From the Guidelines
Esophagogastric junction (EGJ) outflow obstruction can be categorized into several types, including achalasia, mechanical obstruction, functional obstruction, and EGJ outflow obstruction due to various etiologies such as incompletely expressed or early achalasia, isolated disorder of impaired LES relaxation, esophageal wall stiffness, eosinophilic esophagitis, vascular obstruction, sliding or paraesophageal hiatal hernia, abdominal obesity, or the effects of opiates. The types of EGJ outflow obstruction can be further broken down into:
- Achalasia, which includes types I, II, and III, each with distinct manometric features, such as absent peristalsis and no pressurization in type I, absent peristalsis with panesophageal pressurization in type II, and premature or spastic contractions in type III 1.
- Mechanical obstruction, which can result from strictures, tumors, or post-surgical changes that physically block the EGJ.
- Functional obstruction, which occurs when the lower esophageal sphincter fails to relax properly despite normal anatomy.
- EGJ outflow obstruction, which is a heterogeneous group with a spectrum of potential etiologies, including those mentioned above, and requires a comprehensive evaluation to clarify its etiology 1. Diagnosis of EGJ outflow obstruction typically requires high-resolution manometry, which measures esophageal pressures and sphincter function, and treatment varies by type, with achalasia often requiring pneumatic dilation, peroral endoscopic myotomy (POEM), or surgical Heller myotomy, while mechanical obstructions may need endoscopic dilation, stenting, or surgery, and functional obstructions might respond to smooth muscle relaxants like calcium channel blockers or nitrates 1. It is essential to note that EGJ outflow obstruction is not pathognomonic for any diagnosis and should not, in isolation, be used to justify any permanent intervention, but rather should be considered as a manometric finding associated with a multitude of alternative causes, such as obesity 1. Therefore, a comprehensive evaluation with correlation of symptoms is necessary to determine the underlying cause of EGJ outflow obstruction and to guide treatment decisions.
From the Research
Types of Esophageal (Egj) Outflow Obstruction
The types of esophageal (Egj) outflow obstruction can be categorized based on the underlying cause and manometric findings. The main types include:
- Functional obstruction, which is akin to achalasia 2
- Mechanical obstruction, which can be caused by various factors such as tumors or strictures 2
- Medication-induced obstruction, which can be caused by certain medications that affect the lower esophageal sphincter (LES) 2
- Artifact, which can be caused by technical issues during manometric testing 2, 3
- Achalasia-variant esophagogastric junction outflow obstruction, which is a subtype of EGJOO that responds to botulinum toxin injection of the LES 4
Subtypes of Achalasia
Achalasia can be further subdivided into three subtypes based on manometric findings:
- Type I: characterized by minimal contractility of the esophageal body 5
- Type II: characterized by non-peristaltic (simultaneous) contractions with ≥ 20% of swallows 5
- Type III: characterized by premature (spastic) contractions with ≥ 20% of swallows 5
Diagnosis and Treatment
Diagnosis of EGJOO is typically made using high-resolution esophageal manometry, with adjunctive testing such as functional lumen imaging probe (FLIP) and timed barium esophagram (TBE) used to confirm the diagnosis and guide treatment 2, 3, 6. Treatment options for EGJOO include medical therapy, pneumatic dilation, peroral endoscopic myotomy (POEM), and Heller myotomy, with the choice of treatment depending on the underlying cause and subtype of EGJOO 5, 2, 3, 6.