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Name of journal: World Journal of GastroenterologyManuscript NO: 42452Manuscript type: MinireviewsEsophagogastric junction outflow obstruction: Where are we now in diagnosis and management?Samo S et al. Esophagogastric junction outflow obstructionSalih Samo, Emad QayedSalih Samo, Emad Qayed, Department of Medicine, Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA 30322, United StatesORCID number: Salih Samo (0000-0003-1254-3670); Emad Qayed (0000-0003-2129-7694).Author contributions: Samo S drafted and revised the manuscript; Qayed E drafted and revised the manuscript; all authors read and approved the final version of the manuscript.Conflict-of-interest statement: The authors declare no conflicts of interest.Open-Access: This article is an open-access?article?which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance?with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: : Invited?manuscriptCorresponding author to: Emad Qayed, MD, MPH, FACG, Assistant Professor, Chief of Gastroenterology, Department of Medicine, Division of Digestive Diseases, Emory University School of Medicine, 615 Michael Street, Suite 201, Atlanta, GA 30322, United States. eqayed@emory.eduTelephone: +1-404-7781685 Fax: +1-404-7781681Received: September 25, 2018Peer-review started: September 25, 2018First decision: November 8, 2018Revised: December 6, 2018Accepted: December 14, 2018Article in press: December 15, 2018Published online: January 28, 2019AbstractEsophagogastric 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.Key words: Esophagogastric junction outflow obstruction; high-resolution manometry? The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.Core tip: Esophagogastric junction outflow obstruction (EGJOO) is a manometric diagnosis and is considered a major motility disorder. In this condition, it is important to rule out treatable causes of mechanical obstruction at the gastro-esophageal junction. In functional EGJOO, there is no obvious mechanical or structural cause of obstruction. In this condition, presenting symptoms like dysphagia and manometry metrics like IRP and distal contractile integral are associated with persistence of symptoms upon follow up. These patients may benefit from early intervention to disrupt the functional obstruction at the lower esophageal sphincter, using treatment modalities similar to achalasia. Citation: Samo S, Qayed E. Esophagogastric junction outflow obstruction: Where are we now in diagnosis and management? World J Gastroenterol 2019; 25(4): 411-417 URL: DOI: invention of high-resolution manometry (HRM) has substantially redefined the landscape of esophageal motility disorders. The assessment of esophagogastric junction (EGJ) obstructive physiology is fundamental in the evaluation of esophageal motility disorders, which is determined by an elevated integrated relaxation pressure (IRP). According to the Chicago Classification of esophageal motility disorders, version 3.0 (CC v3.0), a median IRP threshold of ≥ 15 mmHg on HRM performed in a supine position is indicative of failed deglutitive lower esophageal sphincter (LES) relaxationPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5LYWhyaWxhczwvQXV0aG9yPjxZZWFyPjIwMTU8L1llYXI+
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PjwvRW5kTm90ZT5=
ADDIN EN.CITE.DATA [1,2]. The cutoff values for IRP are technology dependent and vary per type of instrument (solid-state vs. water perfused). Furthermore, it has been shown that IRP is significantly lower when HRM is performed in the upright sitting position as compared to the supine positionPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5kbyBDYXJtbzwvQXV0aG9yPjxZZWFyPjIwMTU8L1llYXI+
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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5kbyBDYXJtbzwvQXV0aG9yPjxZZWFyPjIwMTU8L1llYXI+
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ADDIN EN.CITE.DATA [3]. The threshold of 15 mmHg used in the CC is for the Sierra design, which is currently acquired by Medtronic (Medtronic Inc. Minnesota, USA)PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5LYWhyaWxhczwvQXV0aG9yPjxZZWFyPjIwMTU8L1llYXI+
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ADDIN EN.CITE.DATA [1].Etiology of EGJOOA variety of conditions can lead to manometric findings consistent with EGJOO. Potential etiologies for EGJOO are summarized in table 1PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5LYWhyaWxhczwvQXV0aG9yPjxZZWFyPjIwMTg8L1llYXI+
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ADDIN EN.CITE.DATA [4-8]. The majority of these disorders involve mechanical obstruction at the EGJ that could be subtle and missed during the initial evaluation with endoscopy. It is very important to carefully review endoscopic records and consider repeat endoscopy, if warranted, to exclude hiatal hernia, post-surgical changes, and intraluminal processes such as strictures in the distal esophagus and EOE before labeling someone with functional EGJOO.Presentation and Diagnosis of EGJOOThe EGJOO varies in its presentation. The diagnosis is made on HRM while the patient is usually being evaluated for esophageal symptoms such as dysphagia, heartburn and/or regurgitation, chest pain, and epigastric pain. However, the diagnosis of EGJOO can be an incidental finding on HRM during evaluation for different indications such as routine manometry prior to anti-reflux proceduresPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TY2h1cGFjazwvQXV0aG9yPjxZZWFyPjIwMTc8L1llYXI+
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ADDIN EN.CITE.DATA [6].The diagnosis of EGJOO is usually reached after performing endoscopic and functional tests of the esophagus. The evaluation of esophageal symptoms usually begins with upper endoscopy, if not previously performed, to assess for mechanical causes for the presenting symptoms. The endoscopic findings may range from normal upper endoscopy with normal peristalsis and LES, tight LES, esophagitis, hiatal hernia, tumors at the EGJ, and eosinophilic esophagitis (EoE) findings like edema, rings, exudates, furrows, and strictures. It is important to carefully assess the EGJ during endoscopy for any visible lesions or abnormalities on both forward and retroflexed views. A finding of an epiphrenic diverticulum is suggestive of increased EGJ pressure and foam (saliva) and stasis in the esophagus suggests dysmotility. If the endoscopy is unrevealing for a mechanical obstruction, the HRM is the reasonable next test to perform. The HRM findings include an elevated median IRP ≥ 15 mmHg (or a different designated cutoff value based on the device used) of ten supine liquid test swallows with preserved peristalsis (figure 1). The term “functional EGJOO” is used when there is no obvious mechanical cause for the obstruction. In achalasia, the IRP is elevated, but in contrast to EGJOO, there is failed peristalsis or absence of normal peristalsisPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5LYWhyaWxhczwvQXV0aG9yPjxZZWFyPjIwMTU8L1llYXI+
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ADDIN EN.CITE.DATA [1].Clinical symptoms and HRM metrics may predict persistence of symptoms in functional EGJOO patients. Presence of dysphagia on presentation and elevated IRP (max 32.1 vs 26.2 mmHg) and DCI (max 10353 vs 5352 mmHg.s.cm) on HRM have been shown to predict persistence of dysphagia in patients with EGJOO on follow upPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TY2h1cGFjazwvQXV0aG9yPjxZZWFyPjIwMTc8L1llYXI+
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ADDIN EN.CITE.DATA [10]. An upright IRP > 12 mmHg (using Sierra HRM system) has been demonstrated to be sensitive, although not specific, to detect EGJOO identified on timed barium esophagram (TBE) or present with dysphagia ADDIN EN.CITE <EndNote><Cite><Author>Triggs</Author><Year>2018</Year><RecNum>137</RecNum><DisplayText><style face="superscript">[11]</style></DisplayText><record><rec-number>137</rec-number><foreign-keys><key app="EN" db-id="t9de09x5aa90v7eptstvd0aofpax5axsrffa" timestamp="1537726922">137</key></foreign-keys><ref-type name="Conference Paper">47</ref-type><contributors><authors><author>Triggs, J, Carlson, D, Beveridge, C, Jain, A, Tye, MY, Kahrilas, PJ, Pandolfino, JE</author></authors></contributors><titles><title>UPRIGHT INTEGRATED RELAXATION PRESSURE FACILITATES CHARACTERIZATION OF ESOPHAGOGASTRIC JUNCTION OUTLET OBSTRUCTION</title><secondary-title>DDW</secondary-title></titles><volume>Mo1506</volume><dates><year>2018</year></dates><work-type>Abstract</work-type><urls></urls></record></Cite></EndNote>[11].In addition to endoscopy and HRM, other ancillary tests such as TBE, functional luminal imaging probe (FLIP), endoscopic ultrasound (EUS), and computed tomography (CT) scan can further elucidate the obstruction at the EGJ and point to a certain etiology ADDIN EN.CITE <EndNote><Cite><Author>Carlson</Author><Year>2018</Year><RecNum>2344</RecNum><DisplayText><style face="superscript">[12]</style></DisplayText><record><rec-number>2344</rec-number><foreign-keys><key app="EN" db-id="50wxdpzd9vd5r7e9t5b595djrfpttrxw9avp" timestamp="1534193236">2344</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Carlson, D. A.</author><author>Gyawali, C. P.</author></authors></contributors><auth-address>Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri. Electronic address: cprakash@wustl.edu.</auth-address><titles><title>Is High-Resolution Manometry Always Needed for the Diagnosis of Achalasia?</title><secondary-title>Clin Gastroenterol Hepatol</secondary-title><alt-title>Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association</alt-title></titles><periodical><full-title>Clin Gastroenterol Hepatol</full-title><abbr-1>Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association</abbr-1></periodical><alt-periodical><full-title>Clin Gastroenterol Hepatol</full-title><abbr-1>Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association</abbr-1></alt-periodical><pages>480-482</pages><volume>16</volume><number>4</number><edition>2017/10/11</edition><dates><year>2018</year><pub-dates><date>Apr</date></pub-dates></dates><isbn>1542-3565</isbn><accession-num>28987504</accession-num><urls></urls><electronic-resource-num>10.1016/j.cgh.2017.06.019</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>[12]. The TBE is a simple test to perform with low radiation exposure. The patient drinks 100-200 ml of low-density barium sulfate in the upright position. Frontal X-ray images are obtained at 1, 2 and 5 minPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5kZSBPbGl2ZWlyYTwvQXV0aG9yPjxZZWFyPjE5OTc8L1ll
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ADDIN EN.CITE.DATA [13]. TBE has been shown to have its greatest value in differentiating non-treated achalasia from EGJOO/non-achalasia dysphagia. It was shown in a recent study with the barium height of 5 cm at 1 minute to have an excellent accuracy with a sensitivity of 94% and specificity of 71% (AUC = 0.915; 95% CI 0.883-0.946; P < 0.0001) in differentiating non-treated achalasia from EGJOO and non-achalasia dysphagia. The diagnostic yield increased to 100% in non-treated achalasia and 60% in EGJOO when 13-mm barium tablet was added to the liquid TBE ADDIN EN.CITE <EndNote><Cite><Author>Blonski</Author><Year>2018</Year><RecNum>2343</RecNum><DisplayText><style face="superscript">[14]</style></DisplayText><record><rec-number>2343</rec-number><foreign-keys><key app="EN" db-id="50wxdpzd9vd5r7e9t5b595djrfpttrxw9avp" timestamp="1534190177">2343</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Blonski, W.</author><author>Kumar, A.</author><author>Feldman, J.</author><author>Richter, J. E.</author></authors></contributors><auth-address>Division of Digestive Diseases and Nutrition, Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida Morsani College of Medicine, Tampa, Florida, USA.
Division of Evidence Based Medicine, University of South Florida Morsani College of Medicine, Tampa, Florida, USA.
Department of Radiology, University of South Florida Morsani College of Medicine, Tampa, Florida, USA.</auth-address><titles><title>Timed Barium Swallow: Diagnostic Role and Predictive Value in Untreated Achalasia, Esophagogastric Junction Outflow Obstruction, and Non-Achalasia Dysphagia</title><secondary-title>Am J Gastroenterol</secondary-title><alt-title>The American journal of gastroenterology</alt-title></titles><periodical><full-title>Am J Gastroenterol</full-title><abbr-1>The American journal of gastroenterology</abbr-1></periodical><alt-periodical><full-title>Am J Gastroenterol</full-title><abbr-1>The American journal of gastroenterology</abbr-1></alt-periodical><pages>196-203</pages><volume>113</volume><number>2</number><edition>2017/12/20</edition><dates><year>2018</year><pub-dates><date>Feb</date></pub-dates></dates><isbn>0002-9270</isbn><accession-num>29257145</accession-num><urls></urls><electronic-resource-num>10.1038/ajg.2017.370</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>[14]. Therefore, abnormal TBE with barium tablet retention is an excellent surrogate to diagnose achalasia when HRM is intolerable, not available, or of poor quality. However, it does not eliminate the need for HRM in cases of EGJOO due to poor accuracy of liquid barium to differentiate EGJOO from non-achalasia dysphagia ADDIN EN.CITE <EndNote><Cite><Author>Blonski</Author><Year>2018</Year><RecNum>2343</RecNum><DisplayText><style face="superscript">[14]</style></DisplayText><record><rec-number>2343</rec-number><foreign-keys><key app="EN" db-id="50wxdpzd9vd5r7e9t5b595djrfpttrxw9avp" timestamp="1534190177">2343</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Blonski, W.</author><author>Kumar, A.</author><author>Feldman, J.</author><author>Richter, J. E.</author></authors></contributors><auth-address>Division of Digestive Diseases and Nutrition, Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida Morsani College of Medicine, Tampa, Florida, USA.
Division of Evidence Based Medicine, University of South Florida Morsani College of Medicine, Tampa, Florida, USA.
Department of Radiology, University of South Florida Morsani College of Medicine, Tampa, Florida, USA.</auth-address><titles><title>Timed Barium Swallow: Diagnostic Role and Predictive Value in Untreated Achalasia, Esophagogastric Junction Outflow Obstruction, and Non-Achalasia Dysphagia</title><secondary-title>Am J Gastroenterol</secondary-title><alt-title>The American journal of gastroenterology</alt-title></titles><periodical><full-title>Am J Gastroenterol</full-title><abbr-1>The American journal of gastroenterology</abbr-1></periodical><alt-periodical><full-title>Am J Gastroenterol</full-title><abbr-1>The American journal of gastroenterology</abbr-1></alt-periodical><pages>196-203</pages><volume>113</volume><number>2</number><edition>2017/12/20</edition><dates><year>2018</year><pub-dates><date>Feb</date></pub-dates></dates><isbn>0002-9270</isbn><accession-num>29257145</accession-num><urls></urls><electronic-resource-num>10.1038/ajg.2017.370</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>[14]. It is proposed that cutoff values of barium column height ( 5 cm at 1 min and 2 cm at 5 min) to separate untreated achalasia from EGJOO and non-achalasia dysphagia ADDIN EN.CITE <EndNote><Cite><Author>Blonski</Author><Year>2018</Year><RecNum>2343</RecNum><DisplayText><style face="superscript">[14]</style></DisplayText><record><rec-number>2343</rec-number><foreign-keys><key app="EN" db-id="50wxdpzd9vd5r7e9t5b595djrfpttrxw9avp" timestamp="1534190177">2343</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Blonski, W.</author><author>Kumar, A.</author><author>Feldman, J.</author><author>Richter, J. E.</author></authors></contributors><auth-address>Division of Digestive Diseases and Nutrition, Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida Morsani College of Medicine, Tampa, Florida, USA.
Division of Evidence Based Medicine, University of South Florida Morsani College of Medicine, Tampa, Florida, USA.
Department of Radiology, University of South Florida Morsani College of Medicine, Tampa, Florida, USA.</auth-address><titles><title>Timed Barium Swallow: Diagnostic Role and Predictive Value in Untreated Achalasia, Esophagogastric Junction Outflow Obstruction, and Non-Achalasia Dysphagia</title><secondary-title>Am J Gastroenterol</secondary-title><alt-title>The American journal of gastroenterology</alt-title></titles><periodical><full-title>Am J Gastroenterol</full-title><abbr-1>The American journal of gastroenterology</abbr-1></periodical><alt-periodical><full-title>Am J Gastroenterol</full-title><abbr-1>The American journal of gastroenterology</abbr-1></alt-periodical><pages>196-203</pages><volume>113</volume><number>2</number><edition>2017/12/20</edition><dates><year>2018</year><pub-dates><date>Feb</date></pub-dates></dates><isbn>0002-9270</isbn><accession-num>29257145</accession-num><urls></urls><electronic-resource-num>10.1038/ajg.2017.370</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>[14].Another diagnostic test which has not made its way widely to the clinical arena yet is the functional luminal imaging probe (FLIP) technology. FLIP measures the cross-sectional area of the esophagus during volume-controlled distension (balloon catheter filled with liquid) which then leads to a software-created high-resolution impedance planimetry with simultaneous measurement of pressure and diameter of the esophagus. This technique assesses the opening dynamics at the EGJ, in addition to esophageal wall stiffness and compliancePEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DYXJsc29uPC9BdXRob3I+PFllYXI+MjAxNjwvWWVhcj48
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ADDIN EN.CITE.DATA [15]. However, this technology is not widely available and is limited to esophageal centers of excellence as an exploratory method with data mostly focused on assessment and outcomes in achalasia and EoEPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IaXJhbm88L0F1dGhvcj48WWVhcj4yMDE3PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA [5]. However, Endoscopic Ultrasound (EUS) should be considered as a complementary imaging technique if there is a suspicion of an infiltrating or submucosal tumor of the EGJ or cardia. This is especially true in older individual with relatively recent onset of symptoms (< 6 mo).Management of EGJOOSince the etiologies of EGJOO are diverse, the treatment strategy relies on accurate diagnosis and treatment of the underlying etiology. Proton pump inhibitors are the treatment for reflux esophagitis and the first step in the management algorithm for EoE before escalating to further therapy such as topical steroids ADDIN EN.CITE <EndNote><Cite><Author>Molina-Infante</Author><Year>2017</Year><RecNum>2349</RecNum><DisplayText><style face="superscript">[17]</style></DisplayText><record><rec-number>2349</rec-number><foreign-keys><key app="EN" db-id="50wxdpzd9vd5r7e9t5b595djrfpttrxw9avp" timestamp="1535321361">2349</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Molina-Infante, J.</author><author>Lucendo, A. J.</author></authors></contributors><auth-address>Department of Gastroenterology, Hospital Universitario San Pedro de Alcantara, Caceres, Spain.
Centro de Investigacion Biomedica en Red Enfermedades Hepaticas y Digestivas (CIBEREHD), Madrid, Spain.
Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain.</auth-address><titles><title>Proton Pump Inhibitor Therapy for Eosinophilic Esophagitis: A Paradigm Shift</title><secondary-title>Am J Gastroenterol</secondary-title><alt-title>The American journal of gastroenterology</alt-title></titles><periodical><full-title>Am J Gastroenterol</full-title><abbr-1>The American journal of gastroenterology</abbr-1></periodical><alt-periodical><full-title>Am J Gastroenterol</full-title><abbr-1>The American journal of gastroenterology</abbr-1></alt-periodical><pages>1770-1773</pages><volume>112</volume><number>12</number><edition>2017/11/01</edition><dates><year>2017</year><pub-dates><date>Dec</date></pub-dates></dates><isbn>0002-9270</isbn><accession-num>29087399</accession-num><urls></urls><electronic-resource-num>10.1038/ajg.2017.404</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>[17]. Esophageal strictures and rings should be treated with esophageal dilation. Patients with post –fundoplication dysphagia usually respond to redo operations of conversion to partial fundoplication or complete reversal. Functional EGJOO (when no structural abnormality is found) seems to carry a benign coursePEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TY2h1cGFjazwvQXV0aG9yPjxZZWFyPjIwMTc8L1llYXI+
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ADDIN EN.CITE.DATA [18]. Since asymptomatic or minimally symptomatic cases may resolve without any intervention, observation with a follow up manometry is a reasonable approach before deciding on any therapy directed at the LES in cases of functional EGJOO. When there is retention of barium tablet at the EGJ, bougie dilation to 18-20 mm may be indicated and failure may need to be treated with pneumatic dilation and/or botulinum injectionPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DbGF5dG9uPC9BdXRob3I+PFllYXI+MjAxNjwvWWVhcj48
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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DbGF5dG9uPC9BdXRob3I+PFllYXI+MjAxNjwvWWVhcj48
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ADDIN EN.CITE.DATA [19]. Peroral endoscopic myotomy (POEM) has showed promise in the management of functional EGJOO when symptoms persistPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5LaGFzaGFiPC9BdXRob3I+PFllYXI+MjAxODwvWWVhcj48
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ADDIN EN.CITE.DATA [21,22]. Therefore, botulinum toxin injection should be reserved for patients who are poor surgical candidates or unclear diagnosis. Pneumatic dilation has been used for the treatment of achalasia and can be considered in cases of functional EGJOO with persistent symptoms. The initial approach is to start with 30-mm dilator with subsequent dilation using 35-mm dilator (graded dilation) in 2-4 wk if initial dilation was insufficient. When performed by experienced operator following conservative approach, the risk of perforation with PD is < 1%PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MeW5jaDwvQXV0aG9yPjxZZWFyPjIwMTI8L1llYXI+PFJl
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ADDIN EN.CITE.DATA [23]. Graded pneumatic dilation has been shown to be non-inferior to surgical Heller myotomy in term of long-term efficacyPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Cb2Vja3hzdGFlbnM8L0F1dGhvcj48WWVhcj4yMDExPC9Z
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ADDIN EN.CITE.DATA [24]. POEM is a novel technique that was shown to be a safe and effective modality (> 90% success rate) for the treatment of achalasiaPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Jbm91ZTwvQXV0aG9yPjxZZWFyPjIwMTU8L1llYXI+PFJl
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ADDIN EN.CITE.DATA [27].conclusionEGJOO is a distinct motility disorder that encompasses a heterogenous group of underlying etiologies. It is a manometric diagnosis and further adjunctive tests (e.g., endoscopy, TBE, and CT scan) can help further reveal the cause of the obstruction at the EGJ. The course of action depends on the underling etiology and the therapeutic strategy should be personalized to each individual patient’s case. In cases of functional EGJOO, therapies directed at the LES (e.g., pneumatic dilation, PEOM, and botulinum injections) are usually needed for patients with persistent symptoms. Perhaps the definition of EGJOO need to be revised based on the manometric predictors and taking into consideration the IRP value in the upright position, as these implicate the course of action that may need to be taken regarding treatment and timing of intervention.References1 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 Gastroenterol 2015; 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, 201812 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 J Gastroenterol 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 AGA Institute. 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 Hepatol 2016; 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: 579-84; discussion 584-6 [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 J Gastroenterol 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/NEJMoa1010502]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. 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Am J Gastroenterol 2017; 112: 1267-1276 [PMID: 28534521 DOI: 10.1038/ajg.2017.139]P-Reviewer: Gupta V, Xiao JW S-Editor: Gong ZML-Editor: A E-Editor: Yin SYSpecialty type: Gastroenterology and hepatologyCountry of origin: United StatesPeer-review report classificationGrade A (Excellent): 0Grade B (Very good): 0Grade C (Good): C, CGrade D (Fair): 0Grade E (Poor): 0 Figure 1 high-resolution manometry image. Panel A represents a normal high-resolution manometry (HRM) image of the esophagus with normal integrated relaxation pressure of 6 mmHg. Panel B represents an HRM image of esophagogastric junction outflow obstruction with IRP of 20 mmHg and reserved peristalsis. The images are based on MMS technology system. Figure 2 A proposed algorithm for the management of esophagogastric junction outflow obstruction. HRM: High resolution manometry; TBE: Time barium swallow; LES: Lower esophageal sphincter; EGJOO: esophagogastric junction outflow obstruction; DCI: Distal contractile integral; IRP: Integrated relaxation pressure; PPI: proton pump inhibitor. Table 1 Etiologies of esophagogastric junction outflow obstructionConditionCommentsEarly or incompletely expressed achalasia The so called functional EGJOO, akin to achalasiaMechanical processExamples include EoE, esophagitis, hiatal hernia, strictures, rings, tumors at the EGJ, obstructing esophageal varices.Esophageal wall stiffnessInfiltrative esophageal processes, fibrosis, or malignancyExtrinsic vascular compressione.g., aneurysmal dilatation of the aortaCentral obesityDue to increased intra-abdominal pressureOpiate effectEGJOO is more prevalent in chronic opiate usersAnatomical changesExamples: Operations that affect EGJ (e.g., fundoplication, bariatric surgery), paraesophageal herniaFalse-positive finding (normal variant)Measurement errorEGJ: esophagogastric junction; EGJOO: esophagogastric junction outflow obstruction; EoE: eosinophilic esophagitis. ................
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