Clinical and manometric characteristics of patients with oesophagogastric outflow obstruction: towards a new classification

BACKGROUND: The Chicago Classification (CC) defines oesophagogastric junction outflow obstruction (EGJOO) as the presence of an elevated integrated residual pressure (IRP) together with preserved oesophageal body peristalsis but its clinical significance is evolving. AIMS: To describe the clinical and manometric characteristics in patients with EGJOO and propose a new classification. METHODS: In this retrospective cohort study, patients with functional oesophageal symptoms underwent clinical and endoscopic assessment and oesophageal high-resolution manometry (HRM). The CC V.3 was used to define and redefine abnormalities. RESULTS: Of 478 HRM studies performed, EGJOO, defined as median IRP >15 mm Hg, was diagnosed in 116 patients; 17 underwent a follow-up HRM. Forty-four patients had otherwise normal oesophageal motility, with the only finding being EGJOO; 14 had achalasia, 19 had EGJOO plus ineffective oesophageal motility (IEM), 28 had EGJOO plus diffuse oesophageal spasm (DES) (n=25) or jackhammer oesophagus (n=3), and 11 had EGJOO plus IEM and DES. Patients with EGJOO+IEM had lower distal contractile integral (DCI) while those with EGJOO+DES had higher DCI. All groups exhibited high percentages of incomplete bolus clearance. On repeat studies, EGJOO preceded or followed another HRM diagnosis and remained permanent in 2/17 patients. Only one patient transitioned to achalasia. CONCLUSIONS: The new classification further defines EGJOO by considering abnormalities in the body of the oesophagus that could contribute to symptoms or require therapy. Most patients with EGJOO have a coexisting motility disorder and do not have isolated EGJOO. There is a fluidity of the HRM diagnosis that needs to be considered prior to therapy.