Management of the patient with esophagogastric junction outflow obstruction

Abstract

Purpose of reviewEsophagogastric junction outflow obstruction (EGJOO), defined as elevated integrated residual pressure (IRP) with preservation of esophageal peristalsis, is a common finding on high-resolution esophageal manometry.Recent findingsThe recent Chicago classification version 4.0 proposes changes to the criteria for diagnosing EGJOO, making this diagnosis more restrictive to now include elevated IRP in both supine and upright positions (with preservation of esophageal peristalsis), presence of obstructive symptoms, and confirmatory tests for EGJOO, such as timed barium esophagram with barium tablet or functional lumen imaging probe.SummaryOnce the diagnosis of EGJOO is established, secondary causes need to be ruled out, especially the use of opioid medications. Upper endoscopy is needed for evaluation of EGJOO patients, though cross-sectional imaging is usually not necessary. Many patients improve without intervention; thus, expectant management is recommended for patients with mild or atypical symptoms. There seems to be a limited role for medical treatment. Botox injection into the lower esophageal sphincter is often used to see if the patient improves before committing to more definitive treatments, such as pneumatic dilation, peroral endoscopic myotomy, or Heller myotomy.

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

“…Available endoscopic treatment modalities for EGJOO, HE, and DES are the same. 21,33,36 Validated treatment options include Botox injection into the LES, pneumatic dilation, POEM, and surgical Heller myotomy. In essence, these patients are receiving appropriate therapy for both of their motility disorders, and greater abnormalities on HRM lead to a better response to treatment.…”

“…Medical management with smooth muscle relaxants, calcium channel blockers, nitrates, and tricyclic antidepressants have had varying rates of success, all of which were directed at motility disorders as defined by Chicago Classification version 3.0 (CCv3). 13,[21][22][23][24][25][26][27][28][29][30][31] Other small studies have demonstrated efficacy in improving symptom scoring using peppermint oil and acotiamide, an acetylcholinesterase inhibitor. 23,24 Under prior EGJOO diagnostic criteria using CCv3, the majority of patients with EGJOO at the 3-year follow-up were asymptomatic at 2.8 years, 73% of which received no medical therapy.…”

“…22,25 Overall, there is limited efficacy of medical therapy for EGJOO, apart from PPI for concomitant GERD symptoms. 21,22 Procedural management of EGJOO includes botulinum toxin (Botox) injection of LES, pneumatic dilation (PD), surgical Heller myotomy, and peroral endoscopic myotomy (POEM). 3,12,13,[26][27][28][29][30]32,33 Therapeutic hydrostatic 30 mm balloon (EsoFLIP, Medtronic, Minneapolis, Minnesota, USA) has also been used to successfully treat EGJOO diagnosed by CCv3; however, there are limited data supporting its efficacy in this population.…”

“…Therapeutic interventions of EGJOO are targeted at reducing muscle tone at the lower esophageal sphincter (LES). Medical management with smooth muscle relaxants, calcium channel blockers, nitrates, and tricyclic antidepressants have had varying rates of success, all of which were directed at motility disorders as defined by Chicago Classification version 3.0 (CCv3) 13,21–31 . Other small studies have demonstrated efficacy in improving symptom scoring using peppermint oil and acotiamide, an acetylcholinesterase inhibitor 23,24 .…”

Changes in the esophagogastric junction outflow obstruction manometric feature based on the Chicago Classification updates

“…Hence, numerous studies focused on the identification of primary motility disorders and excluded motility patterns secondary to medication use, mechanical obstruction, previous surgery, or endoscopic interventions[ 3 , 4 , 17 ], which are critical in making appropriate therapeutic decisions. Since the morphology of LES is affected by position, the CCv4.0 defines IRP in the upright position and IBP; thus, the Chicago Classification update has reduced the number of clinically irrelevant diagnoses and improved the specificity for EGJOO diagnosis[ 7 , 17 , 18 ], enabling us to avoid irreversible treatment for these conditions. According to the results of this study, patients with EGJOO had multiple abnormalities in EGJ parameters compared with the isolated supine IRP elevated group, including LESP, IBP, median supine IRP, median upright IRP, and IRP on RDC, implying that the Chicago Classification update aids in the selection of EGJOO with more severe EGJ dysfunction.…”