Department of Gastroenterology, St Vincent's Hospital, Sydney, Australia.
GI Physiology Unit, University College London Hospital, London, UK.
Am J Gastroenterol. 2021 Feb 1;116(2):280-288. doi: 10.14309/ajg.0000000000000988.
Esophagogastric junction outflow obstruction (EGJOO) defined on high-resolution esophageal manometry (HRM) poses a management dilemma given marked variability in clinical manifestations. We hypothesized that findings from provocative testing (rapid drink challenge and solid swallows) could determine the clinical relevance of EGJOO.
In a retrospective cohort study, we included consecutive subjects between May 2016 and January 2020 with EGJOO. Standard HRM with 5-mL water swallows was followed by provocative testing. Barium esophagography findings were obtained. Cases with structural obstruction were separated from functional EGJOO, with the latter categorized as symptom-positive or symptom-negative. Only symptom-positive subjects were considered for achalasia-type therapies. Sensitivity and specificity for clinically relevant EGJOO during 5-mL water swallows, provocative testing, and barium were calculated.
Of the 121 EGJOO cases, 76% had dysphagia and 25% had holdup on barium. Ninety-seven cases (84%) were defined as functional EGJOO. Symptom-positive EGJOO subjects were more likely to demonstrate abnormal motility and pressurization patterns and to reproduce symptoms during provocative testing, but not with 5-mL water swallows. Twenty-nine (30%) functional EGJOO subjects underwent achalasia-type therapy, with symptomatic response in 26 (90%). Forty-eight (49%) functional EGJOO cases were managed conservatively, with symptom remission in 78%. Although specificity was similar, provocative testing demonstrated superior sensitivity in identifying treatment responders from spontaneously remitting EGJOO (85%) compared with both 5-mL water swallows (54%; P < 0.01) and barium esophagography (54%; P = 0.02).
Provocative testing during HRM is highly accurate in identifying clinically relevant EGJOO that benefits from therapy and should be routinely performed as part of the manometric protocol.
在高分辨率食管测压（HRM）中定义的食管胃交界流出梗阻（EGJOO）由于临床表现存在明显差异，因此在管理上存在困境。我们假设激发试验（快速饮水挑战和固体吞咽）的结果可以确定 EGJOO 的临床相关性。
在一项回顾性队列研究中，我们纳入了 2016 年 5 月至 2020 年 1 月间连续出现 EGJOO 的患者。标准 HRM 结合 5 毫升水吞咽后进行激发试验。获得钡餐造影结果。将结构梗阻与功能性 EGJOO 分开，后者分为症状阳性或症状阴性。只有症状阳性的患者才考虑采用贲门失弛缓症样治疗。计算 5 毫升水吞咽、激发试验和钡餐在诊断有临床意义的 EGJOO 中的敏感性和特异性。
在 121 例 EGJOO 病例中，76%有吞咽困难，25%钡餐有滞留。97 例（84%）被定义为功能性 EGJOO。症状阳性的 EGJOO 患者更有可能表现出异常的运动和加压模式，并在激发试验中再现症状，但 5 毫升水吞咽时不会出现。29 例（30%）功能性 EGJOO 患者接受了贲门失弛缓症样治疗，26 例（90%）有症状缓解。48 例（49%）功能性 EGJOO 患者接受保守治疗，78%的患者症状缓解。虽然特异性相似，但与 5 毫升水吞咽（54%；P < 0.01）和钡餐（54%；P = 0.02）相比，激发试验在识别自发缓解的 EGJOO 中治疗反应者的敏感性更高。
HRM 中的激发试验在识别受益于治疗的有临床意义的 EGJOO 方面具有高度准确性，应作为测压方案的常规内容。
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