The Clinical Relevance of Manometric Esophagogastric Junction Outflow Obstruction Can Be Determined Using Rapid Drink Challenge and Solid Swallows

Abstract

ObjectivesEsophagogastric junction outflow obstruction (EGJOO) defined on high-resolution manometry (HRM) poses a management dilemma given marked variability in clinical manifestations. We hypothesized that findings from provocative testing (rapid drink challenge and solid swallows) could determine clinical relevance of EGJOO. MethodsIn a retrospective cohort study, we included consecutive patients between May 2016 and January 2020 with EGJOO. Standard HRM with 5mL water swallows was followed by provocative testing. Barium esophagography findings were obtained. Cases with structural obstruction were separated from functional EGJOO, with the latter categorized as symptom-positive or symptom-negative. Only symptom-positive subjects were considered for achalasia-type therapies. Sensitivity and specificity for clinically relevant EGJOO during 5mL water swallows, provocative testing and barium was calculated. ResultsOf the 121 EGJOO cases, 76% had dysphagia and 25% had holdup on barium. Ninetyseven (84%) were defined as functional EGJOO. Symptom-positive EGJOO subjects were more likely to demonstrate abnormal motility, pressurization patterns and to reproduce symptoms during provocative testing, but not with 5mL water swallows. Twenty-nine (30%) functional EGJOO patients underwent achalasia-type therapy, with symptomatic response in 26 (90%). Forty-eight (49%) functional EGJOO cases were managed conservatively, with symptom remission in 78%. While specificity was similar, 4 provocative testing demonstrated superior sensitivity in identifying treatment responders from spontaneously remitting EGJOO (85%) compared to both 5mL water swallows (54%; p<0.01) and barium esophagography (54%; p=0.02). ConclusionsProvocative testing during HRM is highly accurate in identifying clinically relevant EGJOO that benefits from therapy and should be routinely performed as part of the manometric protocol.

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

“… 7,24–26 The post‐MRS contraction needs to be true peristaltic contractility and not artifact or pressurization. Rapid Drink Challenge: An intact response to RDC is defined as absence of esophageal body contractility (DCI < 100 mmHg•s•cm) with complete deglutitive inhibition of the LES during the RDC. When assessing response to RDC, IRP >12 mmHg (using Medtronic software) over the first 30 seconds of the RDC challenge and panesophageal pressurization >20 mmHg are criteria for outflow obstruction (Low GRADE, Conditional Recommendation) 9,26–29 . The presence of a normal contraction sequence following the RDC is a specific marker of normal contractility; however, this is not present in all healthy controls 9,27,28 …”

“…Temporal association of ineffective contractions with patient symptoms (e.g. dysphagia) supports diagnosis of clinically relevant, abnormal peristaltic function 10,29 Pharmacologic Provocation: If available at the motility laboratory, pharmacologic provocation using either an amyl nitrite and/or cholecystokinin protocol can be useful to evaluate physiology at the EGJ.…”

“… Supportive evidence for a manometric diagnosis of EGJOO includes outflow obstruction and esophageal pressurization during the RDC (Very Low GRADE, Conditional Recommendation) 9,10,27–30,46 Supportive evidence for a manometric diagnosis of EGJOO includes outflow obstruction during the solid test meal, especially if temporally associated with patient symptoms (Conditional Recommendation) 10,30 (Figure S1) Supportive evidence for a manometric diagnosis of EGJOO includes abnormal EGJ function following pharmacologic provocation 11 (Conditional Recommendation) (Figure S2) …”

“…dysphagia) supports diagnosis of clinically relevant, abnormal peristaltic function. 10,29 • Pharmacologic Provocation: If available at the motility laboratory, pharmacologic provocation using either an amyl nitrite and/or cholecystokinin protocol can be useful to evaluate physiology at the EGJ. The protocol and physiologic responses to pharmacologic provocation are detailed in Table 2.…”

“…• Supportive evidence for a manometric diagnosis of EGJOO includes outflow obstruction and esophageal pressurization during the RDC (Very Low GRADE, Conditional Recommendation) 9,10,[27][28][29][30]46 •…”