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Esophagogastric Junction Morphology and Distal Esophageal Acid Exposure

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Abstract

Background

The Chicago classification has recently added a morphological subclassification for the esophagogastric junction (EGJ). Our aim was to assess the distal esophageal acid exposure in patients with this new Chicago EGJ-type IIIa and IIIb classification.

Study Design

From a prospectively collected high-resolution manometry (HRM) database, we identified patients who underwent 24-h pH study between October 2011 and June 2015 and were diagnosed with EGJ-type III based on HRM. Chicago EGJ-type III is defined as the inter-peak nadir pressure ≤gastric pressure and a lower esophageal sphincter (LES)–crural diaphragm (CD) separation >2 cm [IIIa-pressure inversion point (PIP) remains at CD level and IIIb-PIP remains at LES level]. We classified the patients into reflux group [DeMeester score >14.72 or Fraction time pH (<4) > 4.2 %] and non-reflux group based on 24-h pH study.

Results

Fifty patients were identified that satisfied the study criteria, of which 37 patients (74 %) were EGJ-type IIIa. In those with EGJ-type IIIb, abdominal LES length (AL) in reflux group was significantly shorter than the non-reflux group (0.8 vs. 1.8, p < 0.05). EGJ-type IIIa patients showed significantly higher value for DeMeester score and Fraction time pH and more often had a positive pH study than EGJ-type IIIb patients (DeMeester score: 26.7 vs. 11.7, p < 0.05; Fraction time pH: 7.9 vs. 2.6, p < 0.05; positive pH study: 81.1 vs. 30.8 %, p < 0.001). Reflux was more common in LES–CD ≥ 3 cm than that in LES–CD < 3 cm (85 vs. 56.7 %, p < 0.05).

Conclusion

A subset of patients with >2-cm LES–CD separation (type IIIb) maintain a physiological intra-abdominal location of the EGJ and are less likely to have reflux. A LES–CD ≥ 3 cm seems to discern a hiatus hernia of clinical significance.

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Abbreviations

EGJ:

Esophagogastric junction

LES:

Lower esophageal sphincter

CD:

Crural diaphragm

PIP:

Pressure inversion point

HRM:

High-resolution manometry

OL:

Overall LES length

AL:

Abdominal LES length

LESP:

LES pressure

LESPI:

LESP integral

IRP:

Integrated relaxation pressure

DCI:

Distal contractile integral

GERD:

Gastroesophageal reflux disease

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Author contribution

Shunsuke Akimoto was involved in study conception and design, acquisition of data, analysis and interpretation of results, drafting of manuscript, and final approval to manuscript. Saurabh Singhal was involved in writing assistance and revision, analysis and interpretation, and final Approval. Takahiro Masuda was involved in writing assistance, interpretation, and final approval. Se Ryung Yamamoto was involved in acquisition of data, drafting of article, and final approval. Wendy Jo Svetanoff was involved in writing assistance and revision. Sumeet K. Mittal was involved in study conception and design, writing assistance, drafting and revisions, analysis and interpretation, and final approval supervision. All authors have read the journal publication policy and have no conflicts of interest with regard to this paper.

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Authors and Affiliations

  1. Department of Surgery, Creighton University School of Medicine, Creighton University Medical Center, Omaha, NE, 68131, USA

    Shunsuke Akimoto, Se Ryung Yamamoto, Wendy Jo Svetanoff & Sumeet K. Mittal

  2. Creighton University School of Medicine (Phoenix Campus), Phoenix, AZ, 85013, USA

    Saurabh Singhal, Takahiro Masuda & Sumeet K. Mittal

  3. Norton Thoracic Institute, St Joesph’s Hospital and Medical Center, Dignity Health, Phoenix, AZ, 85013, USA

    Sumeet K. Mittal

Authors
  1. Shunsuke Akimoto
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  2. Saurabh Singhal
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  6. Sumeet K. Mittal
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Correspondence to Sumeet K. Mittal.

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Conflict of interest

Drs. Akimoto, Singhal, Masuda, Yamamoto, Svetanoff, and Mittal have no conflicts of interest.

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Akimoto, S., Singhal, S., Masuda, T. et al. Esophagogastric Junction Morphology and Distal Esophageal Acid Exposure. Dig Dis Sci 61, 3537–3544 (2016). https://doi.org/10.1007/s10620-016-4331-y

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  • DOI: https://doi.org/10.1007/s10620-016-4331-y

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