From the Guidelines
Esophageal gastric outflow obstruction should be treated with per-oral endoscopic myotomy (POEM) as it has shown a 72% success rate in a recent meta-analysis, especially in cases where the disorder is associated with hypercontractile (jackhammer) esophagus, and LES myotomy should be done concomitantly if POEM is applied in these patients. The clinical evaluation of esophageal gastric outflow obstruction is crucial to determine the underlying cause of dysphagia, which can be due to various etiologies such as incompletely expressed or early achalasia, isolated disorder of impaired LES relaxation, esophageal wall stiffness from an infiltrative disease or cancer, eosinophilic esophagitis, vascular obstruction, sliding or paraesophageal hiatal hernia, abdominal obesity, or the effects of opiates 1. Some key points to consider in the treatment of esophageal gastric outflow obstruction include:
- The use of endoscopic ultrasound, computed tomography, and timed barium esophagram to clarify the etiology of the obstruction 1
- The consideration of prior surgery, as similar manometric findings can be found after anti-reflux or bariatric surgery, making it difficult to establish cause and effect 1
- The potential for spontaneous resolution of the disorder in 20%–40% of cases, but also the possibility of progression to achalasia in 12%–40% of cases 1
- The importance of treating the underlying cause of the obstruction, rather than just the symptoms, to provide effective relief and prevent complications. In terms of treatment, POEM has emerged as a promising option for esophageal gastric outflow obstruction, particularly in cases associated with hypercontractile (jackhammer) esophagus, with a 72% success rate reported in a recent meta-analysis 1. It is essential to note that the treatment of esophageal gastric outflow obstruction should be individualized based on the specific cause and severity of the condition, as well as the patient's overall health status and medical history.
From the Research
Definition and Diagnosis of Esophageal Gastric Outflow Obstruction
- Esophagogastric junction outflow obstruction (EGJOO) is a manometric diagnosis based on the Chicago Classification, defined by inadequate relaxation of the gastroesophageal junction (GEJ) with swallowing, but with sufficient peristalsis such that the criteria for achalasia are not met 2, 3, 4.
- High-resolution esophageal manometry is currently the gold standard of diagnosis for EGJOO 2, 4.
- Functional lumen imaging probe (FLIP) and timed barium swallow can be used as adjunctive testing for EGJOO diagnosis 2, 4.
Causes and Clinical Presentation of Esophageal Gastric Outflow Obstruction
- EGJOO can be caused by functional obstruction, mechanical obstruction, medications, or artifact 2.
- Possible causes of EGJOO include anatomical and functional etiologies, such as opioid usage, early achalasia, and mechanical obstruction 3, 4.
- Clinical presentation of EGJOO can vary, with symptoms including dysphagia, chest pain, reflux, regurgitation, and cough 3, 5.
Management and Treatment of Esophageal Gastric Outflow Obstruction
- Management of EGJOO depends on the underlying etiology, with functional EGJOO patients with persistent dysphagia associated with the presence of outflow obstruction may require EGJ disruption therapy 2, 4, 5.
- Endoscopy should be an initial step to exclude anatomical causes, and imaging studies can identify infiltrative lesions, but the reported diagnostic yield is relatively low 4, 5.
- Treatment options for EGJOO include pneumatic dilation, myotomy, and botulinum toxin injection of the lower esophageal sphincter, with variable response seen in small studies 5.