A300 ESOPHAGOGASTRIC JUNCTION OUTFLOW OBSTRUCTION ON MANOMETRY: OUTCOMES AND LACK OF BENEFIT FROM IMAGING

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. Causes include structural (stricture, hiatus hernia, eosinophilic esophagitis, malignancy, and post-fundoplication) and functional/motility etiologies (early achalasia and medication side-effects), although typically most of the structural causes are ruled out by endoscopy prior to manometry. The Chicago group suggests further investigation including computed tomography (CT) or endoscopic ultrasound (EUS) to help elucidate the etiology of EGJOO, but the utility of this approach has not been proven. To assess the therapeutic outcome of EGJOO by assessing which interventions are performed after an EGJOO diagnosis. To assess the proportion of patients with EGJOO who underwent further testing (e.g. CT or EUS of the GEJ) and whether that testing elucidated a cause for the EGJOO. All new diagnoses of EGJOO made in calendar year 2016 at a regional motility lab were included. A comprehensive, province-wide electronic medical database (Alberta Netcare, which includes virtually all publicly-funded imaging, pathology, lab, and endoscopy results) was searched for each patient to assess diagnostic and therapeutic interventions after the EGJOO diagnosis. Ethics board-approved study. 80 EGJOO patients were included (mean age 63 (range 37–95), 76% female). Primary complaint was dysphagia (67.5%), chest pain (12.5%), reflux (8.8%), pre-operative assessment (7.5%), regurgitation (2.5%), or cough (1.2%). The mean IRP was 22 mmHg (range 15–43, normal <15.0). After a mean follow-up period of 439 days (range 92–631), the etiology of our patients’ EGJOO remained unidentified in most cases (70.0%). In the remainder, subsequent evaluation led to a diagnosis of hiatal hernia (10.0%), medication side-effects (5.0%), spontaneous resolution (5.0%), achalasia (3.8%), stricture (3.8%), jackhammer esophagus (1.2%), and eosinophilic esophagitis (1.2%). Regarding interventions, eight patients had esophageal dilation (10.0%), nine had botulinum toxin injection to the GEJ (11.2%), and three had surgery (3.8%). A proportion of patients were investigated with CT (25.0%) or EUS (7.5%) to rule out external compression or malignancy as a cause of EGJOO; none of these tests provided any further information on the cause. EGJOO is a relatively new manometric diagnosis with unclear clinical significance and outcome in most cases. CT and EUS of the GEJ were unhelpful at determining the cause of this entity. Few cases progressed to achalasia. Lack of familiarity with EGJOO may contribute to the low rate of subsequent intervention. None

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