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Biermann M, Obineme C, Godiers M, Kundu S, Jain AS. The functional lumen imaging probe contractile response pattern is the best predictor of botulinum toxin response in esophagogastric junction outflow obstruction. Neurogastroenterol Motil 2024:e14859. [PMID: 38988105 DOI: 10.1111/nmo.14859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 04/12/2024] [Accepted: 06/26/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND Esophagogastric junction outflow obstruction (EGJOO) is a heterogenous disorder in which the correct management strategy is unclear. We assessed whether functional lumen imaging probe (FLIP) topography data could select EGJOO, which would benefit from lower esophageal sphincter Botulinum toxin (Botox) injection. METHODS This was a single-center prospective study of adult patients meeting Chicago Classification (CC) v3.0 criteria for EGJOO. We assessed differences in pretreatment physiologic measurements on high-resolution manometry (HRM) and FLIP and other relevant clinical variables in predicting Botox response (>50% in BEDQ at 2 months). KEY RESULTS Sixty-nine patients were included (ages 33-90, 73.9% female). Of these, 42 (61%) were Botox responders. Majority of physiologic measures on HRM and FLIP and esophageal emptying were not different based on Botox response. However, a spastic-reactive (SR) FLIP contractile response (CR) pattern predicted a Botox response with OR 25.6 (CI 2.9-229.6) when compared to antegrade FLIP CR; and OR for impaired-disordered/absent CR was 22.5 (CI 2.5-206.7). Logistic regression model using backward elimination (p value = 0.0001, AUC 0.79) showed that a SRCR or IDCR/absent response and the upright IRP predicted Botox response. Response rates in tiered diagnostic groups were: (i) CCv3.0 EGJOO (60.9%), (ii) CCv4.0 EGJOO (73.1%), (iii) CCv4.0 + FLIP REO (80%), (iv) CCv4.0, FLIP REO, and abnormal FLIP CR (84.2%), and (v) CCv4.0, FLIP REO, and SR FLIP CR (90%). CONCLUSIONS AND INFERENCES FLIP helps identify patients with EGJOO who are likely to response to LES Botox therapy. An abnormal FLIP contractile response pattern is the single-most important predictor of a Botox response.
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Affiliation(s)
- Maya Biermann
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Chuma Obineme
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Marie Godiers
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Suprateek Kundu
- Department of Medicine, Data Analytics and Biostatistics Core, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Anand S Jain
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
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Bach L, Vela MF. Esophagogastric Junction Outflow Obstruction (EGJOO): A Manometric Phenomenon or Clinically Impactful Problem. Curr Gastroenterol Rep 2024; 26:173-180. [PMID: 38539024 DOI: 10.1007/s11894-024-00928-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2024] [Indexed: 07/10/2024]
Abstract
PURPOSE OF REVIEW Esophagogastric junction outflow obstruction (EGJOO), defined manometrically by impaired esophagogastric junction relaxation (EGJ) with preserved peristalsis, can be artifactual, due to secondary etiologies (mechanical, medication-induced), or a true motility disorder. The purpose of this review is to go over the evolving approach to diagnosing and treating clinically relevant EGJOO. RECENT FINDINGS Timed barium esophagram (TBE) and the functional lumen imaging probe (FLIP) are useful to identify clinically relevant EGJOO that merits lower esophageal sphincter (LES) directed therapies. There are no randomized controlled trials evaluating EJGOO treatment. Uncontrolled trials show effectiveness for pneumatic dilation and peroral endoscopic myotomy to treat confirmed EGJOO; Botox and Heller myotomy may also be considered but data for confirmed EGJOO is more limited. Diagnosis of clinically relevant idiopathic EGJOO requires symptoms, exclusion of mechanical and medication-related etiologies, and confirmation of EGJ obstruction by TBE or FLIP. Botox LES injection has limited durability, it can be used in patients who are not candidates for other treatments. PD and POEM are effective in confirmed EGJOO, Heller myotomy may also be considered but data for confirmed EGJOO is limited. Randomized controlled trials are needed to clarify optimal management of EGJOO.
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Affiliation(s)
- Laura Bach
- Mayo Clinic Arizona, 13400 E. Shea Blvd, Scottsdale, AZ, USA
| | - Marcelo F Vela
- Mayo Clinic Arizona, 13400 E. Shea Blvd, Scottsdale, AZ, USA.
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3
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Chuah KH, Ramasami N, Mahendran HA, Shanmuganathan G, Koleth GG, Voon K, Gew LT, Jahit MS, Lau PC, Muthukaruppan R, Said RHM, Mahadeva S, Ho SH, Lim SY, Tee SC, Siow SL, Ooi WK, Lee YY. Malaysian joint societies' consensus recommendations on diagnosis and management of disorders of esophagogastric junction outflow. J Gastroenterol Hepatol 2024; 39:431-445. [PMID: 38087846 DOI: 10.1111/jgh.16403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 09/13/2023] [Accepted: 10/18/2023] [Indexed: 03/05/2024]
Abstract
Disorders of esophagogastric junction (EGJ) outflow, including achalasia and EGJ outflow obstruction, are motility disorders characterized by inadequate relaxation of lower esophageal sphincter with or without impaired esophageal peristalsis. Current guidelines are technical and less practical in the Asia-Pacific region, and there are still massive challenges in timely diagnosis and managing these disorders effectively. Therefore, a Malaysian joint societies' task force has developed a consensus on disorders of EGJ outflow based on the latest evidence, while taking into consideration the practical relevance of local and regional context and resources. Twenty-one statements were established after a series of meetings and extensive review of literatures. The Delphi method was used in the consensus voting process. This consensus focuses on the definition, diagnostic investigations, the aims of treatment outcome, non-surgical or surgical treatment options, management of treatment failure or relapse, and the management of complications. This consensus advocates the use of high-resolution esophageal manometry for diagnosis of disorders of EGJ outflow. Myotomy, via either endoscopy or laparoscopy, is the preferred treatment option, while pneumatic dilatation can serve as a secondary option. Evaluation and management of complications including post-procedural reflux and cancer surveillance are recommended.
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Affiliation(s)
- Kee Huat Chuah
- Gastroenterology and Hepatology Unit, Department of Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Naveen Ramasami
- Gastroenterology and Hepatology Unit, Department of Medicine, Sultanah Bahiyah Hospital, Alor Setar, Kedah, Malaysia
| | | | | | - Glenn George Koleth
- Gastroenterology and Hepatology Unit, Department of Medicine, Sultan Ismail Hospital, Johor Bahru, Johor, Malaysia
| | - Kelvin Voon
- Department of General Surgery, Penang General Hospital, George Town, Penang, Malaysia
| | - Lai Teck Gew
- Gastroenterology and Hepatology Unit, Department of Medicine, Kuala Lumpur General Hospital, Kuala Lumpur, Malaysia
| | | | - Peng Choong Lau
- Pantai Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
- Department of Surgery, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Raman Muthukaruppan
- Gastroenterology and Hepatology Unit, Department of Medicine, Queen Elizabeth Hospital, Kota Kinabalu, Sabah, Malaysia
| | - Rosaida Hj Md Said
- Gastroenterology and Hepatology Unit, Department of Medicine, Serdang Hospital, Serdang, Selangor, Malaysia
| | - Sanjiv Mahadeva
- Gastroenterology and Hepatology Unit, Department of Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Shiaw-Hooi Ho
- Gastroenterology and Hepatology Unit, Department of Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Shyang Yee Lim
- Department of General Surgery, Penang General Hospital, George Town, Penang, Malaysia
| | - Sze Chee Tee
- Department of Surgery, National Cancer Institute, Putrajaya, Malaysia
| | - Sze Li Siow
- Department of General Surgery, Sarawak General Hospital, Kuching, Sarawak, Malaysia
| | - Wei Keat Ooi
- Department of Surgery, Queen Elizabeth Hospital, Kota Kinabalu, Sabah, Malaysia
| | - Yeong Yeh Lee
- School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Kelantan, Malaysia
- GI Function and Motility Unit, Universiti Sains Malaysia Hospital, Kota Bharu, Kelantan, Malaysia
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4
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Josefsson A, Simrén M, Smolak A, Sabbagh N, Törnblom H. Natural history of symptoms and prognostic information of the rapid drink challenge and solid bolus swallows in esophagogastric junction outflow obstruction defined by manometry. Neurogastroenterol Motil 2024; 36:e14720. [PMID: 38073000 DOI: 10.1111/nmo.14720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 11/15/2023] [Accepted: 11/22/2023] [Indexed: 01/25/2024]
Abstract
BACKGROUND/INTRODUCTION Esophagogastric junction outflow obstruction (EGJOO) is a condition characterized by poor relaxation of the lower esophageal sphincter (LES), which can manifest as dysphagia and chest pain. The best treatment of EGJOO is unknown as some patients improve without any specific therapy, whereas some patients undergo invasive therapy. Currently, prognostic factors are lacking. We aimed to assess the long-term prognosis and predictors of dysphagia and chest pain by the rapid drink challenge and solid bolus swallows in EGJOO. METHODS We retrospectively assessed high-resolution esophageal manometries (HRM) performed at our center between 2015 and 2018. The patients completed a dysphagia and chest pain questionnaire a median of 34 months after the HRM/baseline assessment, including the Impaction dysphagia questionnaire-10 (IDQ-10) complemented with questions regarding chest pain and esophageal treatments. Symptoms were compared with HRM findings. RESULTS In all, 980 HRMs were analyzed and 66 (6.5%) were identified as having HRM findings compatible with EGJOO. Of these, 27 patients with EGJOO (41%) completed the follow-up questionnaires and had no exclusion criteria, and 70% of these patients had dysphagia and 44% chest pain at least once a week. Dysphagia at follow-up was more common in patients with elevated integrated relaxation pressure (IRP) on all three HRM metrics (water swallows, solid bolus swallows, and rapid drink challenge) (p = 0.03, odds ratio: 8.4 (95% CI: 1.2-56.0)), but this was not seen for chest pain (p = 0.45). Abnormal motility patterns on rapid drink challenge or solid bolus swallows were not associated with dysphagia or chest pain at follow-up. CONCLUSIONS Having a high IRP on three HRM metrics-water swallows, solid bolus swallows, and rapid drink challenge-is associated with a worse prognosis in patients with EGJOO and could potentially be used to select candidates suitable for invasive procedures.
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Affiliation(s)
- Axel Josefsson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Magnus Simrén
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Center for Functional GI and Motility Disorders, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, USA
| | - Adam Smolak
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Nour Sabbagh
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Hans Törnblom
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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5
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Salvador R, Forattini F, Provenzano L. Role of surgery for oesophagogastric junction outflow obstruction. Br J Surg 2023; 110:1025-1027. [PMID: 37310184 DOI: 10.1093/bjs/znad170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 05/02/2023] [Accepted: 05/13/2023] [Indexed: 06/14/2023]
Affiliation(s)
- Renato Salvador
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, School of Medicine, Padova, Italy
| | - Francesca Forattini
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, School of Medicine, Padova, Italy
| | - Luca Provenzano
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, School of Medicine, Padova, Italy
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6
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Wang Y, Yu T, Zhu F, Xu Y, Bao Y, Zhang L, Lin L, Tang Y. Esophagogastric Junction Outflow Obstruction Is Likely to Be a Local Manifestation of Other Primary Diseases: Analysis of Single-Center 4-Year Follow-Up Data. Diagnostics (Basel) 2023; 13:2329. [PMID: 37510073 PMCID: PMC10378678 DOI: 10.3390/diagnostics13142329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 06/08/2023] [Accepted: 06/30/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Whether esophagogastric junction outflow obstruction (EGJOO) is a variant of achalasia cardia (AC) or an esophageal motility state of certain organic or systemic diseases remains controversial. We aimed to investigate the differences between EGJOO and AC in clinical characteristics and outcomes through a 4-year follow-up. METHODS Patients diagnosed with primary EGJOO or AC were included. Based on the presence of concomitant disease, EGJOO patients were divided into a functional and an anatomical EGJOO group; similarly, patients with AC were divided into an AC with organic disease group and a true AC group. Disease characteristics and high-resolution manometry (HRM) parameters were retrospectively compared between the groups, and the development of organic diseases that could affect esophageal motility disorders and responses to treatment were examined during the follow-up. Symptom relief was defined as an Eckardt score of ≤3 after the treatment. RESULTS The study included 79 AC patients and 70 EGJOO patients. Compared with patients with AC, EGJOO patients were older, had shorter disease duration, a lower Eckardt score, and were more likely to have concurrent adenocarcinoma of the esophagogastric junction (AEG) and autoimmune disease (p < 0.05 for all). The severity of dysphagia and Eckardt scores were higher in the anatomical EGJOO group than in the functional EGJOO group. Significant differences were seen in HRM parameters (UES residual pressure, LES basal pressure, and LES residual pressure) between AC and EGJOO patients. However, no significant differences in HRM parameters were observed between the functional EGJOO and anatomical EGJOO groups. Sixty-seven (95.71%) patients with EGJOO and sixty-nine (87.34%) patients with AC experienced symptom relief (p = 0.071). Among patients achieving symptom relief, a relatively large proportion of patients with EGJOO had symptom relief after medications (37/67, 55.22%), the resolution of potential reasons (7/67, 10.45%), and spontaneous relief (15/67, 22.39%), while more patients with AC had symptom relief after POEM (66/69, 95.65%). Among EGJOO patients achieving symptom relief, more patients (7/20, 35%) with anatomical EGJOO had symptom relief after the resolution of potential reasons for EGJOO, while more patients (32/47, 68.09%) with functional EGJOO had symptom relief with medications. CONCLUSIONS Concurrent AEG and autoimmune diseases are more likely in EGJOO than in AC. A considerable part of EGJOO may be the early manifestation of an organic disease. Anatomical EGJOO patients experience symptom improvement with the resolution of primary diseases, while most functional EGJOO patients experience symptom relief with pharmacotherapy alone or even without any treatment.
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Affiliation(s)
- Yan Wang
- Department of Gastroenterology, The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China
| | - Ting Yu
- Department of Gastroenterology, The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China
| | - Feng Zhu
- Department of Gastroenterology, The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China
| | - Ying Xu
- Department of Gastroenterology, The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China
| | - Yun Bao
- Department of Gastroenterology, The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China
- Department of Gastroenterology and Hepatology, South China Hospital, Health Science Center, Shenzhen University, Shenzhen 440307, China
| | - Ling Zhang
- Department of Gastroenterology, The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China
- Department of Gastroenterology, Southeast University Zhongda Hospital, Nanjing 210029, China
| | - Lin Lin
- Department of Gastroenterology, The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China
| | - Yurong Tang
- Department of Gastroenterology, The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China
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7
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Leopold AR, Jalalian A, Thaker P, Wellington J, Papademetriou M, Xie G. Major mixed motility disorders: An important subset of esophagogastric junction outflow obstruction. Neurogastroenterol Motil 2023; 35:e14555. [PMID: 37309619 PMCID: PMC10266834 DOI: 10.1111/nmo.14555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 02/07/2023] [Accepted: 02/13/2023] [Indexed: 06/14/2023]
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.
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Affiliation(s)
- Andrew R Leopold
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Aria Jalalian
- University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Parth Thaker
- Department of Internal Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jennifer Wellington
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Atrium Health Gastroenterology and Hepatology, Charlotte, North Carolina, USA
| | - Marianna Papademetriou
- Division of Gastroenterology and Hepatology, Veterans Affairs Washington DC Medical Center, Washington, D.C., USA
| | - Guofeng Xie
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Division of Gastroenterology and Hepatology, Veterans Affairs Maryland Healthcare System, Baltimore, Maryland, USA
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8
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Benson AA, Khoury T, Feldman D, Mintz Y, Herschcovici T. Treatment of esophagogastric junction outflow obstruction with concomitant hypercontractile esophagus: A case series. Indian J Gastroenterol 2023; 42:431-435. [PMID: 37115479 DOI: 10.1007/s12664-022-01267-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 05/25/2022] [Indexed: 04/29/2023]
Abstract
Hypercontractile esophagus with concomitant esophagogastric junction outflow obstruction (EGJOO) is a rare entity that is characterized by both esophageal hypercontractility and lack of relaxation of the EGJ. The clinical characteristics of these patients are not well-described and there is no strict recommendation regarding the treatment of this condition. We report four cases of patients with hypercontractile esophagus and concomitant to EGJOO. All patients underwent upper gastrointestinal (GI) endoscopy, high-resolution esophageal manometry (HRM) and barium swallow and met the criteria of Chicago Classification for both EGJOO and hypercontractile esophagus. Patients were followed up to four years from diagnosis and clinical symptoms were recorded. Four patients, who underwent evaluation for dysphagia, were found to have both EGJOO and hypercontractile esophagus on HRM. Two of them had mild symptoms and did not undergo treatment with no progression of symptoms on follow-up. Of the two patients who underwent treatment, one had botulinum toxin injection to the EGJ via upper GI endoscopy and one underwent per-oral endoscopic myotomy. Symptoms in both patients improved. Patients with concomitant hypercontractile esophagus and EGJOO present with varying degrees of symptoms and the treatment approach should be personalized according to the degree of symptoms and general clinical condition.
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Affiliation(s)
- Ariel A Benson
- Institute of Gastroenterology and Liver Diseases, Department of Internal Medicine, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
| | - Tawfik Khoury
- Department of Gastroenterology, Gallilee Medical Center, Nahariya, Israel
- Faculty of Medicine in the Galilee, Bar Ilan University, Safed, Israel
| | - Dan Feldman
- Department of Gastroenterology, Hillel Yaffe Medical Center, Hadera, Israel
| | - Yoav Mintz
- Department of General Surgery, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Tiberiu Herschcovici
- Institute of Gastroenterology and Liver Diseases, Department of Internal Medicine, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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9
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Alcalá-González LG, Ezquerra-Duran A, Aguilar A, Barber C, Barba E, Araujo IK, Marin I, Naves J, Serra J. Benefit of extending the protocol for high resolution manometry according to the version 4.0 of the Chicago criteria. A multicenter study. Neurogastroenterol Motil 2023; 35:e14503. [PMID: 36443930 DOI: 10.1111/nmo.14503] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 11/02/2022] [Accepted: 11/09/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND The last version of the Chicago Criteria for high resolution esophageal manometry proposes an expanded protocol including complementary maneuvers to improve the diagnostic yield of the exploration. Our aim was to determine the diagnostic gain of the CCv4.0 protocol compared to the CCv3.0 protocol. METHODS All manometry recordings performed in 4 reference centers during the first 10 months after the implementation of the new protocol were retrospectively reviewed. The time spent to complete the protocol was measured, and the changes in diagnosis resulting from the new CCv4.0 were compared to CCv3.0. KEY RESULTS From a total of 756 HRM performed, 606 studies could be properly analyzed. The duration of the studies was 18.3 ± 4.3 min. From these, 11.3 ± 3.4 min were spent to complete the CCv3.0 protocol, and 7.4 ± 3.6 min were spent for the remaining maneuvers. A discordant diagnosis between CCv3.0 and CCv4.0 was obtained in 12% of patients: 32% of patients with ineffective esophageal motility turned to normal motility; 24% of patients with esophagogastric junction outlet obstruction (EGJOO) turned to a non-obstructive disorder; and 1% of patients with an apparently normal EGJ relaxation, turned to an obstructive disorder. EGJOO according to CCv4.0 was more prevalent in patients referred for dysphagia (11%) than those referred for GERD (4%; p = 0.003). CONCLUSIONS AND INFERENCES Prolongation of the time spent to complete the CCv4.0 protocol leads to a change in the diagnosis of 12% of patients. Clinically relevant changes are mainly related to the evaluation of EGJOO.
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Affiliation(s)
- Luis G Alcalá-González
- Digestive System Research Unit, University Hospital Vall d'Hebrón, Barcelona, Spain.,Autonomous University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Alberto Ezquerra-Duran
- Digestive System Research Unit, University Hospital Vall d'Hebrón, Barcelona, Spain.,Neurogastroenterology and Motility Unit, Gastroenterology Department, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Ariadna Aguilar
- Digestive System Research Unit, University Hospital Vall d'Hebrón, Barcelona, Spain.,Autonomous University of Barcelona, Barcelona, Spain
| | - Claudia Barber
- Digestive System Research Unit, University Hospital Vall d'Hebrón, Barcelona, Spain.,Autonomous University of Barcelona, Barcelona, Spain
| | - Elizabeth Barba
- Neurogastroenterology and Motility Unit, Gastroenterology Department, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Isis K Araujo
- Neurogastroenterology and Motility Unit, Gastroenterology Department, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Ingrid Marin
- Autonomous University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,Motility and Functional Gut disorders Unit, University Hospital Germans Trias I Pujol, Badalona, Spain
| | | | - Jordi Serra
- Digestive System Research Unit, University Hospital Vall d'Hebrón, Barcelona, Spain.,Autonomous University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
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10
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Desai N, Kline M, Duncan D, Godiers M, Patel V, Keilin S, Jain AS. Expanding the role of pneumatic dilation for nonachalasia patients: a comparative study. Gastrointest Endosc 2023; 97:251-259. [PMID: 36228696 PMCID: PMC11273289 DOI: 10.1016/j.gie.2022.09.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 08/14/2022] [Accepted: 09/27/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Treatment options for nonachalasia obstructive disorders of the esophagogastric junction (EGJ) are limited. The aim of this study was to assess the treatment efficacy of pneumatic dilation (PD) for the disorders of EGJ outflow obstruction (EGJOO) and postfundoplication EGJ obstruction (PF-EGJO) and to assess attitudes regarding training in PD. METHODS This was a 2-part study. The main study was a prospective, single-center study comparing treatment outcomes after PD in patients with EGJOO and PF-EGJO, defined using manometry criteria, versus achalasia. Treatment success was defined as a post-PD Eckardt score (ES) of ≤2 at the longest duration of follow-up available. In a substudy, a 2-question survey was sent to 78 advanced endoscopy fellowship sites in the United States regarding training in PD. RESULTS Of the 58% of respondents to the advanced endoscopy program director survey, two-thirds reported no training in PD at their program. The primary rationale cited was lack of a clinical need for PD. Sixty-one patients (15 achalasia, 32 EGJOO, and 14 PF-EGJO) were included in the main study with outcomes available at a mean follow-up of 8.8 months. Overall, mean ES decreased from 6.30 to 2.89 (P < .0001), and a mean percentage of improvement in symptoms reported by patients was 55.3%. ES ≤2 was achieved by 33 of 61 patients (54.1%). CONCLUSIONS PD is an effective treatment for the nonachalasia obstructive disorders of the EGJ. There may be a current gap in training and technical expertise in PD.
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Affiliation(s)
- Nikita Desai
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Meredith Kline
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Debra Duncan
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Marie Godiers
- Department of Medicine, Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Vaishali Patel
- Department of Medicine, Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Steven Keilin
- Department of Medicine, Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Anand S Jain
- Department of Medicine, Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia, USA
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11
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Low EE, Yadlapati R. Editorial: reducing false alarms with oesophagogastric junction outflow obstruction. Aliment Pharmacol Ther 2022; 56:890-891. [PMID: 35934856 PMCID: PMC9373465 DOI: 10.1111/apt.17131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
LINKED CONTENTThis article is linked to Visaggi et al papers. To view these articles, visit https://doi.org/10.1111/apt.17101
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Affiliation(s)
- Eric E Low
- Division of Gastroenterology, University of California, San Diego, La Jolla, CA
| | - Rena Yadlapati
- Division of Gastroenterology, University of California, San Diego, La Jolla, CA
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12
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Visaggi P, Ghisa M, Del Corso G, Baiano Svizzero F, Mariani L, Tolone S, Frazzoni M, Buda A, Bellini M, Savarino V, Penagini R, Gyawali CP, Savarino EV, de Bortoli N. Chicago classification v4.0 protocol improves specificity and accuracy of diagnosis of oesophagogastric junction outflow obstruction. Aliment Pharmacol Ther 2022; 56:606-613. [PMID: 35751633 PMCID: PMC9544646 DOI: 10.1111/apt.17101] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 06/09/2022] [Accepted: 06/09/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Chicago classification version 4.0 (CCv4.0) introduced stringent diagnostic criteria for oesophagogastric junction outflow obstruction (EGJOO), in order to increase the clinical relevance of the diagnosis, although this has not yet been demonstrated. AIMS To determine the prevalence of EGJOO using CCv4.0 criteria in patients with CCv3.0-based EGJOO, and to assess if provocative manoeuvres can predict a conclusive CCv4.0 diagnosis of EGJOO. METHODS Clinical presentation, high resolution manometry (HRM) with rapid drink challenge (RDC), and timed barium oesophagogram (TBE) data were extracted for patients diagnosed with EGJOO as per CCv3.0 between 2018 and 2020. Patients were then re-classified according to CCv4.0 criteria, using clinically relevant symptoms (dysphagia and/or chest pain), and abnormal barium emptying at 5 min on TBE. Receiver operating characteristic (ROC) analyses identified HRM predictors of EGJOO. RESULTS Of 2010 HRM studies, 144 (7.2%) fulfilled CCv3.0 criteria for EGJOO (median age 61 years, 56.9% female). Upon applying CCv4.0 criteria, EGJOO prevalence decreased to 1.2%. On ROC analysis, integrated relaxation pressure during RDC (RDC-IRP) was a significant predictor of a conclusive EGJOO diagnosis by CCv4.0 criteria (area under the curve: 96.1%). The optimal RDC-IRP threshold of 16.7 mm Hg had 87% sensitivity, 97.1% specificity, 95.7% negative predictive value and 91.3% positive predictive value for a conclusive EGJOO diagnosis; lower thresholds (10 mmHg, 12 mmHg) had better sensitivity but lower specificity. CONCLUSION CCv4.0 criteria reduced the prevalence of EGJOO by 80%, thereby refining the diagnosis and identifying clinically relevant outflow obstruction. Elevated RDC-IRP can predict conclusive EGJOO per CCv4.0.
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Affiliation(s)
- Pierfrancesco Visaggi
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and SurgeryUniversity of PisaPisaItaly
| | - Matteo Ghisa
- Division of Gastroenterology, Department of Surgery, Oncology and GastroenterologyUniversity of PaduaPaduaItaly,Gastroenterology Unit, Department of Oncological Gastrointestinal SurgeryS. Maria del Prato HospitalFeltreItaly
| | | | - Federica Baiano Svizzero
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and SurgeryUniversity of PisaPisaItaly
| | - Lucia Mariani
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and SurgeryUniversity of PisaPisaItaly
| | - Salvatore Tolone
- Division of Surgery, Department of SurgeryUniversity of Campania Luigi VanvitelliCasertaItaly
| | - Marzio Frazzoni
- Gastroenterology Digestive Pathophysiology UnitBaggiovara HospitalModenaItaly
| | - Andrea Buda
- Division of Gastroenterology, Department of Surgery, Oncology and GastroenterologyUniversity of PaduaPaduaItaly
| | - Massimo Bellini
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and SurgeryUniversity of PisaPisaItaly
| | - Vincenzo Savarino
- Division of Gastroenterology, Department of Internal Medicine (DIMI)University of GenoaGenoaItaly
| | - Roberto Penagini
- Gastroenterology and Endoscopy Unit ‐ Department of Pathophysiology and TransplantationFondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico ‐ University of MilanMilanItaly
| | - C. Prakash Gyawali
- Division of GastroenterologyUniversity Washington University School of MedicineSt. LouisMissouriUSA
| | - Edoardo V. Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and GastroenterologyUniversity of PaduaPaduaItaly
| | - Nicola de Bortoli
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and SurgeryUniversity of PisaPisaItaly
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13
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How provocative tests in addition to wet swallows during high-resolution manometry can direct clinical management. Curr Opin Gastroenterol 2022; 38:402-410. [PMID: 35762700 DOI: 10.1097/mog.0000000000000848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
PURPOSE OF REVIEW Provocative tests have been advocated to address limitations of high-resolution manometry (HRM) with wet swallows. We describe the commonly used provocative manometric manoeuvres [rapid drink challenge (RDC), multiple rapid swallows (MRS), solid swallows and the solid test meal (STM)], compare their diagnostic yield and accuracy to wet swallows, and outline their role in directing clinical management. RECENT FINDINGS Provocative testing with RDC and STM identifies a proportion of achalasia cases missed by standard testing, and RDC can play a similar role to radiology in the evaluation of treatment response. In EGJOO, provocative testing with RDC and STM not only increase the diagnostic yield, but can also help differentiate between spurious cases and those representing true outflow obstruction likely to respond to achalasia-type therapies. MRS and STM can help determine the clinical relevance (or otherwise) of ineffective oesophageal motility, and in this setting, MRS may predict the likelihood of postfundoplication dysphagia. RDC and STM can help identify cases of postfundoplication dysphagia more likely to respond to dilatation. SUMMARY Provocative testing has been shown to increase diagnostic yield of HRM, clarify inconclusive diagnoses, allows corroboration of dysmotility with patient symptoms and helps direct clinical management.
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14
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Functional luminal imaging probe in the evaluation of esophago-gastric junction outflow obstruction. Curr Opin Gastroenterol 2022; 38:388-394. [PMID: 35762698 DOI: 10.1097/mog.0000000000000843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
PURPOSE OF REVIEW Esophagogastric junction outflow obstruction (EGJOO) comprises a heterogeneous group of conditions that demonstrate impaired deglutitive relaxation of the esophagogastric junction (EGJ) with intact esophageal peristalsis on high-resolution manometry. Functional luminal imaging probe (FLIP) panometry is a powerful tool that can help to clarify the etiology of this manometric diagnosis. The aim of this review is to summarize the use of FLIP for the evaluation and management of EGJOO. RECENT FINDINGS FLIP panometry provides measures of esophageal compliance at the EGJ and information on esophageal body contractile responses to balloon distention that have important implications for the management of patients with EGJOO. After excluding anatomic causes of impaired EGJ distensibility, FLIP panometry is useful in differentiating true lower esophageal sphincter dysfunction from manometric artifact. FLIP panometry has been shown to be useful in determining the need for invasive treatment in patients with EGJOO, and in intraoperative tailoring of myotomy procedures. SUMMARY FLIP panometry is easy to perform during endoscopy and provides useful information for characterizing the EGJOO population. FLIP panometry can be used to guide treatment and improve outcomes in the management of patients with EGJOO.
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Patel DA, Yadlapati R, Vaezi MF. Esophageal Motility Disorders: Current Approach to Diagnostics and Therapeutics. Gastroenterology 2022; 162:1617-1634. [PMID: 35227779 PMCID: PMC9405585 DOI: 10.1053/j.gastro.2021.12.289] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 12/03/2021] [Accepted: 12/12/2021] [Indexed: 12/13/2022]
Abstract
Dysphagia is a common symptom with significant impact on quality of life. Our diagnostic armamentarium was primarily limited to endoscopy and barium esophagram until the advent of manometric techniques in the 1970s, which provided the first reliable tool for assessment of esophageal motor function. Since that time, significant advances have been made over the last 3 decades in our understanding of various esophageal motility disorders due to improvement in diagnostics with high-resolution esophageal manometry. High-resolution esophageal manometry has improved the sensitivity for detecting achalasia and has also enhanced our understanding of spastic and hypomotility disorders of the esophageal body. In this review, we discuss the current approach to diagnosis and therapeutics of various esophageal motility disorders.
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Affiliation(s)
- Dhyanesh A. Patel
- Division of Gastroenterology, Hepatology and Nutrition, University of California San Diego
| | - Rena Yadlapati
- Vanderbilt University Medical Center and Division of Gastroenterology, University of California San Diego
| | - Michael F. Vaezi
- Division of Gastroenterology, Hepatology and Nutrition, University of California San Diego
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16
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Ribolsi M, Ghisa M, Savarino E. Nonachalasic esophageal motor disorders, from diagnosis to therapy. Expert Rev Gastroenterol Hepatol 2022; 16:205-216. [PMID: 35220870 DOI: 10.1080/17474124.2022.2047648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Investigations conducted using conventional manometry and, recently, using high-resolution manometry (HRM), allowed us to explore the field of esophageal motility and understand the potential link between motor features and gastroesophageal reflux disease (GERD) pathogenesis. The management of patients with nonachalasic esophageal motor disorders is often challenging, due to the clinical heterogeneous presentation and the multifactorial nature of the mechanisms underlying symptoms. AREAS COVERED Several studies, carried out using HRM, have better interpreted the esophageal motor function in patients with esophagogastric junction outflow obstruction (EGJOO), distal esophageal spasm (DES), hypertensive esophagus, and hypomotility disorders. Moreover, HRM studies have shown a direct correlation between reduced esophageal motility, disruption of the esophagogastric junction, and gastroesophageal reflux burden. EXPERT OPINION Pathogenesis, clinical presentation, diagnosis, and treatment of nonachalasic esophageal motor disorders still represent a challenging area, requiring future evaluation by multicenter outcome studies carried out in a large cohort of patients and asymptomatic subjects. However, we believe that an accurate clinical, endoscopic, and HRM evaluation is, nowadays, helpful in addressing patients with nonachalasic esophageal motor disorders to optimal treatment options.
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Affiliation(s)
- Mentore Ribolsi
- Unit of Gastroenterology and Digestive Endoscopy, Campus Bio Medico University, Rome, Italy
| | - Matteo Ghisa
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padova, Italy
| | - Edoardo Savarino
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padova, Italy
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17
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High-Resolution Manometry Thresholds and Motor Patterns Among Asymptomatic Individuals. Clin Gastroenterol Hepatol 2022; 20:e398-e406. [PMID: 33144149 DOI: 10.1016/j.cgh.2020.10.052] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 10/27/2020] [Accepted: 10/29/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE High-resolution manometry (HRM) is the current standard for characterization of esophageal body and esophagogastric junction (EGJ) function. We aimed to examine the prevalence of abnormal esophageal motor patterns in health, and to determine optimal thresholds for software metrics across HRM systems. DESIGN Manometry studies from asymptomatic adults were solicited from motility centers worldwide, and were manually analyzed using integrated relaxation pressure (IRP), distal latency (DL), and distal contractile integral (DCI) in standardized fashion. Normative thresholds were assessed using fifth and/or 95th percentile values. Chicago Classification v3.0 criteria were applied to determine motor patterns across HRM systems, study positions (upright vs supine), ages, and genders. RESULTS Of 469 unique HRM studies (median age 28.0, range 18-79 years). 74.6% had a normal HRM pattern; none had achalasia. Ineffective esophageal motility (IEM) was the most frequent motor pattern identified (15.1% overall), followed by EGJ outflow obstruction (5.3%). Proportions with IEM were lower using stringent criteria (10.0%), especially in supine studies (7.1%-8.5%). Other motor patterns were rare (0.2%-4.1% overall) and did not vary by age or gender. DL thresholds were close to current norms across HRM systems, while IRP thresholds varied by HRM system and study position. Both fifth and 95th percentile DCI values were lower than current thresholds, both in upright and supine positions. CONCLUSIONS Motor abnormalities are infrequent in healthy individuals and consist mainly of IEM, proportions of which are lower when using stringent criteria in the supine position. Thresholds for HRM metrics vary by HRM system and study position.
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18
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Beveridge CA, Triggs JR, Thanawala SU, Ahuja NK, Falk GW, Benitez AJ, Lynch KL. Can FLIP guide therapy in idiopathic esophagogastric junction outflow obstruction? Dis Esophagus 2021; 35:6441958. [PMID: 34864928 PMCID: PMC9016893 DOI: 10.1093/dote/doab077] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 11/01/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Esophagogastric junction outflow obstruction (EGJOO) has a variable disease course. Currently, barium swallow (BaS) and manometric parameters are used to characterize clinically significant EGJOO. The esophagogastric junction distensibility index (EGJ-DI) measured via functional lumen imaging probe (FLIP) can provide complementary information. Our aim was to assess symptom response in patients with EGJOO and an abnormal EGJ-DI after botulinum toxin (BT) treatment. METHODS A prospective cohort study of adults with idiopathic EGJOO was performed from September 2019 to March 2021. Patients with dysphagia underwent upper endoscopy with FLIP. If the EGJ-DI was abnormally low, BT was injected. Data examined included demographics, medical history, endoscopic and FLIP findings, BaS, manometry, and Eckardt score (ES). ES improvement was assessed via paired samples t-test. Pearson's chi-square tests were used to assess for associations. RESULTS Of the 20 patients, 75% had an abnormal EGJ-DI and underwent BT injections. Mean ES for patients with abnormal EGJ-DIs significantly improved from baseline to 1, 3, and 6 month follow-up (P-values: 0.01, 0.05, and 0.02, respectively). There was a significant association between an abnormal EGJ-DI with delayed bolus transit and presence of rapid drink challenge panesophageal pressurization on manometry: P = 0.03 and P = 0.03. CONCLUSION This prospective study revealed that an abnormal EGJ-DI can guide BT as assessed via symptomatic response. Additionally, abnormal EGJ-DI measurements were significantly associated with other parameters used previously to determine clinically relevant EGJOO. Larger follow-up studies are warranted to further elucidate guidance for therapy in EGJOO.
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Affiliation(s)
- Claire A Beveridge
- Address correspondence to: Claire Beveridge, MD, 9500 Euclid Avenue, Cleveland, OH 44195, USA. Tel: 216-444-6536;
| | - Joseph R Triggs
- Department of Medicine, Division of Gastroenterology & Hepatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Shivani U Thanawala
- Department of Medicine, Division of Gastroenterology & Hepatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Nitin K Ahuja
- Department of Medicine, Division of Gastroenterology & Hepatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Gary W Falk
- Department of Medicine, Division of Gastroenterology & Hepatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Alain J Benitez
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, & Nutrition, Children’s Hospital of Philadelphia, Philadelphia, PA, USA,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kristle L Lynch
- Department of Medicine, Division of Gastroenterology & Hepatology, University of Pennsylvania, Philadelphia, PA, USA
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19
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Rogers BD, Gyawali CP. Making Sense of Nonachalasia Esophageal Motor Disorders. Gastroenterol Clin North Am 2021; 50:885-903. [PMID: 34717877 DOI: 10.1016/j.gtc.2021.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Achalasia is the prototypical obstructive motor disorder diagnosed using HRM, but non-achalasia motor disorders are often identified in symptomatic patients. The clinical relevance of these disorders are assessed using ancillary HRM maneuvers (multiple rapid swallows, rapid drink challenge, solid swallows) that augment the standard supine HRM evaluation by challenging peristaltic function. Finding obstructive motor physiology in non-achalasia motor disorders may raise the option of invasive management akin to achalasia. Certain non-achalasia disorders, particularly hypermotility disorders, may manifest as epiphenomena seen with esophageal hypersensitivity. Symptomatic management is offered for superimposed reflux disease, psychological disorders, functional esophageal disorders, and behavioral disorders.
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Affiliation(s)
- Benjamin D Rogers
- Division of Gastroenterology, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8124, St Louis, MO 63110, USA; Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville School of Medicine, 550 South Preston Street, Louisville, KY 40202, USA
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8124, St Louis, MO 63110, USA.
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20
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Predictors of Abnormal Functional Luminal Impedance Planimetry Findings in Non-mechanical Esophagogastric Junction Outflow Obstruction. Dig Dis Sci 2021; 66:3968-3975. [PMID: 33249528 PMCID: PMC8248766 DOI: 10.1007/s10620-020-06726-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 11/17/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Esophagogastric junction outflow obstruction (EGJOO) is a common but nonspecific motility pattern identified by esophageal high-resolution manometry (HRM). Functional luminal impedance planimetry (FLIP) provides information regarding lower esophageal sphincter (LES) mechanics, which can identify achalasia spectrum disorders and is useful in evaluating EGJOO. However, the relationship between HRM and FLIP parameters in EGJOO is not clearly defined. AIMS To identify predictors of abnormal FLIP findings in patients with non-mechanical EGJOO. METHODS This is a retrospective cohort study of patients with non-mechanical EGJOO who underwent FLIP between 10/1/16 and 7/1/19. Demographic data including age and gender, examination indication, concomitant medications, HRM parameters, symptom burden, and FLIP metrics of diameter and distensibility index (DI) were collected. DI was categorized as not low (DI > 2.8), borderline low (DI 1.1-2.8), and definitely low (DI ≤ 1). Kruskal-Wallis and Fisher's exact tests were used to assess the relationship between HRM and FLIP parameters and to identify predictors of abnormal FLIP. RESULTS Among the 44 patients studied, most were female (n = 33, 75%) and the median age was 63. The median IRP was 18.2, and 10 (23%) patients used chronic narcotics. Lower total heartburn and regurgitation scores, and LES diameter by FLIP are associated with definitely low DI. CONCLUSIONS In patients with non-mechanical EGJOO, reflux burden scores and FLIP diameters can aid in predicting DI. These results may provide useful adjunctive data to help in differentiating which patients have meaningful outflow obstruction.
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21
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Impact of patient position on esophageal motility disorders using high-resolution esophageal manometry with impedance (HREMI): supine versus upright swallows. Esophagus 2021; 18:880-888. [PMID: 33974190 DOI: 10.1007/s10388-021-00849-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 04/29/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND High-resolution esophageal manometry with impedance (HREMI) performed with supine patient positioning is used to evaluate patients for esophageal dysmotility. However, most patients experience symptoms related to esophageal dysmotility when eating or drinking upright. The aims of this study are to: (1) compare HREMI metrics in supine versus upright position; and (2) determine if upright position alters motility characterization of patients. METHODS HREMI of twelve wet swallows in supine position and five wet swallows in upright position were performed on normal subjects (NS) and consecutive patients. Chicago Classification v3.0 (CC) diagnoses were evaluated in the supine position and a modified version of the Chicago Classification system was used in the upright position using normative upright values for DCI and IRP. RESULTS DCI decreased in NS by 414 mmHg × cm × sec (p = 0.001) and patients by 613 mmHg × cm × sec (p < 0.001). IRP decreased in NS by 6.2 mmHg (p < 0.001) and patients by 4.6 mmHg (p < 0.001). The rate of successful bolus clearance decreased in the upright position in patients by 11% (p < 0.001), but no statistically significant differences were observed in NS. 82 of 200 patients (41%) had a change in CC diagnosis in the upright position. Bolus clearance in the upright position varied in patients depending on their diagnosis in the upright position. CONCLUSIONS Upright swallows had lower LES, IRP, DCI and UES pressures in both normal subjects and patients with decreased bolus clearance in patients. Upright positioning can alter esophageal motility patterns and enhance diagnostic yield. Thus, upright swallows supplement supine swallows to help characterize esophageal dysmotility.
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22
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Bredenoord AJ, Babaei A, Carlson D, Omari T, Akiyama J, Yadlapati R, Pandolfino JE, Richter J, Fass R. Esophagogastric junction outflow obstruction. Neurogastroenterol Motil 2021; 33:e14193. [PMID: 34120375 DOI: 10.1111/nmo.14193] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 05/11/2021] [Accepted: 05/13/2021] [Indexed: 12/13/2022]
Abstract
In the Chicago Classification version 4.0 (CCv4), esophagogastric junction outflow obstruction (EGJOO) is manometrically defined as an elevated median integrated relaxation pressure (IRP) and elevated intrabolus pressure (IBP) during supine wet swallows, and persistently elevated median IRP in the upright position. A clinically relevant conclusive diagnosis of EGJOO requires a manometric diagnosis of EGJOO and associated symptoms such as dysphagia and/or chest pain with at least one of the following supportive investigations (pharmacologic provocation, timed barium esophagogram, and/or endoflip). The Chicago Classification is intended for diagnosis of primary esophageal motor disorders, and thus history and endoscopic evaluation are important to exclude conditions (eg, previous surgery, strictures, or masses) that can secondarily generate the EGJOO pattern on HRM. While a manometric finding of EGJOO is often made and can be an early sign of achalasia, more often it is a manometric finding without clinical implications. The proposed changes in CC4.0 have attempted to make the diagnosis more specific, in order to reduce the number of clinically irrelevant diagnoses and avoid confusion by patients and physicians alike.
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Affiliation(s)
- Albert J Bredenoord
- Department of Gastroenterology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Arash Babaei
- Division of Gastroenterology, Department of Medicine, National Jewish Health, Denver, CO, USA
| | - Dustin Carlson
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Taher Omari
- College or Medicine & Public Health, Flinders University, Adelaide, SA, Australia
| | - Jun Akiyama
- Division of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Rena Yadlapati
- Division of Gastroenterology & Hepatology, Center for Esophageal Diseases, University of California San Diego, La Jolla, CA, USA
| | - John E Pandolfino
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Joel Richter
- Joy McCann Culverhouse Center for Esophageal Diseases, University of South Florida College of Medicine, Tampa, FL, USA
| | - Ronnie Fass
- Esophageal and Swallowing Center, Division of Gastroenterology and Hepatology, Metrohealth Medical System, Case Western Reserve University, Cleveland, OH, USA
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Jacobs CC, Perbtani Y, Yang D, Al-Haddad MA, Obaitan I, Othman M, Groth S, Sethi A, Agarunov E, Repici A, Maselli R, Galtieri A, Moremen J, Jenkins HN, Samarasena JB, Chang KJ, Draganov PV. Per-Oral Endoscopic Myotomy for Esophagogastric Junction Outflow Obstruction: A Multicenter Pilot Study. Clin Gastroenterol Hepatol 2021; 19:1717-1719.e1. [PMID: 32835840 DOI: 10.1016/j.cgh.2020.08.048] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 08/16/2020] [Accepted: 08/19/2020] [Indexed: 12/14/2022]
Abstract
Esophagogastric junction outflow obstruction (EGJOO) is a rare but increasingly recognized diagnosis as described by The Chicago Classification of Esophageal Motility Disorders version 3.0 (version 3.0).1 On high-resolution manometry (HRM), EGJOO is characterized by increased integrated relaxation pressure (IRP) of the lower esophageal sphincter (LES), yet with some preserved esophageal peristalsis.2-4 Little consensus exists on the preferred therapeutic approach.3 Although conceptually per-oral endoscopic myotomy (POEM) should address the measurable dysfunction in the LES, few data exist to support this.5 Thus, we aimed to evaluate the safety and efficacy of POEM for the treatment of symptomatic EGJOO.
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Affiliation(s)
- Chelsea C Jacobs
- Department of Internal Medicine, University of Florida, Gainesville, Florida
| | - Yaseen Perbtani
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida
| | - Dennis Yang
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida
| | - Mohammad A Al-Haddad
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana
| | - Ite Obaitan
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana
| | - Mohamed Othman
- Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas
| | - Shawn Groth
- Division of General Thoracic Surgery, Baylor College of Medicine, Houston, Texas
| | - Amrita Sethi
- Division of Digestive and Liver Diseases, Columbia University, New York, New York
| | - Emil Agarunov
- Division of Digestive and Liver Diseases, Columbia University, New York, New York
| | - Alessandro Repici
- Division of Gastroenterology, Humanitas Research Hospital, Milan, Italy
| | - Roberta Maselli
- Division of Gastroenterology, Humanitas Research Hospital, Milan, Italy
| | - Alessia Galtieri
- Division of Gastroenterology, Humanitas Research Hospital, Milan, Italy
| | - Jacob Moremen
- Department of Surgery, University of Mississippi Medical Center, Jackson, Mississippi
| | - Haley N Jenkins
- Department of Surgery, University of Mississippi Medical Center, Jackson, Mississippi
| | - Jason B Samarasena
- Division of Gastroenterology and Hepatology, University of California Irvine, Irvine, California
| | - Kenneth J Chang
- Division of Gastroenterology and Hepatology, University of California Irvine, Irvine, California
| | - Peter V Draganov
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida.
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Chen S, Liang M, Tan N, Zhang M, Lin Y, Cao P, Zhuang Q, Xiao Y. Upright Integrated Relaxation Pressure Predicts Symptom Outcome for Esophagogastric Junction Outflow Obstruction. J Neurogastroenterol Motil 2021; 27:363-369. [PMID: 34210901 PMCID: PMC8266504 DOI: 10.5056/jnm20106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 12/19/2020] [Indexed: 12/02/2022] Open
Abstract
Background/Aims Esophagogastric junction outflow obstruction (EGJOO) is characterized by elevated integrated relaxation pressure (IRP) and preserved esophageal peristalsis. The clinical significance of EGJOO is uncertain. This study aim to describe the clinical characteristics of these patients and to find out potential parameters to predict patients’ symptom outcome. Methods Consecutive patients who received high-resolution manometry examination in our hospital in 2013-2019 and met the diagnostic criteria of EGJOO were retrospectively included. Motility and reflux parameters as well as endoscopy and barium esophagogram results were studied and compared. Patients were also followed up to record their treatment methods and symptom outcomes. Results A total of 138 EGJOO (accounting for 5.2% of total patients taking high-resolution manometry examination in our hospital) patients were included. Only 2.9% of these patients had persistent dysphagia. A total of 81.8% of EGJOO patients had symptom resolution during follow-up. Patients with persistent dysphagia had significantly higher upright IRP (16.6 [10.3, 19.8] vs 7.8 [3.2, 11.5]; P = 0.026) than those without. Upright IRP can effectively distinguished patients with persistent dysphagia (area under curve 0.826; P = 0.026) using optimal cut-off value of 9.05 mmHg. Conclusion EGJOO patients with persistent dysphagia and higher upright IRP (median > 9.05 mmHg) needs further evaluation and aggressive management.
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Affiliation(s)
- Songfeng Chen
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Mengya Liang
- Department of Cardian Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Niandi Tan
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Mengyu Zhang
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yuqing Lin
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Peixian Cao
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Qianjun Zhuang
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yinglian Xiao
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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Coexisting Abnormal Esophageal Body Motility Predicts Clinical Symptoms and Bolus Transit in Patients With Esophagogastric Junction Outflow Obstruction (EGJOO). J Clin Gastroenterol 2021; 55:499-504. [PMID: 32649446 DOI: 10.1097/mcg.0000000000001390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 06/04/2020] [Indexed: 12/10/2022]
Abstract
GOAL The goal of this study was to compare the clinical presentations of esophagogastric junction outflow obstruction (EGJOO) with coexisting abnormal esophageal body motility (EBM) to isolated EGJOO. BACKGROUND The clinical significance and management of EGJOO remain debated, as patients may have varied to no symptoms. The effect of coexisting abnormal EBM in EGJOO is unclear. We hypothesized that a concomitant EBM disorder is associated with clinical symptoms of EGJOO. STUDY This was a retrospective cohort study of consecutive adults diagnosed with EGJOO on high-resolution impedance-manometry (HRIM) at 2 academic centers in March 2018 to September 2018. Patients with prior treatment for achalasia, foregut surgery, or evidence of obstruction were excluded. Subjects were divided into EGJOO with abnormal EBM per Chicago classification v3.0 and isolated EGJOO. Statistical analyses were performed using Fisher-exact or Student t test (univariate) and logistic or linear regression (multivariate). RESULTS Eighty-two patients (72% women, age 61.1±10.7 y) were included. Thirty-one (37.8%) had abnormal EBM, including 16 (19.5%) ineffective esophageal motility and 15 (18.2%) hypercontractile esophagus. Esophageal symptoms (heartburn, regurgitation, chest pain, dysphagia) were more prevalent among those with abnormal EBM (90.3% vs. 64.7%, P=0.01). On logistic regression adjusting for age, gender, body mass index, and opioid use, abnormal EBM remained predictive of esophageal symptoms (adjusted odds ratio [aOR] 7.51, P=0.007). On separate models constructed, HE was associated with chest pain (aOR 7.45, P=0.01) and regurgitation (aOR 4.06, P=0.046), while ineffective esophageal motility was predictive of heartburn (aOR 5.84, P=0.009) and decreased complete bolus transit (β-coefficient -0.177, P=0.04). CONCLUSION Coexisting abnormal EBM is associated with esophageal symptoms and bolus transit in patients with EGJOO.
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Godoy-Salgado DC, Toro-Monjaraz EM, Padilla-Cortés T, Cadena-León JF, Zárate-Mondragón F, Loredo-Mayer A, Ignorosa-Arellano K, Cervantes-Bustamante R, Ramírez-Mayans JA. Esophagogastric junction outflow obstruction in the differential diagnosis of post-fundoplication dysphagia in children. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2021; 86:253-258. [PMID: 34210459 DOI: 10.1016/j.rgmxen.2021.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 06/05/2020] [Indexed: 12/01/2022]
Abstract
INTRODUCTION AND AIMS Post-fundoplication dysphagia is resolved with no therapeutic intervention in the majority of cases but it can persist in 5.3% of children that undergo the procedure. Among the differential diagnoses, esophagogastric junction outflow obstruction (EGJOO) is a disorder that should be suspected if there is a persistence of dysphagia. The aim of our study was to describe the clinical characteristics, treatment, and follow-up in a case series of patients diagnosed with post-fundoplication EGJOO. MATERIALS AND METHODS The clinical records of patients diagnosed with EGJOO at a tertiary care hospital within the time frame of September 2015 to September 2019 were reviewed, with respect to manometry, etiology, treatment, and clinical course of the disease. RESULTS Of the 213 high-resolution esophageal manometries performed, 4 patients met the criteria for post-fundoplication EGJOO. The primary symptom was dysphagia, presenting 15 days after the procedure. Esophageal dilations were carried out on all the patients but with no improvement. Symptoms related to the condition resolved spontaneously in three of the four patients. CONCLUSION The management of children with post-fundoplication EGJOO continues to be a challenge. Even though more than half of the cases resolve with no intervention, optimum management of the motility disorder is still limited, given the scant experience with the condition in the pediatric population.
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Affiliation(s)
- D C Godoy-Salgado
- Departamento de Gastroenterología y nutrición Pediátrica, Instituto Nacional de Pediatría, Mexico City, Mexico
| | - E M Toro-Monjaraz
- Departamento de Gastroenterología y nutrición Pediátrica, Instituto Nacional de Pediatría, Mexico City, Mexico.
| | - T Padilla-Cortés
- Departamento de Gastroenterología y nutrición Pediátrica, Instituto Nacional de Pediatría, Mexico City, Mexico
| | - J F Cadena-León
- Departamento de Gastroenterología y nutrición Pediátrica, Instituto Nacional de Pediatría, Mexico City, Mexico
| | - F Zárate-Mondragón
- Departamento de Gastroenterología y nutrición Pediátrica, Instituto Nacional de Pediatría, Mexico City, Mexico
| | - A Loredo-Mayer
- Departamento de Gastroenterología y nutrición Pediátrica, Instituto Nacional de Pediatría, Mexico City, Mexico
| | - K Ignorosa-Arellano
- Departamento de Gastroenterología y nutrición Pediátrica, Instituto Nacional de Pediatría, Mexico City, Mexico
| | - R Cervantes-Bustamante
- Departamento de Gastroenterología y nutrición Pediátrica, Instituto Nacional de Pediatría, Mexico City, Mexico
| | - J A Ramírez-Mayans
- Departamento de Gastroenterología y nutrición Pediátrica, Instituto Nacional de Pediatría, Mexico City, Mexico
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Csucska M, Masuda T, Bremner RM, Mittal SK. Esophagogastric Junction Outflow Obstruction: Are We Missing Anything? J Clin Gastroenterol 2021; 55:121-126. [PMID: 32301830 DOI: 10.1097/mcg.0000000000001355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 03/11/2020] [Indexed: 12/10/2022]
Abstract
GOALS The authors aimed to compare preperistaltic distal esophageal pressure in patients with esophagogastric junction outflow obstruction (EGJOO) with and without reported dysphagia. BACKGROUND Manometric EGJOO is characterized by elevated integral relaxation pressure (>15 mm Hg) without achalasia. The nomenclature inherently implies that it should be associated with impaired food bolus transit and should theoretically present clinically as dysphagia. STUDY The authors queried an esophageal functional test database to identify patients diagnosed with EGJOO. They excluded patients who presented with ≥2 swallows with abnormal (ie, weak, failed or hypercontractile) esophageal body motility. To elucidate differences in manometric findings, the authors formed 2 cohorts of patients on the basis of a standard esophageal symptom questionnaire: those without dysphagia and those with severe or very severe dysphagia. All studies were reanalyzed to determine the distal esophageal pressure before each peristaltic wave (ie, the preperistaltic pressure) for individual swallows. The Mann-Whitney U test was used to compare categorical variables between groups. The level of significance was set to P<0.05. RESULTS In total, 149 patients were diagnosed with EGJOO during the study period. Of these, 42 patients with ≥9 (out of 10) peristalsis (20 without dysphagia and 22 with severe/very severe dysphagia) formed the study cohorts. Patients with severe dysphagia had significantly higher median preperistaltic pressures in the distal esophagus. Preperistaltic pressure measurements showed better sensitivity and specificity for dysphagia than integral relaxation pressure. CONCLUSIONS Elevated preperistaltic pressure is noted in symptomatic EGJOO patients. Inclusion of preperistaltic pressure in the diagnostic criteria for EGJOO may increase the clinical relevance of manometric classification.
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Affiliation(s)
- Máté Csucska
- Norton Thoracic Institute, St Joseph's Hospital Medical Center
| | - Takahiro Masuda
- Norton Thoracic Institute, St Joseph's Hospital Medical Center
- Creighton University School of Medicine, Phoenix Regional Campus, Phoenix, AZ
| | - Ross M Bremner
- Norton Thoracic Institute, St Joseph's Hospital Medical Center
| | - Sumeet K Mittal
- Norton Thoracic Institute, St Joseph's Hospital Medical Center
- Creighton University School of Medicine, Phoenix Regional Campus, Phoenix, AZ
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The Clinical Relevance of Manometric Esophagogastric Junction Outflow Obstruction Can Be Determined Using Rapid Drink Challenge and Solid Swallows. Am J Gastroenterol 2021; 116:280-288. [PMID: 33136563 DOI: 10.14309/ajg.0000000000000988] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 09/08/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Esophagogastric junction outflow obstruction (EGJOO) defined on high-resolution esophageal manometry (HRM) poses a management dilemma given marked variability in clinical manifestations. We hypothesized that findings from provocative testing (rapid drink challenge and solid swallows) could determine the clinical relevance of EGJOO. METHODS In a retrospective cohort study, we included consecutive subjects between May 2016 and January 2020 with EGJOO. Standard HRM with 5-mL water swallows was followed by provocative testing. Barium esophagography findings were obtained. Cases with structural obstruction were separated from functional EGJOO, with the latter categorized as symptom-positive or symptom-negative. Only symptom-positive subjects were considered for achalasia-type therapies. Sensitivity and specificity for clinically relevant EGJOO during 5-mL water swallows, provocative testing, and barium were calculated. RESULTS Of the 121 EGJOO cases, 76% had dysphagia and 25% had holdup on barium. Ninety-seven cases (84%) were defined as functional EGJOO. Symptom-positive EGJOO subjects were more likely to demonstrate abnormal motility and pressurization patterns and to reproduce symptoms during provocative testing, but not with 5-mL water swallows. Twenty-nine (30%) functional EGJOO subjects underwent achalasia-type therapy, with symptomatic response in 26 (90%). Forty-eight (49%) functional EGJOO cases were managed conservatively, with symptom remission in 78%. Although specificity was similar, provocative testing demonstrated superior sensitivity in identifying treatment responders from spontaneously remitting EGJOO (85%) compared with both 5-mL water swallows (54%; P < 0.01) and barium esophagography (54%; P = 0.02). DISCUSSION Provocative testing during HRM is highly accurate in identifying clinically relevant EGJOO that benefits from therapy and should be routinely performed as part of the manometric protocol.
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Hypercontractile Esophagus From Pathophysiology to Management: Proceedings of the Pisa Symposium. Am J Gastroenterol 2021; 116:263-273. [PMID: 33273259 DOI: 10.14309/ajg.0000000000001061] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 10/22/2020] [Indexed: 12/11/2022]
Abstract
Hypercontractile esophagus (HE) is a heterogeneous major motility disorder diagnosed when ≥20% hypercontractile peristaltic sequences (distal contractile integral >8,000 mm Hg*s*cm) are present within the context of normal lower esophageal sphincter (LES) relaxation (integrated relaxation pressure < upper limit of normal) on esophageal high-resolution manometry (HRM). HE can manifest with dysphagia and chest pain, with unclear mechanisms of symptom generation. The pathophysiology of HE may entail an excessive cholinergic drive with temporal asynchrony of circular and longitudinal muscle contractions; provocative testing during HRM has also demonstrated abnormal inhibition. Hypercontractility can be limited to the esophageal body or can include the LES; rarely, the process is limited to the LES. Hypercontractility can sometimes be associated with esophagogastric junction (EGJ) outflow obstruction and increased muscle thickness. Provocative tests during HRM can increase detection of HE, reproduce symptoms, and predict delayed esophageal emptying. Regarding therapy, an empiric trial of a proton pump inhibitor, should be first considered, given the overlap with gastroesophageal reflux disease. Calcium channel blockers, nitrates, and phosphodiesterase inhibitors have been used to reduce contraction vigor but with suboptimal symptomatic response. Endoscopic treatment with botulinum toxin injection or pneumatic dilation is associated with variable response. Per-oral endoscopic myotomy may be superior to laparoscopic Heller myotomy in relieving dysphagia, but available data are scant. The presence of EGJ outflow obstruction in HE discriminates a subset of patients who may benefit from endoscopic treatment targeting the EGJ.
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Salvador R, Provenzano L, Nezi G, Capovilla G, Nicoletti L, Pierobon ES, Moletta L, Valmasoni M, Merigliano S, Costantini M. Laparoscopic Heller-Dor Is an Effective Treatment for Esophageal-Gastric Junction Outflow Obstruction. J Gastrointest Surg 2021; 25:2201-2207. [PMID: 33959877 PMCID: PMC8484249 DOI: 10.1007/s11605-021-05021-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 04/18/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND The treatment of esophagogastric junction outflow obstruction (EGJOO) currently mirrors that of achalasia, but this is based on only a few studies on small case series. The aim of this prospective, controlled study was to assess the outcome of laparoscopic Heller-Dor (LHD) in patients with EGJOO, as compared with patients with esophageal achalasia. MATERIALS AND METHODS Between 2016 and 2019, patients with manometric diagnosis of idiopathic EGJOO and patients with radiological stage I achalasia, both treated with LHD, were compared. The achalasia group was further analyzed by subgrouping the patients based on the manometric pattern. Treatment failure was defined as the persistence or reoccurrence of an Eckardt score > 3 or the need for retreatment. RESULTS During the study period, 150 patients were enrolled: 25 patients had EGJOO and 125 had radiological stage I achalasia (25 pattern I, 74 pattern II, and 26 pattern III). The median follow-up was 24 months (IQR: 34-16). Treatment was successful in 96% of patients in the EGJOO group and in 96% of achalasia patients with pattern I, 98.7% in those with pattern II, and 96.2% of those with pattern III (p=0.50). High-resolution manometry showed a reduction in the LES resting pressure and integrated relaxation pressure for all patients in all 4 groups (p<0.001). CONCLUSION This is the first comparative study based on prospective data collection to assess the outcome of LHD in patients with EGJOO. LHD emerged as an effective treatment for EGJOO, with an excellent success rate, comparable with the procedure's efficacy in treating early-stage achalasia.
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Affiliation(s)
- Renato Salvador
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, School of Medicine, Clinica Chirurgica 3, Azienda Ospedale Università di Padova, Padova, Italy
| | - Luca Provenzano
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, School of Medicine, Clinica Chirurgica 3, Azienda Ospedale Università di Padova, Padova, Italy
| | - Giulia Nezi
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, School of Medicine, Clinica Chirurgica 3, Azienda Ospedale Università di Padova, Padova, Italy
| | - Giovanni Capovilla
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, School of Medicine, Clinica Chirurgica 3, Azienda Ospedale Università di Padova, Padova, Italy
| | - Loredana Nicoletti
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, School of Medicine, Clinica Chirurgica 3, Azienda Ospedale Università di Padova, Padova, Italy
| | - Elisa Sefora Pierobon
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, School of Medicine, Clinica Chirurgica 3, Azienda Ospedale Università di Padova, Padova, Italy
| | - Lucia Moletta
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, School of Medicine, Clinica Chirurgica 3, Azienda Ospedale Università di Padova, Padova, Italy
| | - Michele Valmasoni
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, School of Medicine, Clinica Chirurgica 3, Azienda Ospedale Università di Padova, Padova, Italy
| | - Stefano Merigliano
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, School of Medicine, Clinica Chirurgica 3, Azienda Ospedale Università di Padova, Padova, Italy
| | - Mario Costantini
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, School of Medicine, Clinica Chirurgica 3, Azienda Ospedale Università di Padova, Padova, Italy
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Yadlapati R, Kahrilas PJ, Fox MR, Bredenoord AJ, Gyawali CP, Roman S, Babaei A, Mittal RK, Rommel N, Savarino E, Sifrim D, Smout A, Vaezi MF, Zerbib F, Akiyama J, Bhatia S, Bor S, Carlson DA, Chen JW, Cisternas D, Cock C, Coss-Adame E, de Bortoli N, Defilippi C, Fass R, Ghoshal UC, Gonlachanvit S, Hani A, Hebbard GS, Jung KW, Katz P, Katzka DA, Khan A, Kohn GP, Lazarescu A, Lengliner J, Mittal SK, Omari T, In Park M, Penagini R, Pohl D, Richter JE, Serra J, Sweis R, Tack J, Tatum RP, Tutuian R, Vela MF, Wong RK, Wu JC, Xiao Y, Pandolfino JE. Esophageal motility disorders on high-resolution manometry: Chicago classification version 4.0 ©. Neurogastroenterol Motil 2021; 33:e14058. [PMID: 33373111 PMCID: PMC8034247 DOI: 10.1111/nmo.14058] [Citation(s) in RCA: 403] [Impact Index Per Article: 134.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 11/21/2020] [Accepted: 11/24/2020] [Indexed: 12/12/2022]
Abstract
Chicago Classification v4.0 (CCv4.0) is the updated classification scheme for esophageal motility disorders using metrics from high-resolution manometry (HRM). Fifty-two diverse international experts separated into seven working subgroups utilized formal validated methodologies over two-years to develop CCv4.0. Key updates in CCv.4.0 consist of a more rigorous and expansive HRM protocol that incorporates supine and upright test positions as well as provocative testing, a refined definition of esophagogastric junction (EGJ) outflow obstruction (EGJOO), more stringent diagnostic criteria for ineffective esophageal motility and description of baseline EGJ metrics. Further, the CCv4.0 sought to define motility disorder diagnoses as conclusive and inconclusive based on associated symptoms, and findings on provocative testing as well as supportive testing with barium esophagram with tablet and/or functional lumen imaging probe. These changes attempt to minimize ambiguity in prior iterations of Chicago Classification and provide more standardized and rigorous criteria for patterns of disorders of peristalsis and obstruction at the EGJ.
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Affiliation(s)
- Rena Yadlapati
- Center for Esophageal Diseases, University of California San Diego, La Jolla, CA, USA
| | - Peter J. Kahrilas
- Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mark R. Fox
- University of Zürich, CH-8091 Zürich & Department of Gastroenterology, Klinik Arlesheim, CH-4144 Arlesheim
| | - Albert J. Bredenoord
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - C. Prakash Gyawali
- Division of Gastroenterology & Hepatology, Washington University School of Medicine, St. Louis, MO, USA
| | - Sabine Roman
- Univ Lyon, Université Lyon I, Hospices Civils de Lyon, Digestive Physiology, F-69003, Lyon, France,Univ Lyon, Université Lyon I, Hospices Civils de Lyon, INSERM, LabTAU, F-69003, Lyon, France
| | | | - Ravinder K. Mittal
- Center for Esophageal Diseases, University of California San Diego, La Jolla, CA, USA,Veteran Affairs San Diego Healthcare System, La Jolla, CA, USA
| | - Nathalie Rommel
- University of Leuven, Neurosciences, Experimental ORL, Deglutology - University Hospitals Leuven Dept Gastroenterology, Neurogastroenterology & Motility
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Daniel Sifrim
- Wingate institute of Neurogastroenterology, Queen Mary University of London
| | - André Smout
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | | | - Frank Zerbib
- CHU de Bordeaux, Centre Medico-chirurgical Magellan, Hôpital Haut-Lévêque, Gastroenterology department; Université de Bordeaux; INSERM CIC 1401; Bordeaux, France
| | | | | | - Serhat Bor
- Ege University School of Medicine, Div. Gastroenterology, Turkey
| | - Dustin A. Carlson
- Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Daniel Cisternas
- Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo. Santiago, Chile
| | | | - Enrique Coss-Adame
- Gastroenterology Department, Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán”
| | - Nicola de Bortoli
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa
| | | | - Ronnie Fass
- MetroHealth System and case Western Reserve University
| | - Uday C. Ghoshal
- Dept. of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Sutep Gonlachanvit
- Excellence Center on Neurogastroenterology and Motility, Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Thailand
| | - Albis Hani
- Pontificia Universidad Javeriana-Hospital San Ignacio, Colombia
| | | | - Kee Wook Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | | | | | - Abraham Khan
- New York University, Langone Health, New York, NY, USA
| | | | | | | | | | - Taher Omari
- College of Medicine & Public Health, Flinders University, South Australia, Australia
| | - Moo In Park
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Roberto Penagini
- Gastroenterology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico and Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Daniel Pohl
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Switzerland
| | - Joel E. Richter
- University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Jordi Serra
- University Hospital Germans Trias i Pujol. Badalona. CIBERehd
| | - Rami Sweis
- University College London Hospital, United Kingdom
| | - Jan Tack
- TARGID, University of Leuven, Belgium
| | - Roger P. Tatum
- University of Washington Department of Surgery/VA Puget Sound HCS
| | - Radu Tutuian
- Bürgerspital Solothurn, University of Bern, University of Zurich, Switzerland
| | | | - Reuben K. Wong
- Yong Loo Lin of Medicine, National University of Singapore, Singapore
| | - Justin C. Wu
- The Chinese University of Hong Kong, Hong Kong SAR
| | - Yinglian Xiao
- Department of Gastroenterology, the First Affiliated Hospital, Sun Yat-sen University, China
| | - John E. Pandolfino
- Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Su H, Ge H, Liu H, Jiang G, Shi S, Xu G, Zhang N, Wu J. High-resolution manometry in the upright position could improve the manometric evaluation of morbidly obese patients with esophagogastric junction outflow obstruction. Neurogastroenterol Motil 2020; 32:e13924. [PMID: 32599674 DOI: 10.1111/nmo.13924] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 05/26/2020] [Accepted: 05/28/2020] [Indexed: 01/01/2023]
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.
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Affiliation(s)
- Hui Su
- Department of Gastroenterology, Capital Medical University Affiliated Beijing Shijitan Hospital, Beijing, China
| | - Hui Ge
- Department of Gastroenterology, Capital Medical University Affiliated Beijing Shijitan Hospital, Beijing, China
| | - Hong Liu
- Department of Gastroenterology, Capital Medical University Affiliated Beijing Shijitan Hospital, Beijing, China
| | - Guojun Jiang
- Department of Gastroenterology, Capital Medical University Affiliated Beijing Shijitan Hospital, Beijing, China
| | - Siwen Shi
- Department of Gastroenterology, Capital Medical University Affiliated Beijing Shijitan Hospital, Beijing, China
| | - Guangzhong Xu
- Department of Gastrointestinal and Hepatobiliary Surgery, Capital Medical University Affiliated Beijing Shijitan Hospital, Beijing, China
| | - Nengwei Zhang
- Department of Gastrointestinal and Hepatobiliary Surgery, Capital Medical University Affiliated Beijing Shijitan Hospital, Beijing, China
| | - Jing Wu
- Department of Gastroenterology, Capital Medical University Affiliated Beijing Shijitan Hospital, Beijing, China.,Department of Gastroenterology and Hepatology, Capital Medical University Affiliated Beijing Friendship Hospital, Beijing, China
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[Study of etiology and esophageal motility characteristics of esophagogastric junction outlet obstruction patients]. BEIJING DA XUE XUE BAO. YI XUE BAN = JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2020; 52. [PMID: 33047715 PMCID: PMC7653411 DOI: 10.19723/j.issn.1671-167x.2020.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To analyze the causes of the esophagogastric junction outlet obstruction (EGJOO) patients, to discuss the differences of the clinical manifestation and esophageal motility characteristics between the anatomic EGJOO (A-EGJOO) and functional EGJOO (F-EGJOO) subgroups, and to search the diagnostic values of the specific metrics for differentiating the subgroups of EGJOO patients. METHODS For the current retrospective study, all the patients who underwent the esophageal high resonance manometry test were retrospectively analyzed from Jan 2012 to Oct 2018 in Peking University Third Hospital. The EGJOO patients were enrolled in the following research. The clinical characteristics, such as symptoms and causes of the patients were studied. Then the patients were divided into two subgroups as A-EGJOO subgroup and F-EGJOO subgroup. The clinical symptoms and the main manometry metrics were compared between these two subgroups. The significant different metrics between the two groups were selected to draw receiver operating characteristic (ROC) curves and the diagnostic values were analyzed in differentiating the A-EGJOO and F-EGJOO subgroups. RESULTS The most common symptom of EGJOO was chest pain or chest discomfort (30.63%), then the dysphagia (29.73%), and acid regurgitation/heartburn (27.03%). Non-erosive reflux disease (36.04%) was the most popular cause for EGJOO, then the reflux esophagitis (17.12%). Besides the intra-EGJOO and extra-EGJOO lesions, the connective tissue disease (6.31%) and central nervous diseases (2.70%) were found to be the etiology of EGJOO. The causes of the rest 19 EGJOO were unknown. A-EGJOO patients presented significantly higher intra bolus pressure (IBP) than that of F-EGJOO [6.80 (5.20, 9.20) mmHg vs. 5.10 (3.10, 7.60) mmHg, P=0.016]. The area under curve of IBP was 0.637. When IBP≥5.15 mmHg, the sensitivity was 78.60% and specificity 50.70% to differentiate A- or F-EGJOO. CONCLUSION Chest pain or chest discomfort was the most common symptom in EGJOO patients. Besides the intraluminal structural disorders, the extra-luminal causes were found in EGJOO patients. A-EGJOO presented higher IBP than that of F-EGJOO patients. The cutoff value of IBP to differentiate A-EGJOO from EGJOO was 5.15 mmHg with sensitivity 78.06% and specificity 50.70%. However for the low area under curve, the diagnostic value of IBP was limited.
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Esophagitis dissecans superficialis (EDS) secondary to esophagogastric junction outflow obstruction (EGJOO): a case report and literature review. Clin J Gastroenterol 2020; 14:26-31. [PMID: 33001361 DOI: 10.1007/s12328-020-01247-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 09/17/2020] [Indexed: 10/23/2022]
Abstract
Esophageal dissecans superficialis (EDS) is a rare disease with endoscopic findings of sloughing squamous tissue with underlying normal mucosa and had no known cause. The literature does support possible causality between the presence of an esophageal stricture and EDS however there has been no association to date between EDS and esophagogastric junction outflow obstruction (EGJOO). We present a case of newly diagnosed EGJOO in a patient with long standing gastroesophageal reflux disease who presented with dysphagia. Evaluation identified endoscopically normal mucosa and a diagnosis of esophagogastric junction outflow obstruction on high resolution impedance manometry. A month later, repeat endoscopy identified diffusely sloughing mucosa consistent with EDS. Endoscopic dilation followed by a robotic Heller myotomy with Dor fundoplication to relive the outflow obstruction resulted in resolution of EDS in this case.
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Obstrucción del tracto de salida de la unión esofagogástrica en el diagnóstico diferencial de disfagia posfunduplicatura en niños. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2020. [DOI: 10.1016/j.rgmx.2020.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Furuzawa-Carballeda J, Coss-Adame E, Romero-Hernández F, Zúñiga J, Uribe-Uribe N, Aguilar-León D, Valdovinos MA, Núñez-Álvarez CA, Hernández-Ramírez DF, Olivares-Martínez E, Cruz-Lagunas A, López-Verdugo F, Priego-Ranero Á, Azamar-Llamas D, Rodríguez-Garcés A, Chávez-Fernández R, Torres-Villalobos G. Esophagogastric junction outflow obstruction: Characterization of a new entity? Clinical, manometric, and neuroimmunological description. Neurogastroenterol Motil 2020; 32:e13867. [PMID: 32368845 DOI: 10.1111/nmo.13867] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 03/09/2020] [Accepted: 04/06/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To determine the differences between clinical, manometric, and neuroimmunological profile of esophagogastric junction outflow obstruction (EGJOO) and achalasia patients. METHODS Seven EGJOO and 27 achalasia patients were enrolled in a blind cross-sectional study. Peripheral blood (PB) of 10 healthy donors and 10 lower esophageal sphincter (LES) muscle biopsies from organ transplant donors were included as controls. The presence of ganglion cells, cells of Cajal, Th22/Th7/Th2/Th1/Tregs/Bregs/pDCregs in tissue, and PB was assessed by immunohistochemistry and flow cytometry. Serum concentration of IL-22/IL-17A/IL-17F/IL-4/IFN-γ/IL-1β/IL-6/IL-23/IL-33/TNF-α/IL-10 was determined using bioplex plates. ANAs and antineuronal antibodies were evaluated by immunofluorescence and Western blot. KEY RESULTS EGJOO and achalasia patients had lower ganglion cells and cells of Cajal percentage vs. controls, while fibrosis was present only in achalasia patients. EGJOO and controls had lower cell percentage of Th22/Th17/Th2 vs. achalasia. EGJOO tissue had lower Th1/Treg cell number vs. achalasia, but higher levels vs. control group. Bregs and pDCregs percentage was higher in EGJOO vs. control group. Percentage of PB subpopulations in EGJOO was not significantly different from control group. Serum cytokine levels were higher for IL-1β/IL-6/TNF-α, while IL-17A levels were lower in EGJOO vs. achalasia and control group. EGJOO group was negative for ANAs, while in achalasia group, 54% were positive. GAD65 and PNMa/Ta2 antibodies were present in achalasia, whereas Yo and recoverin were positive in EGJOO group. CONCLUSIONS AND INFERENCES Although EGJOO shares some clinical characteristics with achalasia, the neuroimmunological profile is completely different, suggesting that EGJOO might be a different entity.
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Affiliation(s)
- Janette Furuzawa-Carballeda
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Enrique Coss-Adame
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Fernanda Romero-Hernández
- Department of Experimental Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Joaquín Zúñiga
- Laboratory of Immunobiology and Genetic, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Mexico City, Mexico.,Escuela de Medicina y Ciencias de la Salud, Tecnologico de Monterrey, Mexico City, Mexico
| | - Norma Uribe-Uribe
- Department of Pathology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Diana Aguilar-León
- Department of Pathology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Miguel A Valdovinos
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Carlos A Núñez-Álvarez
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Diego F Hernández-Ramírez
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Elizabeth Olivares-Martínez
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Alfredo Cruz-Lagunas
- Laboratory of Immunobiology and Genetic, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Mexico City, Mexico
| | - Fidel López-Verdugo
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Ángel Priego-Ranero
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Daniel Azamar-Llamas
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Angélica Rodríguez-Garcés
- Department of Experimental Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Raúl Chávez-Fernández
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Gonzalo Torres-Villalobos
- Department of Experimental Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.,Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico CIty, Mexico
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Patcharatrakul T, Alkaddour A, Pitisuttithum P, Jangsirikul S, Vega KJ, Clarke JO, Gonlachanvit S. How to approach esophagogastric junction outflow obstruction? Ann N Y Acad Sci 2020; 1481:210-223. [DOI: 10.1111/nyas.14412] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 05/11/2020] [Accepted: 05/22/2020] [Indexed: 12/22/2022]
Affiliation(s)
- Tanisa Patcharatrakul
- Center of Excellence on Neurogastroenterology and Motility, Faculty of Medicine Chulalongkorn University Bangkok Thailand
- Division of Gastroenterology, Department of Medicine King Chulalongkorn Memorial Hospital Thai Red Cross Society Bangkok Thailand
| | - Ahmad Alkaddour
- Division of Gastroenterology and Hepatology Augusta University‐Medical College of Georgia Augusta Georgia
| | - Panyavee Pitisuttithum
- Division of General Internal Medicine, Department of Medicine King Chulalongkorn Memorial Hospital Thai Red Cross Society Bangkok Thailand
| | - Sureeporn Jangsirikul
- Division of Gastroenterology, Department of Medicine King Chulalongkorn Memorial Hospital Thai Red Cross Society Bangkok Thailand
| | - Kenneth J. Vega
- Division of Gastroenterology and Hepatology Augusta University‐Medical College of Georgia Augusta Georgia
| | - John O. Clarke
- Stanford Multidimensional Program for Innovation and Research in the Esophagus (S‐MPIRE), Division of Gastroenterology and Hepatology Stanford University School of Medicine Redwood City California
| | - Sutep Gonlachanvit
- Center of Excellence on Neurogastroenterology and Motility, Faculty of Medicine Chulalongkorn University Bangkok Thailand
- Division of Gastroenterology, Department of Medicine King Chulalongkorn Memorial Hospital Thai Red Cross Society Bangkok Thailand
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Moosavi S, Woo M, Jacob DA, Pradhan S, Wilsack L, Buresi M, Gupta M, Al-Awadh Y, Li D, Andrews CN. Anticholinergic, anti-depressant and other medication use is associated with clinically relevant oesophageal manometric abnormalities. Aliment Pharmacol Ther 2020; 51:1130-1138. [PMID: 32383253 DOI: 10.1111/apt.15758] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 02/07/2020] [Accepted: 04/07/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Medications can affect gastrointestinal tract motility. However, their effects on oesophageal motility in particular are often not as widely known or may be underestimated. AIM To review the effect of existing medication use on high-resolution oesophageal manometry (HRM) in a 'real-world' setting. METHODS Adult patients with upper gut symptoms and normal endoscopy or imaging who had HRM over a 22-month period were analysed. Achalasia and major disorders of peristalsis were excluded. All medications taken within 24 hours of the procedure were prospectively recorded and compared with HRM results, controlling for age, gender and proton pump inhibitor use. RESULTS A total of 502 patients (323 female, mean age 51) were recruited. Of these, 41.2% had normal oesophageal HRM, while 41.4% had ineffective oesophageal motility (IOM) and 7.6% had oesophagogastric junction outflow obstruction (OGJOO). Serotonin/norepinephrine reuptake inhibitors (SNRI) and opioids were associated with significantly higher resting lower oesophageal sphincter pressure. Benzodiazepines and opioids were associated with elevated integrated relaxation pressure. SNRI and inhaled beta-agonists were associated with increased distal contractile index, whereas calcium channel blockers were associated with a lower distal contractile index. Odds ratio of being on anticholinergics was higher in IOM patients vs normal (3.6, CI 1.2-10.8). Odds ratio for anticholinergics, inhaled beta-agonists, anticonvulsants, SNRIs and opioids (trend) were all > 3 for OGJOO patients vs normal. CONCLUSION Many medication classes are associated with abnormal HRM variables and diagnoses such as OGJOO and IOM; some of these associations are probably causal. These possible links should be taken into consideration during manometry interpretation.
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Affiliation(s)
- Sarvee Moosavi
- Department of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Division of Gastroenterology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Matthew Woo
- Department of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Deepti A Jacob
- Department of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Gastroenterology and Hepatology, Mayo Clinic Health Systems, Eau Claire, WI, USA
| | - Sarah Pradhan
- Department of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Lynn Wilsack
- Department of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Michelle Buresi
- Department of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Milli Gupta
- Department of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Yacoub Al-Awadh
- Department of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Haya Al-Habeeb Gastroenterology Center, Mubarak Al-Kabeer Hospital, Jabriya, Kuwait
| | - Dorothy Li
- Department of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Christopher N Andrews
- Department of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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Nabi Z, Reddy DN. Non-achalasia esophageal motility disorders: Role of per-oral endoscopic myotomy. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2020. [DOI: 10.18528/ijgii200003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Zaheer Nabi
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
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40
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Zhao Q, Chen P, Wang X, Ye H, Zhang X, Song Y, Zhang X. Is Peroral Endoscopic Myotomy a Potential Therapy for Esophageal Absent Contractility? Surg Laparosc Endosc Percutan Tech 2020; 30:129-133. [PMID: 32168166 PMCID: PMC7147407 DOI: 10.1097/sle.0000000000000770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 01/02/2020] [Indexed: 11/26/2022]
Abstract
AIM Peroral endoscopic myotomy (POEM) is recommended for the endoscopic treatment of achalasia and esophageal junction outflow obstruction (EGJOO); however, absent contractility, a subtype of peristalsis disorders classified by the Chicago Classification of esophageal motility v3.0, has no effective treatment. The purpose of this study was to assess the efficacy of POEM in absent contractility, in the part of the patients presents with dysphagia. METHODS We conducted a single-center retrospective study at a tertiary referral center. We included 30 patients who mainly complain with dysphagia, and they underwent POEM from January 2013 to December 2018. The data of high-resolution esophageal manometry was collected before and after POEM. They were divided into 3 groups: EGJOO, Achalasia, and Absent contractility according to the Chicago Classification of esophageal motility v3.0 before POEM. Telephone follow-up was made in February 2019 to obtain Eckardt scores and weight changes. RESULTS We found that both Eckardt scores and integrated relaxation pressure decreased post-POEM in the 3 groups (P<0.05). Eckardt score was significantly lower in the EGJOO group than in the Absent contractility group (P=0.004) post-POEM. The difference of Eckardt Score was higher in the EGJOO group (P=0.010) and the Achalasia group (P=0.007) than in the Absent contractility group, as was weight gain (P=0.023; P=0.002). CONCLUSIONS These findings suggest that POEM is an effective endoscopic procedure for patients with EGJOO and achalasia. Furthermore, POEM can significantly improve symptoms in patients with absent contractility, although less so than for the other 2 groups. POEM is a potential therapy for absent contractility patients presenting with dysphagia.
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Affiliation(s)
| | | | | | - Hua Ye
- Departments of Gastroenterology
| | | | | | - Xie Zhang
- Pharmacy, Ningbo Medical Center Li Huili Hospital, Zhejiang, China
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Balko RA, Codipilly DC, Ravi K. Minor esophageal functional disorders: are they relevant? CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2020; 18:82-96. [PMID: 31953604 DOI: 10.1007/s11938-020-00279-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW High resolution esophageal manometry (HRM) has expanded understanding of esophageal motor function. The Chicago Classification scheme has allowed systematic categorization of the myriad of manometric parameters identified during HRM. Multichannel intraluminal impedance pH has enhanced ambulatory reflux monitoring through complete assessment of esophageal content transit. However, the clinical implications of identified minor esophageal functional disorders remain unclear. RECENT FINDINGS Esophagogastric junction outlet obstruction is defined by esophagogastric junction obstruction with preserved peristalsis and may be managed expectantly, or in a manner similar to achalasia. Hypercontractile esophagus has been associated with dysphagia and non-cardiac chest pain, but the clinical significance is unclear as a majority of patients will improve without specific therapy. Additionally, these findings may be confounded by chronic opiate use. Ineffective esophageal motility is characterized by diminished esophageal contraction amplitude, potentially causing dysphagia and GERD. However, this is commonly identified in asymptomatic volunteers and may represent a normal variant. The multiple rapid swallow sequence can assess esophageal contraction reserve, which may predict post fundoplication dysphagia. The post-swallow induced peristaltic wave can serve as a surrogate of gastric refluxate clearance, providing important prognostic value. However, the associated time burden and lack of alternative therapeutic options limit its clinical utility. SUMMARY Minor esophageal functional disorders provide new therapeutic targets for symptomatic patients. However, these findings have inconsistent associations with symptoms and poorly defined therapeutic options. Minor esophageal function disorders should not be interpreted in isolation, with management decisions accounting for clinical, endoscopic, and radiographic factors in addition.
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Affiliation(s)
- Ryan A Balko
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Don C Codipilly
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Karthik Ravi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA.
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Zikos TA, Triadafilopoulos G, Clarke JO. Esophagogastric Junction Outflow Obstruction: Current Approach to Diagnosis and Management. Curr Gastroenterol Rep 2020; 22:9. [PMID: 32020310 DOI: 10.1007/s11894-020-0743-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE OF REVIEW We summarize the current epidemiology, presentation, diagnostic workup, and treatment of esophagogastric junction outflow obstruction (EGJOO). We also propose a treatment algorithm based upon the literature and our personal clinical experience. RECENT FINDINGS EGJOO can be caused by functional obstruction (akin to achalasia), mechanical obstruction, medications, or artifact. High-resolution esophageal manometry is currently the gold standard of diagnosis. Recent research on FLIP (functional lumen imaging probe) and timed barium support use as adjunctive testing. The diagnostic yield of cross-sectional imaging is low. Current diagnostic testing and treatment should be targeted to the suspected underlying etiology and clinical presentation of EGJOO. If functional obstruction is present with significant and persistent dysphagia, and either an abnormal FLIP or timed barium swallow, we consider therapy aimed at LES disruption (similar to achalasia). Pharmacologic therapy has a limited role. More research is needed on diagnostic and treatment modalities.
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Affiliation(s)
- Thomas A Zikos
- Stanford Multidimensional Program for Innovation and Research in the Esophagus (S-MPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 430 Broadway Street, Pavilion C, 3rd Floor, GI suite, Redwood City, CA, 94063, USA
| | - George Triadafilopoulos
- Stanford Multidimensional Program for Innovation and Research in the Esophagus (S-MPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 430 Broadway Street, Pavilion C, 3rd Floor, GI suite, Redwood City, CA, 94063, USA
| | - John O Clarke
- Stanford Multidimensional Program for Innovation and Research in the Esophagus (S-MPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 430 Broadway Street, Pavilion C, 3rd Floor, GI suite, Redwood City, CA, 94063, USA.
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Abstract
GOALS Awareness of functional esophagogastric junction outflow obstruction (fEGJOO) has increased, but because there is no consensus on its management, we performed a systematic review of the literature to explore treatment strategies and outcomes. BACKGROUND EGJOO is a heterogenous disorder defined by high-resolution manometry parameters of elevated integrated relaxation pressure with preserved esophageal peristalsis. The etiology may be mechanical obstruction or idiopathic, the latter being fEGJOO. STUDY The PubMed/MEDLINE, Embase, and the Cochrane library electronic databases were searched through June 2018 for all studies of adult patients describing a treatment strategy for fEGJOO or incomplete lower esophageal sphincter relaxation. The search strategy yielded 1792 studies and 8 (0.4%) met inclusion criteria. RESULTS All but one included studies were retrospective (n=184 patients). There were 5 interventions described, with botulinum toxin (Botox) injection (n=69) and expectant management (n=82) the most frequently reported, with success rates of 58% and 54%, respectively. There was substantial heterogeneity among patients and treatments were not directly compared, though reported symptom resolution was similar among all strategies with a mean follow-up time of 15 months. CONCLUSIONS There are a variety of management strategies available for fEGJOO and some patients may not require any intervention. However, among 4 potential approaches aimed at disrupting lower esophageal sphincter hypertonicity, the largest existing evidence base supports either a therapeutic challenge of Botox injection or watchful waiting. Ultimately, these data indicate the need for further study with controlled trials to identify a definitive approach.
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Liu A, Woo M, Nasser Y, Gupta M, Buresi MC, Curley M, Li DY, Wilsack L, Andrews CN. Esophagogastric junction outflow obstruction on manometry: Outcomes and lack of benefit from CT and EUS. Neurogastroenterol Motil 2019; 31:e13712. [PMID: 31523911 DOI: 10.1111/nmo.13712] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 07/31/2019] [Accepted: 08/18/2019] [Indexed: 01/03/2023]
Abstract
BACKGROUND Esophagogastric junction outflow obstruction (EGJOO) is a manometric diagnosis based on the Chicago Classification defined by inadequate relaxation of the gastroesophageal junction (GEJ) with swallowing, but with sufficient peristalsis such that the criteria for achalasia are not met. Possible causes include anatomical and functional etiologies. Further investigations, including computed tomography (CT) of the chest and endoscopic ultrasound (EUS), to help elucidate the etiology of EGJOO have been suggested, but the utility of this approach has not been proven. METHODS All new diagnoses of EGJOO made in the calendar years 2015-2016 were included. A review was performed for each patient to assess clinical outcomes, diagnostic, and therapeutic interventions after the EGJOO diagnosis. KEY RESULTS 107 EGJOO patients were included. Their primary complaints were dysphagia (68%), chest pain (12%), reflux (8%), pre-operative assessment (6%), regurgitation (3%), and cough (3%). The mean IRP was 21.8 mm Hg. After a mean follow-up period of 463 days, the etiology of EGJOO remained undetermined in 67% of patients. 48% of patients were investigated with cross-sectional imaging (and 10% with EUS to rule out external compression or malignancy as a cause of EGJOO; none of these tests provided any further useful information). In only two cases did the EGJOO progress to achalasia. CONCLUSIONS & INFERENCES EGJOO is a manometric diagnosis with unclear clinical significance and outcome. CT and EUS of the GEJ were unhelpful at determining the cause of this entity. In this series, very few appear to progress to achalasia, none were due to malignancy, and many resolved spontaneously.
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Affiliation(s)
- Andy Liu
- Division of Gastroenterology & Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Matthew Woo
- Division of Gastroenterology & Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Yasmin Nasser
- Division of Gastroenterology & Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Milli Gupta
- Division of Gastroenterology & Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Michelle C Buresi
- Division of Gastroenterology & Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Michael Curley
- Division of Gastroenterology & Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Dorothy Y Li
- Division of Gastroenterology & Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Lynn Wilsack
- Division of Gastroenterology & Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Christopher N Andrews
- Division of Gastroenterology & Hepatology, University of Calgary, Calgary, Alberta, Canada
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Nikaki K, Sawada A, Ustaoglu A, Sifrim D. Neuronal Control of Esophageal Peristalsis and Its Role in Esophageal Disease. Curr Gastroenterol Rep 2019; 21:59. [PMID: 31760496 DOI: 10.1007/s11894-019-0728-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE OF REVIEW Esophageal peristalsis is a highly sophisticated function that involves the coordinated contraction and relaxation of striated and smooth muscles in a cephalocaudal fashion, under the control of central and peripheral neuronal mechanisms and a number of neurotransmitters. Esophageal peristalsis is determined by the balance of the intrinsic excitatory cholinergic, inhibitory nitrergic and post-inhibitory rebound excitatory output to the esophageal musculature. RECENT FINDINGS Dissociation of the longitudinal and circular muscle contractions characterizes different major esophageal disorders and leads to esophageal symptoms. Provocative testing during esophageal high-resolution manometry is commonly employed to assess esophageal body peristaltic reserve and underpin clinical diagnosis. Herein, we summarize the main factors that determine esophageal peristalsis and examine their role in major and minor esophageal motility disorders and eosinophilic esophagitis.
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Affiliation(s)
- K Nikaki
- Wingate Institute of Neurogastroenterology, Blizard Institute, Barts and The London School of Medicine and Dentistry, QMUL, 26 Ashfield Street, Whitechapel, London, E1 2AJ, UK
| | - A Sawada
- Wingate Institute of Neurogastroenterology, Blizard Institute, Barts and The London School of Medicine and Dentistry, QMUL, 26 Ashfield Street, Whitechapel, London, E1 2AJ, UK
| | - A Ustaoglu
- Wingate Institute of Neurogastroenterology, Blizard Institute, Barts and The London School of Medicine and Dentistry, QMUL, 26 Ashfield Street, Whitechapel, London, E1 2AJ, UK
| | - D Sifrim
- Wingate Institute of Neurogastroenterology, Blizard Institute, Barts and The London School of Medicine and Dentistry, QMUL, 26 Ashfield Street, Whitechapel, London, E1 2AJ, UK.
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Hoscheit M, Gabbard S. Elevated Intrabolus Pressure Predicts Abnormal Timed Barium Esophagram in Esophagogastric Junction Outflow Obstruction. J Neurogastroenterol Motil 2019; 25:521-524. [PMID: 31587543 PMCID: PMC6786449 DOI: 10.5056/jnm19025] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 07/20/2019] [Indexed: 02/01/2023] Open
Abstract
Background/Aims Timed barium esophagram (TBE) is used the classification of esophageal motility disorders and assessing esophageal function. Currently, there are no published studies examining the relationship between high-resolution manometry and TBE in patients with esophagogastric junction outflow obstruction (EGJOO). This study seeks to evaluate this relationship and identify manometric variables that may indicate further evaluation using TBE. Methods Retrospective review of medical records identified patients with a diagnosis of EGJOO per the Chicago classification version 3.0. TBE was performed using standard protocol. Patients were divided into 2 groups based on complete emptying or persistence of standing barium column at 5 minutes. Results Eleven patients were identified with EGJOO who underwent both high-resolution manometry and TBE within 3 months. Five patients had no standing barium column at 5 minutes, while 6 patients had a persistent barium column. Mean age of each group was 54.0 years and 57.8 years, respectively. Patients with abnormal TBE were found to have significantly elevated intrabolus pressure (IBP) compared with patients who had a normal TBE. Conclusions In our study, we found significant differences in IBP between these patient groups. These findings suggest that patients with EGJOO and elevated IBP may prompt further clinical evaluation with TBE in order to clarify clinical diagnosis and guide therapeutic intervention.
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Affiliation(s)
- Matthew Hoscheit
- Departments of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Scott Gabbard
- Departments of Gastroenterology, Cleveland Clinic Foundation, Cleveland, OH, USA
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Triggs JR, Carlson DA, Beveridge C, Jain A, Tye MY, Kahrilas PJ, Pandolfino JE. Upright Integrated Relaxation Pressure Facilitates Characterization of Esophagogastric Junction Outflow Obstruction. Clin Gastroenterol Hepatol 2019; 17:2218-2226.e2. [PMID: 30708108 PMCID: PMC6663640 DOI: 10.1016/j.cgh.2019.01.024] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 01/10/2019] [Accepted: 01/18/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Under the Chicago Classification of esophageal motility disorders, esophagogastric junction outflow obstruction (EGJOO) includes a varied clinical spectrum that results in diagnostic and management difficulties. We aimed to demonstrate that including upright swallows during high-resolution manometry (HRM) helps identify patients with clinically significant EGJOO. METHODS We performed a retrospective study of consecutive patients diagnosed with EGJOO on HRM from January 2015 through July 2017. HRM studies included 10 supine and 5 upright 5-ml liquid swallows. HRM values, esophagrams, and patient-reported outcomes were evaluated to identify factors associated with objective EGJOO (defined by esophagram) and symptomatic dysphagia (brief esophageal dysphagia questionnaire scores, >10). RESULTS Of the 1911 patients who had HRM during the study period, 16.2% (310) were diagnosed with EGJOO; 155 patients completed an esophagram and 227 completed the brief esophageal dysphagia questionnaire. Of these patients, 30.3% (47/155) had radiographic evidence of EGJOO and 52.4% (119/227) had symptomatic dysphagia. The median upright integrated relaxation pressure for patients with radiographic evidence of EGJOO or symptomatic dysphagia was higher than for patients without. An upright integrated relaxation pressure >12 mmHg identified patients with radiographic evidence of EGJOO with 97.9% sensitivity and 15.7% specificity; for symptomatic dysphagia these values were 88.2% and 23.1%, respectively. CONCLUSION An upright integrated relaxation pressure of >12 mmHg identifies patients with clinically significant esophageal outflow obstruction or dysphagia with a high level of sensitivity. This simple manometric maneuver (upright swallows) should be added to the standard manometric protocol.
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Affiliation(s)
- Joseph R Triggs
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
| | - Dustin A Carlson
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Claire Beveridge
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Anand Jain
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Michael Y Tye
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Peter J Kahrilas
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - John E Pandolfino
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Babaei A, Shad S, Szabo A, Massey BT. Pharmacologic interrogation of patients with esophagogastric junction outflow obstruction using amyl nitrite. Neurogastroenterol Motil 2019; 31:e13668. [PMID: 31236998 PMCID: PMC6693956 DOI: 10.1111/nmo.13668] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 06/18/2019] [Accepted: 06/19/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND The Chicago Classification of esophageal motility includes a group of patients who show evidence of esophagogastric junction outflow obstruction (EGJOO) as demonstrated by elevated integrated relaxation pressure (IRP) and preserved peristalsis. Our aim is to classify EGJOO patients based on response to amyl nitrite (AN) during high-resolution manometry. METHODS Patients were considered to have true EGJOO if elevated IRP during supine swallow persisted in the upright position and was associated with high intrabolus pressure. The EGJ response to AN was compared between patients with achalasia type 2 (A2) and normal esophageal motility. Based on the relaxation gain (deglutitive IRP-AN IRP) value that best discriminated these two groups (10 mm Hg), patients with true EGJOO were categorized as being in either the AN-responsive (AN-R) or AN-unresponsive (AN-U) subgroups. KEY RESULTS In the group of 49 patients with true EGJOO, the AN response classified 27 patients (IRP = 25 ± 10 mm Hg) with AN-R and 22 patients (IRP = 20 ± 5 mm Hg) with AN-U (P = 0.2). In AN-R, AN produced a relaxation gain and rebound after-contraction response at the EGJ comparable to A2 patients. AN-U patients had an elevated IRP after AN and a relaxation gain similar to normal esophageal motility patients. AN-U patients were obese and had higher prevalence of sleep apnea (P < 0.05). CONCLUSIONS Among patients with true EGJOO, only half have pharmacologic evidence of impaired LES relaxation. Pharmacologic interrogation of the EGJ is thus necessary to identify the subgroup of EGJOO patients who could be expected to benefit from LES ablative therapies.
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Affiliation(s)
- Arash Babaei
- Division of Gastroenterology, Department of Medicine, National Jewish Health, Denver, CO, USA,Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Sadaf Shad
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Aniko Szabo
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Benson T. Massey
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
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Lee JH, Lee YJ, Lee JM, Ju MJ, Yang MA, Choi MW, Yun SH. Early Phase of Achalasia Manifested as an Esophageal Subepithelial Tumor. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2019; 74:110-114. [PMID: 31438662 DOI: 10.4166/kjg.2019.74.2.110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 05/16/2019] [Accepted: 05/17/2019] [Indexed: 11/03/2022]
Abstract
The Chicago classification (CC) defines an esophagogastric junction outflow obstruction (EGJOO) as the presence of several instances of intact or weak peristalsis, elevated median integrated relaxation pressure above 15 mmHg, and a discrepancy from the criteria of achalasia. The revised CC addresses the potential etiology of EGJOO, including the early forms of achalasia, mechanical obstruction, esophageal wall stiffness, or manifestation of hiatal hernia. A 58-year-old woman visited the Presbyterian Medical Center with swallowing difficulty. The patient underwent a high resolution manometry (HRM) examination and was diagnosed with EGJOO. Chest CT was performed to exclude a mechanical obstruction as a cause, and CT revealed a subepithelial tumor (SET) at the upper part of the esophagogastric junction. Therefore, laparoscopic surgery was performed and eccentric muscular hypertrophy of the distal esophagus was observed. Longitudinal myotomy and Dor fundoplication were also performed. The histology findings of the surgical specimens were consistent with achalasia. This paper reports a case of early achalasia that was finally diagnosed by the histology findings, but was initially diagnosed as EGJOO using HRM and misdiagnosed as SET in the image study.
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Affiliation(s)
- Jong Hwa Lee
- Division of Gastroenterology, Department of Internal Medicine, Presbyterian Medical Center, Jeonju, Korea
| | - Young Jae Lee
- Division of Gastroenterology, Department of Internal Medicine, Presbyterian Medical Center, Jeonju, Korea
| | - Jong Myeong Lee
- Division of Gastroenterology, Department of General Surgery, Presbyterian Medical Center, Jeonju, Korea
| | - Myoung Jin Ju
- Division of Gastroenterology, Department of Pathology, Presbyterian Medical Center, Jeonju, Korea
| | - Min A Yang
- Division of Gastroenterology, Department of Internal Medicine, Presbyterian Medical Center, Jeonju, Korea
| | - Myung Woo Choi
- Division of Gastroenterology, Department of Internal Medicine, Presbyterian Medical Center, Jeonju, Korea
| | - So Hee Yun
- Division of Gastroenterology, Department of Internal Medicine, Presbyterian Medical Center, Jeonju, Korea
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Laparoscopic Nissen fundoplication improves disease-specific quality of life in patients with gastroesophageal reflux disease and functional gastroesophageal outflow obstruction. Surg Endosc 2019; 34:2608-2612. [DOI: 10.1007/s00464-019-07031-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 07/19/2019] [Indexed: 12/27/2022]
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