. The aim of this study was to investigate the clinical response of pneumatic dilation (PD) in idiopathic EGJOO patients with a standing barium column and/or with pill arrest on timed barium esophagram (TBE) before and after undergoing PD. Methods Idiopathic EGJOO patients with retained liquid barium on TBE at 1 minute and/or with pill arrest in esophagus at 5 minutes were included. Patients were treated with PD and evaluated with post‐procedural TBE. Results A total of 33 patients with Idiopathic EGJOO and poor esophageal emptying on TBE were treated with PD. 67% of Idiopathic EGJOO patients reported subjective symptom relief, 18% improved and symptoms later recurred, 6% were lost to follow up, and 9% reported no change. TBE results of pre‐PD showed 1 minute average barium column height of 11.0 cm and 1 minute barium column width of 1.7 cm. There was significant decrease in 1 minute liquid barium column height and width (P < 0.001 and <0.001, respectively) as well as significant improvement in pill passing (P < 0.006) after undergoing PD. No complications occurred after PD. Conclusion PD is an effective initial treatment for Idiopathic EGJOO patients with abnormal TBE. Pneumatic dilation relieved symptoms and improved esophageal emptying in Idiopathic EGJOO patients on TBE

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“…Furthermore, a completely normal TBE may make achalasia extremely unlikely, but the patient may have EGJOO that was not detected by the TBE in 40% of instances. Although admittedly a very heterogeneous group ( 7 ), ∼ 20 to 30% of EGJOO cases end up being treated as achalasia (8)(9)(10)(11).…”

mentioning

confidence: 99%

Assessing Esophageal Function in Achalasia: The Old and the New

Triggs

Kahrilas

2018

American Journal of Gastroenterology

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Achalasia is currently diagnosed according to the Chicago Classifi cation v3.0 using highresolution manometry and treatment focuses on disruption of the esophagogastric junction. A paper in this issue examines the utility of a timed barium esophagram with a 13 mm tablet challenge in differentiating achalasia from other diagnoses, fi nding 100% sensitivity. However, a large proportion of patients with non-achalasia dysphagia are also identifi ed. Another paper in this issue proposes utilizing intraprocedure functional luminal imaging probe measurement during pneumatic dilation as a guide for upsizing dilations. This appears promising, but prospective validation is necessary before this becomes standard of care. Am J Gastroenterol 2018; 113:213-215; doi: 10.1038/ajg.2017 High-resolution manometry (HRM), along with the analysis algorithms initially put forth in the Chicago Classifi cation (CC), and most recently updated in 2015 have led to a major reclassifi cation of esophageal motility disorders ( 1 ). Nowhere is this evolution more evident than in our concept of achalasia, now diff erentiated into three subtypes and proving to be substantially more prevalent than previously recognized ( 2,3 ). In fact, many disorders previously rendered to alternative diagnoses, or deemed to be "non-specifi c, " are also now recognized to be either achalasia subtypes or cases of incompletely expressed achalasia ( 4 ). In parallel with the global adoption of the CC, the functional luminal imaging probe (FLIP) has emerged as a novel technology capable of quantifying the distensibility of the esophagogastric junction (EGJ), and reduced EGJ distensibility has proven to be a key abnormality in achalasia. In fact, the detection of reduced EGJ distensibility can be complimentary to HRM in achalasia cases with equivocal, or even negative, HRM fi ndings ( 5 ). Furthermore, FLIP measurements can be made in real time with sedated patients, thereby off ering the potential to tailor treatment as the treatment is in progress. Together, these developments have reinvigorated our thinking about the management of esophageal motor disorders in general and achalasia in particular. Contained in this issue of the Journal are two papers pertinent to achalasia management: one exploring how an old methodology, the timed barium esophagram (TBE), fi ts into the new CC diagnostic paradigms, and the second on how FLIP might facilitate a more effi cient protocol for pneumatic dilation (PD) in achalasia therapeutics.In the fi rst paper, Blonski et al. ( 6 ) report on a retrospective analysis of 309 patients comparing TBE (including a 13 mm barium tablet challenge) with HRM in the detection and diff erentiation of achalasia, EGJ outfl ow obstruction (EGJOO), and non-achalasia dysphagia as defi ned by CC v3.0. Applying post hoc determined cutoff s for barium retention height at 1 and 5 min, they report a sensitivity and specifi city for TBE of 85% and 86%, respectively, for distinguishing achalasia from EGJOO and nonachalasia dysphagia using a retaine...

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Functional and Anatomic Esophagogastic Junction Outflow Obstruction: Manometry, Timed Barium Esophagram Findings, and Treatment Outcomes

Cited by 90 publications

References 12 publications

What is the role of radiological testing of lower esophageal sphincter function?

What is the role of radiological testing of lower esophageal sphincter function?

Pneumatic dilation improves esophageal emptying and symptoms in patients with idiopathic esophago‐gastric junction outflow obstruction

Assessing Esophageal Function in Achalasia: The Old and the New

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