How do I manage esophagogastric junction outflow obstruction?
Sutep Gonlachanvit, M.D. Professor of medicine, Center of Excellence in Neurogastroenterology and Motility, Chulalongkorn University, Bangkok, Thailand.
According to the Chicago Classification version 4.0, esophagogastric junction outflow obstruction is characterized by 1) elevated IRP in both supine and upright position, 2) > 20% of esophageal contractions in response to wet swallows had elevated intrabolus pressure, and 3) not meeting the criteria for achalasia. In addition, the patients should have clinically relevant symptom especially dysphagia symptom and additional test including time barium esophagogram (TBE) or functional luminal imaging probe (FLIP) suggestive of EGJOO. The causes of EGJOO are 1) medication related (opioid and anticholinergic medications), 2) mechanical obstruction (stricture, EGJ cancer or mass, esophageal rings or external luminal compression), 3) functional obstruction and 4) artifact of no clinical significance. The new C.C v 4.0 required elevated IRP in both supine and upright position and relevant symptom of dysphagia. These new criteria should decrease the patients with artifact of no clinical significance. However, clinician should be careful on thermal compensation procedure during HRM analysis as the thermal compensation point should be located immediately after catheter withdrawal.
EGD should be an initial investigation in patients with EGJOO to identify mechanical causes of EGJ obstruction and exclude eosinophilic esophagitis which require adequate upper and lower esophageal biopsy. CT scan of the chest and endoscopic ultrasound can identify infiltrative lesion not detected by endoscopy. If mechanical obstruction is identified the treatment should be provided accordingly.
Available information of functional EGJOO patients suggests benign nature of the condition. Thus, non-aggressive treatment including observation in mild symptoms, medication or botox injection in more severe symptoms is preferred. Esophageal dilation, POEM or myotomy should be preserved for minority of patients with persistence severe dysphagia symptoms and impaired esophageal clearance.