What is the treatment for Esophageal (Egj) outflow obstruction?

From the Guidelines

Treatment for esophagogastric junction (EGJ) outflow obstruction should begin with less invasive alternatives, such as medical therapy, botulinum toxin injections, and endoscopic dilation, before considering Per-Oral Endoscopic Myotomy (POEM) in carefully selected cases. According to the most recent and highest quality study 1, the role of POEM for EGJ outflow obstruction is not well-defined, and less invasive alternatives should be exhausted before consideration of POEM.

Treatment Options

• Medications like calcium channel blockers (nifedipine 10-30mg before meals) or nitrates (isosorbide dinitrate 5-10mg before meals) to relax the lower esophageal sphincter
• Endoscopic interventions, including pneumatic dilation (gradually increasing balloon size from 30mm to 40mm) or botulinum toxin injection (100 units divided into quadrants)
• Surgical options, including laparoscopic Heller myotomy with partial fundoplication, which cuts the muscle fibers causing the obstruction while preventing reflux
• POEM, creating a submucosal tunnel to divide the circular muscle fibers, may be considered in selected cases, with a reported long-term success rate of 80%–85% 1

Important Considerations

• Careful consideration of potential false positives and confirmatory compliance testing (eg, impedance planimetry, timed barium esophagram, and pH study) to exclude GERD and document symptomatic delayed esophageal emptying are mandatory 1
• The distinction between manometric and clinically relevant diagnoses of EGJ outflow obstruction and other non-achalasia spastic motility disorders should be made 1
• Treatment choice depends on patient characteristics, with medications tried first in mild cases, while more invasive options are reserved for severe or refractory cases 1

Recent Guidelines

The AGA clinical practice update on advances in POEM and remaining questions 1 provides best practice advice statements, including the recommendation to consider POEM for type III achalasia and to exhaust less invasive alternatives before considering POEM for EGJ outflow obstruction. Another study 1 emphasizes the importance of a comprehensive diagnostic workup, including clinical history, upper endoscopy, timed barium esophagram, and high-resolution manometry, to clarify the etiology of EGJ outflow obstruction.

From the Research

Treatment Options for Esophageal (Egj) Outflow Obstruction

The treatment for esophageal outflow obstruction, also known as esophagogastric junction outflow obstruction (EGJOO), depends on the underlying cause and subtype of the disorder. The following treatment options are available:

• Medical treatments, including drugs like acotiamide and/or diltiazem, which can be used as a first-line treatment for EGJOO 2
• Endoscopic pneumatic dilation (PD), which can be used as a first-line treatment for achalasia type I and II, and as a second-line treatment for EGJOO 2
• Laparoscopic Heller myotomy (LHM), which can be used as a first-line treatment for achalasia type I, and as a treatment for patients with recurrent dysphagia after PD 3, 4
• Per-oral endoscopic myotomy (POEM), which can be used as a first-line treatment for achalasia type III, and as a third-line treatment for EGJOO 2
• Botulinum toxin (BT) injection of the lower esophageal sphincter, which can be used as a diagnostic test to identify achalasia-variant EGJOO likely to respond to LES muscle-directed invasive therapy 5

Treatment Strategies Based on Subtypes

The treatment strategy for EGJOO should be based on the subtype of the disorder, as follows:

• Achalasia type I: PD or LHM can be considered as a first-line treatment 2
• Achalasia type II: PD or POEM can be considered as a first-line treatment 2
• Achalasia type III: POEM can be considered as a first-line treatment 2
• EGJOO: medical treatments, including drugs like acotiamide and/or diltiazem, can be used as a first-line treatment, followed by PD and POEM as second and third-line treatments, respectively 2

Multidisciplinary Approach

A multidisciplinary approach to the treatment of EGJOO, involving radiologists, gastroenterologists, and surgeons, can improve patient outcomes 4. This approach allows for a comprehensive evaluation of the patient's condition and the development of a personalized treatment plan.