Major mixed motility disorders: An important subset of esophagogastric junction outflow obstruction

Abstract

Background Esophagogastric junction outflow obstruction (EGJOO) is an esophageal motility disorder characterized by a lack of relaxation of the esophagogastric junction (EGJ), with preserved esophageal body peristalsis. We propose new terminology for the coexistence of EGJOO with hypercontractile esophagus and distal esophageal spasm as a major mixed motility disorder (MMMD), and normal peristalsis or a minor disorder of peristalsis such as ineffective esophageal motility with EGJOO as isolated or ineffective EGJOO (IEGJOO). Methods We reviewed prior diagnoses of EGJOO, stratified diagnoses as IEGJOO or MMMD, and compared their symptomatic presentations, high‐resolution manometry (HRM) and endoluminal functional lumen imaging probe (EndoFLIP) metrics, and treatment responses at 2–6 months of follow‐up. Results Out of a total of 821 patients, 142 met CCv3 criteria for EGJOO. Twenty‐two were confirmed by CCv4 and EndoFLIP as having EGJOO and were clinically managed. Thirteen had MMMD, and nine had IEGJOO. Groups had no difference in demographic data or presenting symptoms by Eckardt score (ES). HRM showed MMMD had greater distal contractile integral, frequency of hypercontractile swallows, and frequency of spastic swallows, and greater DI by EndoFLIP. Patients with MMMD showed greater reduction in symptoms after LES‐directed intervention when measured by ES compared with IEGJOO (7.2 vs. 4.0). Conclusion Patients with MMMD and IEGJOO present similarly. Detectable differences in HRM portend different responses to endoscopic therapy. Because patients with MMMD have greater short‐term prognosis, they should be considered a different diagnostic classification to guide therapy.

Compartmentalized pressurization is a novel prognostic factor for hypercontractile esophagus

“…The pattern of CP was previously identified as having high prevalence in patients with clinically relevant EGJOO 9 . In a cohort of patients with EGJOO by CCv4, 100% of patients with EGJOO had CP 11 . As such, it appeared to be a marker for obstruction of the EGJ.…”

“…Extension of vertical pressure from the contractile front to the LES without breaks on a single hypercontractile swallow was required to establish CP (Figure 1). This follows previously established protocols 9,11 . MPP was defined by two contraction peaks, with a pressure trough that is greater than zero, separation of pressure peaks by at least 1 s, and pressure peaking at more than 10 mmHg.…”

“…9 In a cohort of patients with EGJOO by CCv4, 100% of patients with EGJOO had CP. 11 As such, it appeared to be a marker for obstruction of the EGJ.…”

“…This follows previously established protocols. 9,11 MPP was defined by two contraction peaks, with a pressure trough that is greater than zero, separation of pressure peaks by at least 1 s, and pressure peaking at more than 10 mmHg. MPP was evaluated using conventional manometry.…”

“…CP is highly predictive of symptoms of dysphagia in patients with esophagogastric junction outflow obstruction (EGJOO) 9 . A cohort of patients with EGJOO with 96% endoscopic treatment success rate were found to have CP 100% of the time, indicating a high positive predictive value for detecting clinically relevant EGJOO 11 . The presence and relevance of CP to HE has yet to be studied.…”