Evaluation of symptomatic esophagogastric junction outflow obstruction.

BACKGROUND AND AIM: Esophagogastric junction outflow obstruction (EGJOO) may be due to anatomical abnormalities, but it is unclear how to evaluate them after high-resolution manometry. We aimed to determine (i) clinical and high-resolution manometry parameters differentiating anatomical EGJOO from functional EGJOO, (ii) investigations chosen and yield for anatomical EGJOO, and (iii) clinical outcomes of functional EGJOO.

METHODS: Medical records of consecutive patients with symptomatic EGJOO from February 2012 to December 2015 were reviewed. EGJOO was defined as anatomical if investigations identified a macroscopic or microscopic pathology accounting for EGJOO.

RESULTS: Forty of 292 (13.7%) had EGJOO, of which 6/40 (15%) had anatomical EGJOO (two PPI-responsive esophageal eosinophilia, two infiltrating cancers, and two external compressions). Anatomical EGJOO was more likely to present with dysphagia (100% vs 29.4%, P = 0.001) and less likely with regurgitation (0% vs 41.2%, P = 0.05). Anatomical EGJOO had higher frequencies of premature contraction (50% vs 5.9%, P = 0.003) and lower mean values of distal latency (5.6 +/- 1.3 vs 6.7 +/- 1.2, P = 0.004). Computed tomography scans revealed 50% (3/6) of etiologies of anatomical EGJOO. Approximately, 73.5% (25/34) of patients with functional EGJOO had spontaneous resolution of their symptoms. One underwent pneumatic dilatation with symptom resolution while remaining eight with persistent symptoms were attributed to gastroesophageal reflux disease.

CONCLUSION: Anatomical causes are present in 15% of EGJOO. Evaluation is warranted especially in patients presenting with dysphagia. Esophageal biopsies, barium swallows, computed tomography scans, and endoscopic ultrasound are complementary in EGJOO evaluation. In patients with non-obstructive symptoms and no anatomical etiologies, monitoring for spontaneous resolution is an option.