From the Guidelines
The primary goal of managing esophageal gastric outflow obstruction is to alleviate or bypass the obstruction, with options including endoscopy with stent placement, surgery, or other interventions to reduce symptoms and improve quality of life. The management of esophageal gastric outflow obstruction involves a multidisciplinary approach, considering the patient's overall condition, the cause of the obstruction, and the potential benefits and risks of different interventions 1.
Key Considerations
- Alleviating or bypassing the obstruction is the primary goal, which can be achieved through endoscopy with stent placement for relief of outlet obstruction or esophageal stent for EGJ/gastric cardia obstruction 1.
- Surgery, such as gastrojejunostomy, may be considered in select patients, and gastrectomy may be an option for some cases 1.
- External beam radiation therapy (EBRT) and chemotherapy can also play a role in managing the underlying cause of the obstruction, particularly in cases of malignant obstruction 1.
- For patients who cannot take an oral diet, feeding gastrostomy tubes or jejunal feeding tubes can be placed, depending on the tumor location, to ensure adequate nutrition 1.
Recent Advances
The use of per-oral endoscopic myotomy (POEM) has been explored for the treatment of esophagogastric outflow obstruction, offering a minimally invasive option for patients with conditions like achalasia 1. However, the decision to proceed with POEM or other interventions should be based on the most recent and highest quality evidence, considering the individual patient's needs and circumstances.
Clinical Approach
In clinical practice, the management of esophageal gastric outflow obstruction should prioritize reducing symptoms, improving nutritional status, and enhancing quality of life. A comprehensive approach, including medical management, endoscopic interventions, and surgical options, should be tailored to the individual patient, taking into account the latest evidence and guidelines. Patients should be closely monitored, and treatment plans adjusted as necessary to optimize outcomes.
From the Research
Medical Management of Esophageal Gastric Outflow Obstruction
The medical management of esophageal gastric outflow obstruction (EGJOO) involves various approaches, including:
- Diagnosis using high-resolution esophageal manometry, which is the gold standard for diagnosing EGJOO 2
- Adjunctive testing with functional lumen imaging probe (FLIP) and timed barium swallow to confirm the diagnosis 2
- Treatment targeted at the suspected underlying etiology and clinical presentation of EGJOO, which may include:
- Pharmacologic therapy, although its role is limited 2
- LES disruption therapy, similar to achalasia, for functional obstruction with significant and persistent dysphagia 2
- Endoscopic treatments, such as balloon dilatation or placement of self-expandable stents, for mechanical obstruction 3
- Surgery, in some cases, for malignant causes of GOO 3
Treatment Strategies for Functional EGJOO
For functional EGJOO, various treatment strategies have been reported, including:
- Botulinum toxin (Botox) injection, with a success rate of 58% 4
- Expectant management, with a success rate of 54% 4
- Watchful waiting, with similar reported symptom resolution rates among all strategies 4
- Pneumatic dilation or myotomy, for patients with significant symptoms and objective evidence of obstruction on imaging 5
Role of Proton Pump Inhibitors
Proton pump inhibitors (PPIs) have been shown to reverse endoscopic features of fibrosis in eosinophilic esophagitis, a condition that can cause esophageal remodeling and stricture formation 6. However, the role of PPIs in the management of EGJOO is not well established, and more research is needed to determine their effectiveness in this context.