Skip to main content
SpringerLink
Log in

Esophagogastric Junction Outflow Obstruction (EGJOO): A Manometric Phenomenon or Clinically Impactful Problem

  • Published:
Current Gastroenterology Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

Esophagogastric junction outflow obstruction (EGJOO), defined manometrically by impaired esophagogastric junction relaxation (EGJ) with preserved peristalsis, can be artifactual, due to secondary etiologies (mechanical, medication-induced), or a true motility disorder. The purpose of this review is to go over the evolving approach to diagnosing and treating clinically relevant EGJOO.

Recent Findings

Timed barium esophagram (TBE) and the functional lumen imaging probe (FLIP) are useful to identify clinically relevant EGJOO that merits lower esophageal sphincter (LES) directed therapies. There are no randomized controlled trials evaluating EJGOO treatment. Uncontrolled trials show effectiveness for pneumatic dilation and peroral endoscopic myotomy to treat confirmed EGJOO; Botox and Heller myotomy may also be considered but data for confirmed EGJOO is more limited.

Summary

Diagnosis of clinically relevant idiopathic EGJOO requires symptoms, exclusion of mechanical and medication-related etiologies, and confirmation of EGJ obstruction by TBE or FLIP. Botox LES injection has limited durability, it can be used in patients who are not candidates for other treatments. PD and POEM are effective in confirmed EGJOO, Heller myotomy may also be considered but data for confirmed EGJOO is limited. Randomized controlled trials are needed to clarify optimal management of EGJOO.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

Data Availability

No datasets were generated or analysed during the current study.

References

  1. Yadlapati R, Kahrilas PJ, Fox MR, Bredenoord AJ, PrakashGyawali C, Roman S, et al. Esophageal motility disorders on high-resolution manometry: Chicago classification version 4.0(©). Neurogastroenterol Motil. 2021;33(1):e14058. https://doi.org/10.1111/nmo.14058.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Kahrilas PJ, Bredenoord AJ, Fox M, Gyawali CP, Roman S, Smout AJ, et al. The Chicago Classification of esophageal motility disorders v3.0. Neurogastroenterol Motil. 2015;27(2):160–74. https://doi.org/10.1111/nmo.12477.

    Article  CAS  PubMed  Google Scholar 

  3. Beveridge CA, Triggs JR, Thanawala SU, Ahuja NK, Falk GW, Benitez AJ, et al. Can FLIP guide therapy in idiopathic esophagogastric junction outflow obstruction? Dis Esophagus. 2022;35(4):doab077. https://doi.org/10.1093/dote/doab077.

  4. Beveridge C, Lynch K. Diagnosis and Management of Esophagogastric Junction Outflow Obstruction. Gastroenterol Hepatol (N Y). 2020;16(3):131–8.

    PubMed  Google Scholar 

  5. Patel DA, Yadlapati R, Vaezi MF. Esophageal Motility Disorders: Current Approach to Diagnostics and Therapeutics. Gastroenterology. 2022;162(6):1617–34. https://doi.org/10.1053/j.gastro.2021.12.289.

    Article  CAS  PubMed  Google Scholar 

  6. Bredenoord AJ, Babaei A, Carlson D, Omari T, Akiyama J, Yadlapati R, et al. Esophagogastric junction outflow obstruction. Neurogastroenterol Motil. 2021;33(9): e14193. https://doi.org/10.1111/nmo.14193.

    Article  PubMed  Google Scholar 

  7. Zikos TA, Triadafilopoulos G, Clarke JO. Esophagogastric Junction Outflow Obstruction: Current Approach to Diagnosis and Management. Curr Gastroenterol Rep. 2020;22(2):9. https://doi.org/10.1007/s11894-020-0743-0.

    Article  PubMed  Google Scholar 

  8. Liu A, Woo M, Nasser Y, Gupta M, Buresi MC, Curley M, et al. Esophagogastric junction outflow obstruction on manometry: Outcomes and lack of benefit from CT and EUS. Neurogastroenterol Motil. 2019;31(12): e13712. https://doi.org/10.1111/nmo.13712.

    Article  PubMed  Google Scholar 

  9. Snyder DL, Vela MF. Impact of opioids on esophageal motility. Neurogastroenterol Motil. 2023;35(5): e14587. https://doi.org/10.1111/nmo.14587.

    Article  PubMed  Google Scholar 

  10. Misselwitz B, Hollenstein M, Bütikofer S, Ang D, Heinrich H, Fox M. Prospective serial diagnostic study: the effects of position and provocative tests on the diagnosis of oesophageal motility disorders by high-resolution manometry. Aliment Pharmacol Ther. 2020;51(7):706–18. https://doi.org/10.1111/apt.15658.

    Article  PubMed  Google Scholar 

  11. Triggs JR, Carlson DA, Beveridge C, Jain A, Tye MY, Kahrilas PJ, et al. Upright Integrated Relaxation Pressure Facilitates Characterization of Esophagogastric Junction Outflow Obstruction. Clin Gastroenterol Hepatol. 2019;17(11):2218-26.e2. https://doi.org/10.1016/j.cgh.2019.01.024.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Kahrilas PJ, Carlson DA, Pandolfino JE. Advances in the Diagnosis and Management of Achalasia and Achalasia-Like Syndromes: Insights From HRM and FLIP. Gastro Hep Adv. 2023;2(5):701–10. https://doi.org/10.1016/j.gastha.2023.02.001.

    Article  PubMed  PubMed Central  Google Scholar 

  13. de Oliveira JM, Birgisson S, Doinoff C, Einstein D, Herts B, Davros W, et al. Timed barium swallow: a simple technique for evaluating esophageal emptying in patients with achalasia. AJR Am J Roentgenol. 1997;169(2):473–9. https://doi.org/10.2214/ajr.169.2.9242756.

    Article  PubMed  Google Scholar 

  14. Blonski W, Kumar A, Feldman J, Richter JE. Timed Barium Swallow: Diagnostic Role and Predictive Value in Untreated Achalasia, Esophagogastric Junction Outflow Obstruction, and Non-Achalasia Dysphagia. Am J Gastroenterol. 2018;113(2):196–203. https://doi.org/10.1038/ajg.2017.370.

    Article  PubMed  Google Scholar 

  15. Clayton SB, Shin CM, Ewing A, Blonski W, Richter J. Pneumatic dilation improves esophageal emptying and symptoms in patients with idiopathic esophago-gastric junction outflow obstruction. Neurogastroenterol Motil. 2019;31(3): e13522. https://doi.org/10.1111/nmo.13522.

    Article  CAS  PubMed  Google Scholar 

  16. Savarino E, di Pietro M, Bredenoord AJ, Carlson DA, Clarke JO, Khan A, et al. Use of the Functional Lumen Imaging Probe in Clinical Esophagology. Am J Gastroenterol. 2020;115(11):1786–96. https://doi.org/10.14309/ajg.0000000000000773.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Triggs JR, Carlson DA, Beveridge C, Kou W, Kahrilas PJ, Pandolfino JE. Functional Luminal Imaging Probe Panometry Identifies Achalasia-Type Esophagogastric Junction Outflow Obstruction. Clin Gastroenterol Hepatol. 2020;18(10):2209–17. https://doi.org/10.1016/j.cgh.2019.11.037.

    Article  CAS  PubMed  Google Scholar 

  18. Carlson DA, Schauer JM, Kou W, Kahrilas PJ, Pandolfino JE. Functional Lumen Imaging Probe Panometry Helps Identify Clinically Relevant Esophagogastric Junction Outflow Obstruction per Chicago Classification v4.0. Am J Gastroenterol. 2023;118(1):77–86. https://doi.org/10.14309/ajg.0000000000001980.

    Article  PubMed  Google Scholar 

  19. Khashab MA, Familiari P, Draganov PV, Aridi HD, Cho JY, Ujiki M, et al. Peroral endoscopic myotomy is effective and safe in non-achalasia esophageal motility disorders: an international multicenter study. Endosc Int Open. 2018;6(8):E1031–6. https://doi.org/10.1055/a-0625-6288.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Marin I, Serra J. Patterns of esophageal pressure responses to a rapid drink challenge test in patients with esophageal motility disorders. Neurogastroenterol Motil. 2016;28(4):543–53. https://doi.org/10.1111/nmo.12749.

    Article  CAS  PubMed  Google Scholar 

  21. Krause AJ, Su H, Triggs JR, Beveridge C, Baumann AJ, Donnan E, et al. Multiple rapid swallows and rapid drink challenge in patients with esophagogastric junction outflow obstruction on high-resolution manometry. Neurogastroenterol Motil. 2021;33(3): e14000. https://doi.org/10.1111/nmo.14000.

    Article  CAS  PubMed  Google Scholar 

  22. Shaker A, Stoikes N, Drapekin J, Kushnir V, Brunt LM, Gyawali CP. Multiple rapid swallow responses during esophageal high-resolution manometry reflect esophageal body peristaltic reserve. Am J Gastroenterol. 2013;108(11):1706–12. https://doi.org/10.1038/ajg.2013.289.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Dodds WJ, Stewart ET, Kishk SM, Kahrilas PJ, Hogan WJ. Radiologic amyl nitrite test for distinguishing pseudoachalasia from idiopathic achalasia. AJR Am J Roentgenol. 1986;146(1):21–3. https://doi.org/10.2214/ajr.146.1.21.

    Article  CAS  PubMed  Google Scholar 

  24. Mayrand S, Diamant NE. Measurement of human esophageal tone in vivo. Gastroenterology. 1993;105(5):1411–20. https://doi.org/10.1016/0016-5085(93)90146-4.

    Article  CAS  PubMed  Google Scholar 

  25. González M, Mearin F, Vasconez C, Armengol JR, Malagelada JR. Oesophageal tone in patients with achalasia. Gut. 1997;41(3):291–6. https://doi.org/10.1136/gut.41.3.291.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Babaei A, Shad S, Szabo A, Massey BT. Pharmacologic interrogation of patients with esophagogastric junction outflow obstruction using amyl nitrite. Neurogastroenterol Motil. 2019;31(9): e13668. https://doi.org/10.1111/nmo.13668.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  27. Babaei A, Szabo A, Shad S, Massey BT. Chronic daily opioid exposure is associated with dysphagia, esophageal outflow obstruction, and disordered peristalsis. Neurogastroenterol Motil. 2019;31(7): e13601. https://doi.org/10.1111/nmo.13601.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Snyder DL, Vela MF. Opioid-induced esophageal dysfunction. Curr Opin Gastroenterol. 2020;36(4):344–50. https://doi.org/10.1097/mog.0000000000000648.

    Article  PubMed  Google Scholar 

  29. Ravi K, Murray JA, Geno DM, Katzka DA. Achalasia and chronic opioid use: innocent bystanders or associated conditions? Dis Esophagus. 2016;29(1):15–21. https://doi.org/10.1111/dote.12291.

    Article  CAS  PubMed  Google Scholar 

  30. Jacobs CC, Al-Haddad M, Stainko S, Perkins A, DeWitt JM. Prevalence and impact of opioid use in patients undergoing peroral endoscopic myotomy. Gastrointest Endosc. 2023;97(4):655-63.e2. https://doi.org/10.1016/j.gie.2022.12.006.

    Article  PubMed  Google Scholar 

  31. Lynch KL, Yang YX, Metz DC, Falk GW. Clinical presentation and disease course of patients with esophagogastric junction outflow obstruction. Dis Esophagus. 2017;30(6):1–6. https://doi.org/10.1093/dote/dox004.

    Article  CAS  PubMed  Google Scholar 

  32. Garbarino S, von Isenburg M, Fisher DA, Leiman DA. Management of Functional Esophagogastric Junction Outflow Obstruction: A Systematic Review. J Clin Gastroenterol. 2020;54(1):35–42. https://doi.org/10.1097/mcg.0000000000001156.

    Article  PubMed  Google Scholar 

  33. Scherer JR, Kwiatek MA, Soper NJ, Pandolfino JE, Kahrilas PJ. Functional esophagogastric junction obstruction with intact peristalsis: a heterogeneous syndrome sometimes akin to achalasia. J Gastrointest Surg. 2009;13(12):2219–25. https://doi.org/10.1007/s11605-009-0975-7.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Salvador R, Provenzano L, Nezi G, Capovilla G, Nicoletti L, Pierobon ES, et al. Laparoscopic Heller-Dor Is an Effective Treatment for Esophageal-Gastric Junction Outflow Obstruction. J Gastrointest Surg. 2021;25(9):2201–7. https://doi.org/10.1007/s11605-021-05021-1.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Clayton SB, Patel R, Richter JE. Functional and Anatomic Esophagogastic Junction Outflow Obstruction: Manometry, Timed Barium Esophagram Findings, and Treatment Outcomes. Clin Gastroenterol Hepatol. 2016;14(6):907–11. https://doi.org/10.1016/j.cgh.2015.12.041.

    Article  PubMed  Google Scholar 

  36. Pérez-Fernández MT, Santander C, Marinero A, Burgos-Santamaría D, Chavarría-Herbozo C. Characterization and follow-up of esophagogastric junction outflow obstruction detected by high resolution manometry. Neurogastroenterol Motil. 2016;28(1):116–26. https://doi.org/10.1111/nmo.12708.

    Article  PubMed  Google Scholar 

  37. Desai N, Kline M, Duncan D, Godiers M, Patel V, Keilin S, et al. Expanding the role of pneumatic dilation for nonachalasia patients: a comparative study. Gastrointest Endosc. 2023;97(2):251–9. https://doi.org/10.1016/j.gie.2022.09.032.

    Article  PubMed  Google Scholar 

  38. Okeke FC, Raja S, Lynch KL, Dhalla S, Nandwani M, Stein EM, et al. What is the clinical significance of esophagogastric junction outflow obstruction? evaluation of 60 patients at a tertiary referral center. Neurogastroenterol Motil. 2017;29(6). https://doi.org/10.1111/nmo.13061.

  39. Ichkhanian Y, Sanaei O, Canakis A, Vosoughi K, Almazan E, Ghandour B, et al. Esophageal peroral endoscopic myotomy (POEM) for treatment of esophagogastric junction outflow obstruction: results from the first prospective trial. Endosc Int Open. 2020;8(9):E1137–43. https://doi.org/10.1055/a-1198-4643.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Sanaka M, Kumar P, Mohammed A, Sudarshan M, Murthy S, Raja S. Efficacy of Peroral Endoscopic Myotomy for the Treatment of Functional Esophagogastric Junction Outflow Obstruction. iGIE. 2023;2(4):467–71. https://doi.org/10.1016/j.igie.2023.08.003.

Download references

Author information

Authors and Affiliations

  1. Mayo Clinic Arizona, 13400 E. Shea Blvd, Scottsdale, AZ, USA

    Laura Bach & Marcelo F. Vela

Authors
  1. Laura Bach
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Marcelo F. Vela
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

LB wrote the main manuscript, MFV edited the manuscript. All authors reviewed the final version prior to submission.

Corresponding author

Correspondence to Marcelo F. Vela.

Ethics declarations

Competing Interests

Marcelo F. Vela: Medtronic (consultation fees).

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Bach, L., Vela, M.F. Esophagogastric Junction Outflow Obstruction (EGJOO): A Manometric Phenomenon or Clinically Impactful Problem. Curr Gastroenterol Rep (2024). https://doi.org/10.1007/s11894-024-00928-6

Download citation

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1007/s11894-024-00928-6

Keywords

Search

Navigation