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World J Gastroenterol. Jan 28, 2019; 25(4): 411-417
Published online Jan 28, 2019. doi: 10.3748/wjg.v25.i4.411
Esophagogastric junction outflow obstruction: Where are we now in diagnosis and management?
Salih Samo, Emad Qayed
Salih Samo, Emad Qayed, Department of Medicine, Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA 30322, United States
Author contributions: Samo S drafted and revised the manuscript; Qayed E drafted and revised the manuscript; all authors read and approved the final version of the manuscript.
Conflict-of-interest statement: The authors declare no conflicts of interest.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Emad Qayed, MD, MPH, FACG, Assistant Professor, Department of Medicine, Division of Digestive Diseases, Emory University School of Medicine, 615 Michael Street, Suite 201, Atlanta, GA 30322, United States. eqayed@emory.edu
Telephone: +1-404-7781685 Fax: +1-404-7781681
Received: September 25, 2018
Peer-review started: September 25, 2018
First decision: November 8, 2018
Revised: December 6, 2018
Accepted: December 14, 2018
Article in press: December 15, 2018
Published online: January 28, 2019
Processing time: 124 Days and 9.7 Hours
Abstract

Esophagogastric junction outflow obstruction (EGJOO) is a major motility disorder based on the Chicago Classification of esophageal motility disorders. This entity involves a heterogenous group of underlying etiologies. The diagnosis is reached by performing high-resolution manometry. This reveals evidence of obstruction at the esophagogastric junction, manifested by an elevated integrated relaxation pressure (IRP) above a cutoff value (IRP threshold varies by the manometric technology and catheter used), with preserved peristalsis. Further tests like endoscopy, timed barium esophagram, and cross-sectional imaging can help further elucidate the underlying etiology and rule out mechanical causes. Treatment is tailored to the underlying cause. Similar to achalasia, treatment targeting lower esophageal sphincter disruption like pneumatic dilation, peroral endoscopic myotomy, and botulinum injection are used in patients with functional EGJOO and persistent symptoms.

Keywords: Esophagogastric junction outflow obstruction; High-resolution manometry

Core tip: Esophagogastric junction outflow obstruction (EGJOO) is a manometric diagnosis and is considered a major motility disorder. In this condition, it is important to rule out treatable causes of mechanical obstruction at the gastro-esophageal junction. In functional EGJOO, there is no obvious mechanical or structural cause of obstruction. In this condition, presenting symptoms like dysphagia and manometry metrics like IRP and distal contractile integral are associated with persistence of symptoms upon follow up. These patients may benefit from early intervention to disrupt the functional obstruction at the lower esophageal sphincter, using treatment modalities similar to achalasia.