Upper esophageal sphincter metrics on high‐resolution manometry differentiate etiologies of esophagogastric junction outflow obstruction

Abstract

Background Upper esophageal sphincter (UES) metrics on high‐resolution manometry (HRM), particularly nadir UES residual pressure (UES‐RP), are abnormal in achalasia and may help characterize the underlying mechanism or predict management outcome in esophagogastric junction outflow obstruction (EGJOO). Methods A database of consecutive patients undergoing esophageal HRM from 2008 to 2013 yielded 134 patients (59.8 ± 1.4 years, 68% F) with EGJOO. Final clinical diagnoses and treatment response were extracted from chart review. Esophageal body, UES, and lower esophageal sphincter (LES) metrics were compared between EGJOO and asymptomatic healthy controls (n = 16, 27.7 ± 0.7 years, 56% F). Logistic regression evaluated differences between HRM metrics amongst etiologies of EGJOO grouped into motor versus mechanical disorders. Key results Distal contractile integral, distal latency, and nadir UES‐RP were significantly different between EGJOO subgroups (P ≤ 0.01 for each comparison), but only nadir UES‐RP remained independently predictive of subgroups (adjusted odds ratio 1.15, 95% confidence intervals 1.05‐1.27, P < 0.01). Nadir UES‐RP was highest in achalasia variants, and lowest in mechanical EGJOO and controls (P < 0.001). Of 19 patients who underwent LES myotomy, durable benefit was reported by 68.4% over mean 3.6 years of follow‐up. Significantly higher nadir UES‐RP was noted with symptom relief (3.4 vs −0.7 mm Hg with symptom recurrence, 95% confidence intervals of difference = 1.35‐6.83). A threshold UES‐RP of ≥2.0 mm Hg yielded a sensitivity of 84.6% and specificity of 83.3% in predicting symptom resolution following myotomy. Conclusions and inferences Nadir UES‐RP offers clues to differentiation of subtypes within EGJOO and may predict symptom outcome from myotomy.

Pharyngeal and upper esophageal sphincter motor dynamics during swallow in children

“…Our subjects had lower UNP than neonates and similar to adults. In healthy adults, the mean of UNP has been reported to vary from −5.1 to 5.4 mm Hg 10,13,14,16,20,26 which is similar to our results. The previously reported value of UNP of 7 ± 4 to 8 ± 4 and 8 ± 10 mm Hg in preterm and term infants, respectively, is higher than in our cohort 1,2 .…”

“…In neonates, URP was also noted to be highly dependent on behavioral and arousal state and tended to increase with age 1,19 . Moreover, it was established that the UNP in infants was higher than those reported in adults and the UNP was even higher in adults with dysphagia, globus symptoms, and esophagogastric junction outflow obstruction compared to healthy controls 1,14,16,18,20 …”

Upright Integrated Relaxation Pressure Predicts Symptom Outcome for Esophagogastric Junction Outflow Obstruction

“… 3 , 4 , 14 , 16 Although it was considered as a major motility disorder, most patients diagnosed with EGJOO were dysphagia-free, not to speak of persistent dysphagia. 2 - 5 Therefore, whether EGJOO is clinically significant remains controversial. The current study was designed to describe the clinical characteristics of these patients.…”

“…The most common chief complaints of these patients are heartburn, regurgitation, and dysphagia. 2 - 5 In most cases, patients’ symptoms can resolve spontaneously, 4 , 6 with only a few progressing to achalasia. 3 Its potential etiologies may include organic causes (eg, hiatus hernia, stricture, eosinophilic esophagitis, vascular obstruction, and malignancy) and functional causes (eg, early or incompletely express achalasia, esophageal wall stiffness, and drug effect).…”

ESNM/ANMS Review. Diagnosis and management of globus sensation: A clinical challenge

“…It is assumed, although not clearly demonstrated, that impaired bolus transit and esophageal distension may generate globus sensation. Many studies report cases of achalasia and esophageal spasm in patients presenting with globus as primary symptom, and UES pressures can be elevated from a reflex mechanism with esophageal pressurization 28,29 . As an example, a study reported 27% of patients with achalasia in patients with globus, but other symptoms more typical of achalasia like dysphagia and regurgitation were also found to be present in most patients after careful interview 30 .…”