Esophagogastric junction outflow obstruction: Where are we now in diagnosis and management?
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摘要
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.
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.
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.
引文
1 Kahrilas PJ,Bredenoord AJ,Fox M,Gyawali CP,Roman S,Smout AJ,Pandolfino JE;International High Resolution Manometry Working Group.The Chicago Classification of esophageal motility disorders,v3.0.Neurogastroenterol Motil 2015;27:160-174[PMID:25469569 DOI:10.1111/nmo.12477]
2 Ghosh SK,Pandolfino JE,Rice J,Clarke JO,Kwiatek M,Kahrilas PJ.Impaired deglutitive EGJ relaxation in clinical esophageal manometry:a quantitative analysis of 400 patients and 75 controls.Am J Physiol Gastrointest Liver Physiol 2007;293:G878-G885[PMID:17690172 DOI:10.1152/ajpgi.00252.2007]
3 do Carmo GC,Jafari J,Sifrim D,de Oliveira RB.Normal esophageal pressure topography metrics for data derived from the Sandhill-Unisensor high-resolution manometry assembly in supine and sitting positions.Neurogastroenterol Motil 2015;27:285-292[PMID:25557525 DOI:10.1111/nmo.12501]
4 Kahrilas PJ,Bredenoord AJ,Carlson DA,Pandolfino JE.Advances in Management of Esophageal Motility Disorders.Clin Gastroenterol Hepatol 2018;16:1692-1700[PMID:29702296 DOI:10.1016/j.cgh.2018.04.026]
5 Okeke FC,Raja S,Lynch KL,Dhalla S,Nandwani M,Stein EM,Chander Roland B,Khashab MA,Saxena P,Kumbhari V,Ahuja NK,Clarke JO.What is the clinical significance of esophagogastric junction outflow obstruction?evaluation of 60 patients at a tertiary referral center.Neurogastroenterol Motil 2017;29[PMID:28393437 DOI:10.1111/nmo.13061]
6 Schupack D,Katzka DA,Geno DM,Ravi K.The clinical significance of esophagogastric junction outflow obstruction and hypercontractile esophagus in high resolution esophageal manometry.Neurogastroenterol Motil 2017;29:1-9[PMID:28544670 DOI:10.1111/nmo.13105]
7 Ratuapli SK,Crowell MD,DiBaise JK,Vela MF,Ramirez FC,Burdick GE,Lacy BE,Murray JA.Opioid-Induced Esophageal Dysfunction(OIED)in Patients on Chronic Opioids.Am J Gastroenterol2015;110:979-984[PMID:26032150 DOI:10.1038/ajg.2015.154]
8 Kahrilas PJ,Katzka D,Richter JE.Clinical Practice Update:The Use of Per-Oral Endoscopic Myotomy in Achalasia:Expert Review and Best Practice Advice From the AGA Institute.Gastroenterology 2017;153:1205-1211[PMID:28989059 DOI:10.1053/j.gastro.2017.10.001]
9 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;13:2219-2225[PMID:19672666 DOI:10.1007/s11605-009-0975-7]
10 Song BG,Min YW,Lee H,Min BH,Lee JH,Rhee PL,Kim JJ.Clinicomanometric factors associated with clinically relevant esophagogastric junction outflow obstruction from the Sandhill high-resolution manometry system.Neurogastroenterol Motil 2018;30[PMID:29024314 DOI:10.1111/nmo.13221]
11 Triggs J,Carlson D,Beveridge C,Jain A,Tye MY,Kahrilas PJ,Pandolfino JE.Upright integrated relaxation pressure facilitates characterization of esophagogastric junction outlet obstruction.DDW,2018.
12 Carlson DA,Gyawali CP.Is High-Resolution Manometry Always Needed for the Diagnosis of Achalasia?Clin Gastroenterol Hepatol 2018;16:480-482[PMID:28987504 DOI:10.1016/j.cgh.2017.06.019]
13 de Oliveira JM,Birgisson S,Doinoff C,Einstein D,Herts B,Davros W,Obuchowski N,Koehler RE,Richter J,Baker ME.Timed barium swallow:a simple technique for evaluating esophageal emptying in patients with achalasia.AJR Am J Roentgenol 1997;169:473-479[PMID:9242756 DOI:10.2214/ajr.169.2.9242756]
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;113:196-203[PMID:29257145 DOI:10.1038/ajg.2017.370]
15 Carlson DA,Kahrilas PJ,Lin Z,Hirano I,Gonsalves N,Listernick Z,Ritter K,Tye M,Ponds FA,Wong I,Pandolfino JE.Evaluation of Esophageal Motility Utilizing the Functional Lumen Imaging Probe.Am JGastroenterol 2016;111:1726-1735[PMID:27725650 DOI:10.1038/ajg.2016.454]
16 Hirano I,Pandolfino JE,Boeckxstaens GE.Functional Lumen Imaging Probe for the Management of Esophageal Disorders:Expert Review From the Clinical Practice Updates Committee of the AGAInstitute.Clin Gastroenterol Hepatol 2017;15:325-334[PMID:28212976 DOI:10.1016/j.cgh.2016.10.022]
17 Molina-Infante J,Lucendo AJ.Proton Pump Inhibitor Therapy for Eosinophilic Esophagitis:A Paradigm Shift.Am J Gastroenterol 2017;112:1770-1773[PMID:29087399 DOI:10.1038/ajg.2017.404]
18 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;28:116-126[PMID:26517978 DOI:10.1111/nmo.12708]
19 Clayton SB,Patel R,Richter JE.Functional and Anatomic Esophagogastic Junction Outflow Obstruction:Manometry,Timed Barium Esophagram Findings,and Treatment Outcomes.Clin Gastroenterol Hepatol2016;14:907-911[PMID:26792374 DOI:10.1016/j.cgh.2015.12.041]
20 Khashab MA,Familiari P,Draganov PV,Aridi HD,Cho JY,Ujiki M,Rio Tinto R,Louis H,Desai PN,Velanovich V,Albéniz E,Haji A,Marks J,Costamagna G,Devière J,Perbtani Y,Hedberg M,Estremera F,Martin Del Campo LA,Yang D,Bukhari M,Brewer O,Sanaei O,Fayad L,Agarwal A,Kumbhari V,Chen YI.Peroral endoscopic myotomy is effective and safe in non-achalasia esophageal motility disorders:an international multicenter study.Endosc Int Open 2018;6:E1031-E1036[PMID:30105290 DOI:10.1055/a-0625-6288]
21 Smith CD,Stival A,Howell DL,Swafford V.Endoscopic therapy for achalasia before Heller myotomy results in worse outcomes than heller myotomy alone.Ann Surg 2006;243:579-584;discussion 584-586[PMID:16632991 DOI:10.1097/01.sla.0000217524.75529.2d]
22 Pandolfino JE,Kahrilas PJ.Presentation,diagnosis,and management of achalasia.Clin Gastroenterol Hepatol 2013;11:887-897[PMID:23395699 DOI:10.1016/j.cgh.2013.01.032]
23 Lynch KL,Pandolfino JE,Howden CW,Kahrilas PJ.Major complications of pneumatic dilation and Heller myotomy for achalasia:single-center experience and systematic review of the literature.Am JGastroenterol 2012;107:1817-1825[PMID:23032978 DOI:10.1038/ajg.2012.332]
24 Boeckxstaens GE,Annese V,des Varannes SB,Chaussade S,Costantini M,Cuttitta A,Elizalde JI,Fumagalli U,Gaudric M,Rohof WO,Smout AJ,Tack J,Zwinderman AH,Zaninotto G,Busch OR;European Achalasia Trial Investigators.Pneumatic dilation versus laparoscopic Heller's myotomy for idiopathic achalasia.N Engl J Med 2011;364:1807-1816[PMID:21561346 DOI:10.1056/NEJ-Moa1010502]
25 Inoue H,Minami H,Kobayashi Y,Sato Y,Kaga M,Suzuki M,Satodate H,Odaka N,Itoh H,Kudo S.Peroral endoscopic myotomy(POEM)for esophageal achalasia.Endoscopy 2010;42:265-271[PMID:20354937 DOI:10.1055/s-0029-1244080]
26 Inoue H,Sato H,Ikeda H,Onimaru M,Sato C,Minami H,Yokomichi H,Kobayashi Y,Grimes KL,Kudo SE.Per-Oral Endoscopic Myotomy:A Series of 500 Patients.J Am Coll Surg 2015;221:256-264[PMID:26206634 DOI:10.1016/j.jamcollsurg.2015.03.057]
27 Haito-Chavez Y,Inoue H,Beard KW,Draganov PV,Ujiki M,Rahden BHA,Desai PN,Pioche M,Hayee B,Haji A,Saxena P,Reavis K,Onimaru M,Balassone V,Nakamura J,Hata Y,Yang D,Pannu D,Abbas A,Perbtani YB,Patel LY,Filser J,Roman S,Rivory J,Mion F,Ponchon T,Perretta S,Wong V,Maselli R,Ngamruengphong S,Chen YI,Bukhari M,Hajiyeva G,Ismail A,Pieratti R,Kumbhari V,GaldosCardenas G,Repici A,Khashab MA.Comprehensive Analysis of Adverse Events Associated With Per Oral Endoscopic Myotomy in 1826 Patients:An International Multicenter Study.Am J Gastroenterol2017;112:1267-1276[PMID:28534521 DOI:10.1038/ajg.2017.139]
2 Ghosh SK,Pandolfino JE,Rice J,Clarke JO,Kwiatek M,Kahrilas PJ.Impaired deglutitive EGJ relaxation in clinical esophageal manometry:a quantitative analysis of 400 patients and 75 controls.Am J Physiol Gastrointest Liver Physiol 2007;293:G878-G885[PMID:17690172 DOI:10.1152/ajpgi.00252.2007]
3 do Carmo GC,Jafari J,Sifrim D,de Oliveira RB.Normal esophageal pressure topography metrics for data derived from the Sandhill-Unisensor high-resolution manometry assembly in supine and sitting positions.Neurogastroenterol Motil 2015;27:285-292[PMID:25557525 DOI:10.1111/nmo.12501]
4 Kahrilas PJ,Bredenoord AJ,Carlson DA,Pandolfino JE.Advances in Management of Esophageal Motility Disorders.Clin Gastroenterol Hepatol 2018;16:1692-1700[PMID:29702296 DOI:10.1016/j.cgh.2018.04.026]
5 Okeke FC,Raja S,Lynch KL,Dhalla S,Nandwani M,Stein EM,Chander Roland B,Khashab MA,Saxena P,Kumbhari V,Ahuja NK,Clarke JO.What is the clinical significance of esophagogastric junction outflow obstruction?evaluation of 60 patients at a tertiary referral center.Neurogastroenterol Motil 2017;29[PMID:28393437 DOI:10.1111/nmo.13061]
6 Schupack D,Katzka DA,Geno DM,Ravi K.The clinical significance of esophagogastric junction outflow obstruction and hypercontractile esophagus in high resolution esophageal manometry.Neurogastroenterol Motil 2017;29:1-9[PMID:28544670 DOI:10.1111/nmo.13105]
7 Ratuapli SK,Crowell MD,DiBaise JK,Vela MF,Ramirez FC,Burdick GE,Lacy BE,Murray JA.Opioid-Induced Esophageal Dysfunction(OIED)in Patients on Chronic Opioids.Am J Gastroenterol2015;110:979-984[PMID:26032150 DOI:10.1038/ajg.2015.154]
8 Kahrilas PJ,Katzka D,Richter JE.Clinical Practice Update:The Use of Per-Oral Endoscopic Myotomy in Achalasia:Expert Review and Best Practice Advice From the AGA Institute.Gastroenterology 2017;153:1205-1211[PMID:28989059 DOI:10.1053/j.gastro.2017.10.001]
9 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;13:2219-2225[PMID:19672666 DOI:10.1007/s11605-009-0975-7]
10 Song BG,Min YW,Lee H,Min BH,Lee JH,Rhee PL,Kim JJ.Clinicomanometric factors associated with clinically relevant esophagogastric junction outflow obstruction from the Sandhill high-resolution manometry system.Neurogastroenterol Motil 2018;30[PMID:29024314 DOI:10.1111/nmo.13221]
11 Triggs J,Carlson D,Beveridge C,Jain A,Tye MY,Kahrilas PJ,Pandolfino JE.Upright integrated relaxation pressure facilitates characterization of esophagogastric junction outlet obstruction.DDW,2018.
12 Carlson DA,Gyawali CP.Is High-Resolution Manometry Always Needed for the Diagnosis of Achalasia?Clin Gastroenterol Hepatol 2018;16:480-482[PMID:28987504 DOI:10.1016/j.cgh.2017.06.019]
13 de Oliveira JM,Birgisson S,Doinoff C,Einstein D,Herts B,Davros W,Obuchowski N,Koehler RE,Richter J,Baker ME.Timed barium swallow:a simple technique for evaluating esophageal emptying in patients with achalasia.AJR Am J Roentgenol 1997;169:473-479[PMID:9242756 DOI:10.2214/ajr.169.2.9242756]
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;113:196-203[PMID:29257145 DOI:10.1038/ajg.2017.370]
15 Carlson DA,Kahrilas PJ,Lin Z,Hirano I,Gonsalves N,Listernick Z,Ritter K,Tye M,Ponds FA,Wong I,Pandolfino JE.Evaluation of Esophageal Motility Utilizing the Functional Lumen Imaging Probe.Am JGastroenterol 2016;111:1726-1735[PMID:27725650 DOI:10.1038/ajg.2016.454]
16 Hirano I,Pandolfino JE,Boeckxstaens GE.Functional Lumen Imaging Probe for the Management of Esophageal Disorders:Expert Review From the Clinical Practice Updates Committee of the AGAInstitute.Clin Gastroenterol Hepatol 2017;15:325-334[PMID:28212976 DOI:10.1016/j.cgh.2016.10.022]
17 Molina-Infante J,Lucendo AJ.Proton Pump Inhibitor Therapy for Eosinophilic Esophagitis:A Paradigm Shift.Am J Gastroenterol 2017;112:1770-1773[PMID:29087399 DOI:10.1038/ajg.2017.404]
18 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;28:116-126[PMID:26517978 DOI:10.1111/nmo.12708]
19 Clayton SB,Patel R,Richter JE.Functional and Anatomic Esophagogastic Junction Outflow Obstruction:Manometry,Timed Barium Esophagram Findings,and Treatment Outcomes.Clin Gastroenterol Hepatol2016;14:907-911[PMID:26792374 DOI:10.1016/j.cgh.2015.12.041]
20 Khashab MA,Familiari P,Draganov PV,Aridi HD,Cho JY,Ujiki M,Rio Tinto R,Louis H,Desai PN,Velanovich V,Albéniz E,Haji A,Marks J,Costamagna G,Devière J,Perbtani Y,Hedberg M,Estremera F,Martin Del Campo LA,Yang D,Bukhari M,Brewer O,Sanaei O,Fayad L,Agarwal A,Kumbhari V,Chen YI.Peroral endoscopic myotomy is effective and safe in non-achalasia esophageal motility disorders:an international multicenter study.Endosc Int Open 2018;6:E1031-E1036[PMID:30105290 DOI:10.1055/a-0625-6288]
21 Smith CD,Stival A,Howell DL,Swafford V.Endoscopic therapy for achalasia before Heller myotomy results in worse outcomes than heller myotomy alone.Ann Surg 2006;243:579-584;discussion 584-586[PMID:16632991 DOI:10.1097/01.sla.0000217524.75529.2d]
22 Pandolfino JE,Kahrilas PJ.Presentation,diagnosis,and management of achalasia.Clin Gastroenterol Hepatol 2013;11:887-897[PMID:23395699 DOI:10.1016/j.cgh.2013.01.032]
23 Lynch KL,Pandolfino JE,Howden CW,Kahrilas PJ.Major complications of pneumatic dilation and Heller myotomy for achalasia:single-center experience and systematic review of the literature.Am JGastroenterol 2012;107:1817-1825[PMID:23032978 DOI:10.1038/ajg.2012.332]
24 Boeckxstaens GE,Annese V,des Varannes SB,Chaussade S,Costantini M,Cuttitta A,Elizalde JI,Fumagalli U,Gaudric M,Rohof WO,Smout AJ,Tack J,Zwinderman AH,Zaninotto G,Busch OR;European Achalasia Trial Investigators.Pneumatic dilation versus laparoscopic Heller's myotomy for idiopathic achalasia.N Engl J Med 2011;364:1807-1816[PMID:21561346 DOI:10.1056/NEJ-Moa1010502]
25 Inoue H,Minami H,Kobayashi Y,Sato Y,Kaga M,Suzuki M,Satodate H,Odaka N,Itoh H,Kudo S.Peroral endoscopic myotomy(POEM)for esophageal achalasia.Endoscopy 2010;42:265-271[PMID:20354937 DOI:10.1055/s-0029-1244080]
26 Inoue H,Sato H,Ikeda H,Onimaru M,Sato C,Minami H,Yokomichi H,Kobayashi Y,Grimes KL,Kudo SE.Per-Oral Endoscopic Myotomy:A Series of 500 Patients.J Am Coll Surg 2015;221:256-264[PMID:26206634 DOI:10.1016/j.jamcollsurg.2015.03.057]
27 Haito-Chavez Y,Inoue H,Beard KW,Draganov PV,Ujiki M,Rahden BHA,Desai PN,Pioche M,Hayee B,Haji A,Saxena P,Reavis K,Onimaru M,Balassone V,Nakamura J,Hata Y,Yang D,Pannu D,Abbas A,Perbtani YB,Patel LY,Filser J,Roman S,Rivory J,Mion F,Ponchon T,Perretta S,Wong V,Maselli R,Ngamruengphong S,Chen YI,Bukhari M,Hajiyeva G,Ismail A,Pieratti R,Kumbhari V,GaldosCardenas G,Repici A,Khashab MA.Comprehensive Analysis of Adverse Events Associated With Per Oral Endoscopic Myotomy in 1826 Patients:An International Multicenter Study.Am J Gastroenterol2017;112:1267-1276[PMID:28534521 DOI:10.1038/ajg.2017.139]