Esophagogastric junction outflow obstruction

Esophagogastric junction outflow obstruction (EGJOO) is an

Esophagogastric junction
esophageal motility disorder characterized by increased pressure
where the esophagus connects to the stomach at the lower outflow obstruction
esophageal sphincter. EGJOO is diagnosed by esophageal Other EGJOO
manometry. However, EGJOO has a variety of etiologies; names
evaluating the cause of obstruction with additional testing, such as
Specialty Gastroenterology
upper endoscopy, computed tomography (CT imaging), or
endoscopic ultrasound may be necessary.[2] When possible, Symptoms Asymptomatic,
treatment of EGJOO should be directed at the cause of obstruction. dysphagia, chest pain
When no cause for obstruction is found (functional EGJOO), Usual 56-57 years
observation alone may be considered if symptoms are minimal. onset
Functional EGJOO with significant or refractory symptoms may
be treated with pneumatic dilation, per-oral endoscopic myotomy Types Mechanical,
(POEM), or botulinum toxin injection. functional,
medication, artifact[1]

Types Risk Female gender,

factors overweight
EGJOO may be broadly categorized into 4 subgroups: mechanical, Diagnostic High resolution
functional, medication-related, and artifact.[1] method manometry
(esophageal
Signs and symptoms manometry)
Differential Achalasia
In some cases, EGJOO may cause no symptoms, and the diagnosis
manometry findings are identified during an evaluation prior to
Treatment Pneumatic dilation,
anti-reflux surgery. In other cases, EGJOO may be identified after
Per-oral endoscopic
an evaluation for esophageal symptoms. The most common
symptoms are dysphagia (50-75%, typical reflux (29-67%), myotomy (POEM),
atypical reflux (21-36%), chest pain (16-46%), abdominal pain botulinum toxin
(43%) or regurgitation (38%).[1] One study suggested about 5% of injection
individuals have no symptoms.[1] Prognosis Depends on etiology
Frequency Unknown
Causes
Several causes for EGJOO exist.[2] Etiologies include early achalasia, mechanical processes (eosinophilic
esophagitis, hiatal hernia, strictures, etc.), esophageal wall thickness (fibrosis, cancer, etc.), compression by
nearby blood vessels (external vascular compression), obesity, opioid medication effect, or anatomic
abnormalities.[2] The findings associated with EGJOO may be falsely abnormal due to measurement
errors.[2]

Diagnosis
EGJOO is diagnosed using esophageal manometry.[2] High
resolution esophageal manometry will show elevated pressure at
the LES with normal peristalsis.[2] The LES pressure is
evaluated immediately following a swallow, when the sphincter
should relax.[3] The overall LES pressure after a swallow is
represented by the integrated relaxation pressure (IRP).[3] If the Normal in (A). EGJOO in (B).
IRP is abnormally elevated (>15 mmHg), this indicates an Pressure waves in blue. Cross-sectional
obstruction is present. Normal peristalsis with an obstruction at areas CSA) in fucsia.
the esophagogastric junction (elevated IRP) is consistent with
EGJOO.[3]

Upper endoscopy is used to evaluate for mechanical causes of obstruction.[2] Endoscopic findings may
include a hiatal hernia, esophagitis, strictures, tumors, or masses.[2] Increased pressure at the LES over time
may result in an epiphrenic diverticulum.[2] Further evaluation for mechanical causes of obstruction may
include CT scans, MRI, or endoscopic ultrasound.[2]

Several additional tests may be used to further evaluate EGJOO.[2] Further evaluation of esophageal motor
function may be accomplished with functional lumen imaging probe (FLIP).[2] Although not widely
available, FLIP may help assess esophageal wall stiffness and compliance.[2] FLIP may help identify
individuals with EGJOO who are likely to benefit from therapeutic procedures.[4]

Timed barium esophagram can help distinguish EGJOO from untreated achalasia.[2]

Treatment
Treatment primarily consists of addressing the underlying cause of EGJOO.[2] For example,
gastroesophageal reflux disease (GERD) with reflux esophagitis is treated with proton pump inhibitors.
Esophageal rings or strictures may be treated with esophageal dilation.

Simple observation may be considered,[5] especially if symptoms are minimal or absent. If symptoms are
severe or persistent, peroral endoscopic myotomy (POEM) may be offered.[2]

Pneumatic dilation may be used for persistent symptoms in the absence of identified causes of mechanical
obstruction.[2] Botulinum toxin may be considered,[5] especially for individuals who are unlikely to tolerate
surgery.[2]

Prognosis
The prognosis for EGJOO depends on the etiology of obstruction. In the absence of anatomic or
mechanical causes, such as cancer, outcomes are generally favorable. Individuals with minimal or no
symptoms often experience resolution of the EGJOO, even without treatment.[2]

Epidemiology
The overall prevalence of EGJOO is unclear.[1] The prevalence of EGJOO among all patients undergoing
high resolution manometry was up to 10 percent.[3] The diagnostic criteria were later adjusted to distinguish
relevant (symptomatic) EGJOO from isolated manometric findings of EGJOO without symptoms.[3]
Individuals diagnosed with EGJOO based on Chicago 3.0 classification have an average age of 56–57
years.[1] EGJOO more commonly affects women (51-88%).[1] The average BMI is between 25 and 30.[1]

References
1. Zikos, TA; Triadafilopoulos, G; Clarke, JO (2020-02-05). "Esophagogastric Junction Outflow
Obstruction: Current Approach to Diagnosis and Management". Current Gastroenterology
Reports. 22 (2): 9. doi:10.1007/s11894-020-0743-0 (https://doi.org/10.1007%2Fs11894-020-
0743-0). PMID 32020310 (https://pubmed.ncbi.nlm.nih.gov/32020310). S2CID 211034929
(https://api.semanticscholar.org/CorpusID:211034929).
2. Samo, S; Qayed, E (2019-01-28). "Esophagogastric junction outflow obstruction: Where are
we now in diagnosis and management?" (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC63
50167). World Journal of Gastroenterology. 25 (4): 411–417. doi:10.3748/wjg.v25.i4.411 (htt
ps://doi.org/10.3748%2Fwjg.v25.i4.411). PMC 6350167 (https://www.ncbi.nlm.nih.gov/pmc/a
rticles/PMC6350167). PMID 30700938 (https://pubmed.ncbi.nlm.nih.gov/30700938).
3. Yadlapati, R; Kahrilas, PJ; Fox, MR; Bredenoord, AJ; Prakash Gyawali, C; 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;
Wook Jung, K; Katz, P; Katzka, DA; Khan, A; Kohn, GP; Lazarescu, A; Lengliner, J; Mittal,
SK; Omari, T; Park, MI; 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 (January 2021).
"Esophageal motility disorders on high-resolution manometry: Chicago classification version
4.0©" (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8034247). Neurogastroenterology and
Motility. 33 (1): e14058. doi:10.1111/nmo.14058 (https://doi.org/10.1111%2Fnmo.14058).
PMC 8034247 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8034247). PMID 33373111
(https://pubmed.ncbi.nlm.nih.gov/33373111).
4. Savarino, E; di Pietro, M; Bredenoord, AJ; Carlson, DA; Clarke, JO; Khan, A; Vela, MF;
Yadlapati, R; Pohl, D; Pandolfino, JE; Roman, S; Gyawali, CP (November 2020). "Use of the
Functional Lumen Imaging Probe in Clinical Esophagology" (https://www.ncbi.nlm.nih.gov/p
mc/articles/PMC9380028). The American Journal of Gastroenterology. 115 (11): 1786–1796.
doi:10.14309/ajg.0000000000000773 (https://doi.org/10.14309%2Fajg.000000000000077
3). PMC 9380028 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9380028).
PMID 33156096 (https://pubmed.ncbi.nlm.nih.gov/33156096).
5. Garbarino, S; von Isenburg, M; Fisher, DA; Leiman, DA (January 2020). "Management of
Functional Esophagogastric Junction Outflow Obstruction: A Systematic Review". Journal of
Clinical Gastroenterology. 54 (1): 35–42. doi:10.1097/MCG.0000000000001156 (https://doi.
org/10.1097%2FMCG.0000000000001156). PMID 30575636 (https://pubmed.ncbi.nlm.nih.g
ov/30575636). S2CID 58589325 (https://api.semanticscholar.org/CorpusID:58589325).

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