Esophagogastric junction outflow obstruction – Etiology and management of a rare motility disorder

Mayank Jain

doi:10.4103/ghep.ghep_30_22

CLINICAL PERSPECTIVE

Year : 2023 | Volume : 3 | Issue : 2 | Page : 54-55

Esophagogastric junction outflow obstruction – Etiology and management of a rare motility disorder

Mayank Jain
Arihant Hospital and Research Centre, Indore, Madhya Pradesh, India

Date of Submission	19-Oct-2022
Date of Decision	25-Nov-2022
Date of Acceptance	27-Nov-2022
Date of Web Publication	09-Mar-2023

Correspondence Address:
Mayank Jain
297, Indrapuri, Near Bhanwarkuan, Indore, Madhya Pradesh
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ghep.ghep_30_22

How to cite this article:
Jain M. Esophagogastric junction outflow obstruction – Etiology and management of a rare motility disorder. Gastroenterol Hepatol Endosc Pract 2023;3:54-5

How to cite this URL:
Jain M. Esophagogastric junction outflow obstruction – Etiology and management of a rare motility disorder. Gastroenterol Hepatol Endosc Pract [serial online] 2023 [cited 2023 Mar 27];3:54-5. Available from: http://www.ghepjournal.com/text.asp?2023/3/2/54/371276

Esophagogastric junction outflow obstruction (EGJOO) is a major motility disorder based on the Chicago Classification of esophageal motility disorders.^[1] It is diagnosed by performing high-resolution esophageal manometry (HREM), which shows an elevated integrated relaxation pressure with preserved peristalsis. Further, tests such as endoscopy, timed barium esophagram, and cross-sectional imaging can help to elucidate the underlying etiology and rule out mechanical causes.^[2] Potential etiologies for EGJOO include early achalasia, mechanical obstruction, extrinsic compression, infiltrative esophageal diseases, central obesity, opiate side effects, and postfundoplication status.^{[3],[4],[5],[6]}

The present retrospective study was done at Arihant Hospital and Research Centre, Indore, to determine the frequency of EGJOO among patients undergoing HREM for a variety of indications. Moreover, the cause of EGJOO, treatment offered, and response to treatment was analyzed. This retrospective study included all patients diagnosed with EGJOO between January 2015 and June 2019. Mechanical reasons for EGJOO were ruled out using upper gastrointestinal endoscopy and computed tomography (CT), whenever necessary. Before HREM, medications that are likely to affect smooth muscle contraction or lower esophageal sphincter relaxation, such as prokinetics and anticholinergics, were withdrawn for 14 days. Informed consent was obtained from all patients. HREM recording was done using 5 mL water for 10 swallows in the supine posture, using 16-channel water-perfusion system (Ready Stock, Australia) and reporting was done using Trace 1.3.3 software (Hebbard, Australia) with Chicago classification version 3.0. The study was approved by the institutional ethics committee. For statistical analysis, the data were expressed as percentages, medians, and ranges. Comparison of medians was done using Mann–Whitney U test and the comparison of proportions was done using the Chi-square test. A P < 0.05 was considered statistically significant.

A total of 168 hEM studies were done by the author during the study period. Of these, 12 patients (7.2%) had features suggestive of EGJOO [Figure 1]. The median age was 42 years (range 21–56) and males outnumbered females (5:1). The comorbid states included diabetes (3), hypertension (2), and hypothyroidism (2). The symptoms reported included – dysphagia for solids and/or liquids (11, 91.7%), chest pain (7, 58.4%), and weight loss (3, 25%). Mechanical causes of EGJOO were noted in six patients (all males). These included postfundoplication status (5) and benign esophageal stricture (1). All patients with mechanical EGJOO underwent endoscopic balloon dilatation up to 15 mm with good resolution of symptoms on follow-up. In six cases with functional EGJOO, medical management was offered. Four patients (three males and one female) had central obesity and a history of weight gain in the preceding 1 year. They were started on proton-pump inhibitors. Moreover, weight loss with diet control and regular aerobic exercises for 30 min per day was advised. On follow-up at 3 months, they lost an average of 3.5 kg weight, and all reported significant improvement in symptoms. In two patients (one male) with functional EGJOO and no central obesity, acotiamide was initiated in a dose of 100 mg thrice a day. On follow-up at 1 month, there was a significant improvement in symptoms in these two cases. None of the patients reported progression of symptoms and required endoscopic interventions in the functional EGJOO. There was no significant difference in the age and symptoms at presentation in the two groups – mechanical and functional EGJOO [Table 1]. However, the median distal contractile integral was higher in patients with functional EGJOO.

Figure 1: Manometry image of EGJOO. EGJOO: Esophagogastric junction outflow obstruction

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Table 1: Comparison of demographic and high-resolution esophageal manometry parameters between mechanical and functional esophagogastric junction outflow obstruction

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To summarize, EGJOO was noted in 7.2% of all cases undergoing HREM. Mechanical causes were noted in 50% of cases and the majority were secondary to fundoplication surgery. All cases responded well to endoscopic balloon dilatation. Functional EGJOO was more common in patients with central obesity and weight gain. The use of proton-pump inhibitors and lifestyle improvement caused significant improvement in symptoms. Acotiamide was beneficial in patients with functional EGJOO with no central obesity.

The present retrospective study offers insight into the management and outcome of patients with EGJOO. This rare motility disorder is well documented. However, there is no consensus on its proper management. In addition to endoscopy and HREM, other tests such as timed barium swallow, functional luminal imaging probe, endoscopic ultrasound, and CT scan help to point to a certain etiology in EGJOO.^[7] Functional EGJOO usually has a benign course as noted in previous studies.^[5],[8] A recent study noted that acotiamide potentially normalizes the impaired LES relaxation in patients with EGJOO, with no adverse effects on normal esophageal motility patterns.^[9]

The present study is limited by its small sample size and retrospective design. Moreover, repeat HREM studies and timed barium swallows were not done to document improvement in EGJOO. Despite this, it throws light on a rare motility disorder which is often neglected. Multicentric studies are required to determine guidelines for the proper management of patients with EGJOO.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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