High‐resolution manometry in the upright position could improve the manometric evaluation of morbidly obese patients with esophagogastric junction outflow obstruction

Abstract

Background: Esophagogastric junction outflow obstruction (EGJOO) detected by manometry in the supine position is prevalent in patients with morbid obesity, but not all EGJOOs are clinically significant. We investigated whether including upright swallows during high-resolution manometry (HRM) could help identify non-clinically significant EGJOO in patients with morbid obesity. Methods: We performed a retrospective study of consecutive morbidly obese patients diagnosed with EGJOO by HRM from July 2012 through July 2018. The HRM protocol included 10 supine and five upright 5-mL water swallows. Endoscopy, esophagram, and computed tomography were performed to identify whether the patients should be diagnosed as having clinically significant EGJOO. Key Results: A total of 230 patients with morbid obesity underwent HRM in the supine position during the study period. Fifty (21.7%) patients were diagnosed with EGJOO, among which 32 completed HRM both in the supine and upright positions. Only 8/32 patients were diagnosed with EGJOO in an upright position. Fewer artifacts were displayed in esophageal pressure topography in the upright position. None of the 32 patients could be diagnosed as clinically significant EGJOO based on all the examinations. Median esophageal gastric junction pressure, integrated relaxation pressure, and distal contractile integral were higher, and median distal latency was longer in the supine position compared with the upright position (all P < .05). Conclusions and Inferences: Esophagus manometry in the upright position could reduce EGJOO overdiagnosis in patients with morbid obesity. Prolongation of the HRM study with some swallows in the upright position could be recommended in obese patients.

Esophagogastric junction outflow obstruction

“…It can be concluded that esophageal manometry in the upright position could reduce EGJOO overdiagnosis in patients with morbid obesity. Looking more critically at the study it could be concluded that the finding of EGJOO can probably entirely be ignored in the morbidly obese, even when still present in the upright position 19 …”

“…It can also be erroneously elevated due to various pressure measurement artifacts 5,29‐32 . Given these factors, it is not surprising that findings of elevated IRP are not always reproducible on repeat HRM testing, 4,20 or after postural changes 12,13,19 . Some patients with elevated IRP do not present with obstructive symptoms or radiographic evidence of impaired esophageal bolus transport 17 …”

“…Su et al performed a retrospective analysis of HRM in 230 morbid obese subjects 19 . Fifty (22%) patients were diagnosed with EGJOO, among which 32 completed HRM both in the supine and upright positions.…”

“…The Chicago Classification version 3.0 (CCv3) of esophageal motility defined esophagogastric junction outflow obstruction (EGJOO) as impaired deglutitive esophagogastric junction (EGJ) relaxation (quantified by the metric of integrated relaxation pressure, IRP) and preserved peristaltic sequence such that criteria for achalasia are not met 1 . The prevalence of EGJOO in several cohorts (more than total 20,000 cases) ranges from 5% to 24% in patients undergoing high‐resolution manometry (HRM) 2‐19 . Dysphagia is the predominantly reported symptom among these patients 2‐5,8,10‐16 .…”

“…Later studies described that 32%–94% of EGJOO did not require any therapy 2,4,15,16 as the attributed symptoms resolved spontaneously with medical observation, 2,17 raising doubt about the clinical significance of an isolated HRM finding of elevated IRP 4,19,20 . Diagnostic agreement over the HRM diagnosis of EGJOO (kappa inter‐rater agreement K = 0.45, 95%CI 041–0.49) has been suboptimal, 21 and EGJOO patients have often undergone unnecessary additional diagnostic testing 8,10,14,17 and even aggressive therapeutic interventions 12 .…”