Pneumatic dilation improves esophageal emptying and symptoms in patients with idiopathic esophago‐gastric junction outflow obstruction

Abstract

Background and aims Idiopathic Esophago‐gastric outflow obstruction (EGJOO) is a new clinical entity resulting in delayed esophageal emptying secondary to a poorly relaxing lower esophageal sphincter. Little is known about treatment outcomes of idiopathic EGJOO patients. The aim of this study was to investigate the clinical response of pneumatic dilation (PD) in idiopathic EGJOO patients with a standing barium column and/or with pill arrest on timed barium esophagram (TBE) before and after undergoing PD. Methods Idiopathic EGJOO patients with retained liquid barium on TBE at 1 minute and/or with pill arrest in esophagus at 5 minutes were included. Patients were treated with PD and evaluated with post‐procedural TBE. Results A total of 33 patients with Idiopathic EGJOO and poor esophageal emptying on TBE were treated with PD. 67% of Idiopathic EGJOO patients reported subjective symptom relief, 18% improved and symptoms later recurred, 6% were lost to follow up, and 9% reported no change. TBE results of pre‐PD showed 1 minute average barium column height of 11.0 cm and 1 minute barium column width of 1.7 cm. There was significant decrease in 1 minute liquid barium column height and width (P < 0.001 and <0.001, respectively) as well as significant improvement in pill passing (P < 0.006) after undergoing PD. No complications occurred after PD. Conclusion PD is an effective initial treatment for Idiopathic EGJOO patients with abnormal TBE. Pneumatic dilation relieved symptoms and improved esophageal emptying in Idiopathic EGJOO patients on TBE

Pharmacologic interrogation of patients with esophagogastric junction outflow obstruction using amyl nitrite

“…Although our follow‐up data are incomplete, we did observe that patients undergoing LES ablative therapy experienced more improvement in symptoms of dysphagia and regurgitation compared to medical therapy. Our findings (Table ) are consistent with those in a recent study, in which patients with a pattern of EGJOO on manometry and impaired bolus transport on fluoroscopic barium studies had symptomatic improvement following pneumatic dilation, a standard treatment for achalasia . Furthermore, we have observed manometric improvement in EGJOO following standard achalasia treatment in some AN‐R patients (Figure ).…”

“…However, because there is some preservation of esophageal motility in AN-R patients, they had less weight loss, lower basal esophageal body pressure (reflecting less fluid retention), and less and impaired bolus transport on fluoroscopic barium studies had symptomatic improvement following pneumatic dilation, a standard treatment for achalasia. 32 Furthermore, we have observed manometric improvement in EGJOO following standard achalasia treatment in some AN-R patients ( Figure 5). Longer follow-up is needed to determine whether earlier intervention in EGJOO from LES dysfunction reduces the subsequent development of the full achalasia phenotype.…”

Esophageal motility disorders on high‐resolution manometry: Chicago classification version 4.0©

“… The cutoff of spasm in 20% of swallows is arbitrary, and confidence in a diagnosis of a type III achalasia variant may be increased with a higher number of premature/spastic swallows. Supportive testing with a TBE, preferably in conjunction with a barium tablet swallow, and/or FLIP should be performed in patients with an inconclusive diagnosis of achalasia in the setting of dysphagia as a presenting symptom (Very Low GRADE, Strong Recommendation) 12,13,37–43 Opioids are associated with type III achalasia and patients should be studied off opioid medication if possible (Low GRADE, Conditional Recommendation) 44,45 .…”

“…• Supportive testing with a TBE, preferably in conjunction with a barium tablet swallow, and/or FLIP should be performed in patients with an inconclusive diagnosis of achalasia in the setting of dysphagia as a presenting symptom (Very Low GRADE, Strong Recommendation). 12,13,[37][38][39][40][41][42][43] • Opioids are associated with type III achalasia and patients should be studied off opioid medication if possible (Low GRADE, Conditional Recommendation). 44,45 Timing of opioid discontinuation should be based on medication half-life.…”

How to approach esophagogastric junction outflow obstruction?

“…Small case series of EGJOO patients have employed numerous therapies, including observation, smooth muscle relaxants, acid-suppressive therapy, botulinum toxin, dilation (either stan-dard or pneumatic), and myotomy (POEM or Heller). 2,16,23,24,28,53,54 When one explores the collated outcomes from these publications, it becomes apparent that patients with highly suspected functional EGJOO seem to respond to most therapies aimed at disruption of the EGJ. Pooled response rates for botulinum toxin, pneumatic dilatation, and POEM are all >60%.…”