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.
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.
Authors: Anjan Dhar; Hasan N Haboubi; Stephen E Attwood; Marcus K H Auth; Jason M Dunn; Rami Sweis; Danielle Morris; Jenny Epstein; Marco R Novelli; Hannah Hunter; Amanda Cordell; Sharon Hall; Jamal O Hayat; Kapil Kapur; Andrew Robert Moore; Carol Read; Sarmed S Sami; Paul J Turner; Nigel J Trudgill Journal: Gut Date: 2022-05-23 Impact factor: 31.793
Authors: Rena Yadlapati; Peter J Kahrilas; Mark R Fox; Albert J Bredenoord; C Prakash Gyawali; Sabine Roman; Arash Babaei; Ravinder K Mittal; Nathalie Rommel; Edoardo Savarino; Daniel Sifrim; André Smout; Michael F Vaezi; Frank Zerbib; Junichi Akiyama; Shobna Bhatia; Serhat Bor; Dustin A Carlson; Joan W Chen; Daniel Cisternas; Charles Cock; Enrique Coss-Adame; Nicola de Bortoli; Claudia Defilippi; Ronnie Fass; Uday C Ghoshal; Sutep Gonlachanvit; Albis Hani; Geoffrey S Hebbard; Kee Wook Jung; Philip Katz; David A Katzka; Abraham Khan; Geoffrey Paul Kohn; Adriana Lazarescu; Johannes Lengliner; Sumeet K Mittal; Taher Omari; Moo In Park; Roberto Penagini; Daniel Pohl; Joel E Richter; Jordi Serra; Rami Sweis; Jan Tack; Roger P Tatum; Radu Tutuian; Marcelo F Vela; Reuben K Wong; Justin C Wu; Yinglian Xiao; John E Pandolfino Journal: Neurogastroenterol Motil Date: 2021-01 Impact factor: 3.598