Esophagogastric junction outflow obstruction (EGJOO) is an esophageal motility disorder characterized by increased pressure where the esophagus connects to the stomach at the lower esophageal sphincter. EGJOO is diagnosed by esophageal manometry. However, EGJOO has a variety of etiologies; evaluating the cause of obstruction with additional testing, such as upper endoscopy, computed tomography (CT imaging), or endoscopic ultrasound may be necessary. When possible, treatment of EGJOO should be directed at the cause of obstruction. When no cause for obstruction is found (functional EGJOO), observation alone may be considered if symptoms are minimal. Functional EGJOO with significant or refractor symptoms may be treated with pneumatic dilation, per-oral endoscopic myotomy (POEM), or botulinum toxin injection. Types
EGJOO may be broadly categorized into 4 subgroups: mechanical, functional, medication-related, and artifact. Signs and symptoms
In some cases, EGJOO may cause no symptoms, and the manometry findings are identified during an evaluation prior to anti-reflux surgery. In other cases, EGJOO may be identified after an evaluation for esophageal symptoms. The most common symptoms are dysphagia (50-75%, typical reflux (29-67%), atypical reflux (21-36%), chest pain (16-46%), abdominal pain (43%) or regurgitation (38%). One study suggested about 5% of individuals have no symptoms. Causes
Several causes for EGJOO exist. Etiologies include early achalasia, mechanical processes (eosinophilic esophagitis, hiatal hernia, strictures, etc. ), esophageal wall thickness (fibrosis, cancer, etc. ), compression by nearby blood vessels (external vascular compression), obesity, opioid medication effect, or anatomic abnormalities. The findings associated with EGJOO may be falsely abnormal due to measurement errors. Diagnosis
EGJOO is diagnosed using esophageal manometry.
If symptoms are severe or persistent, peroral endoscopic myotomy (POEM) may be offered.Pneumatic dilation may be used for persistent symptoms in the absence of identified causes of mechanical obstruction. Botulinum toxin may be considered, especially for individuals who are unlikely to tolerate surgery. Prognosis
The prognosis for EGJOO depends on the etiology of obstruction. In the absence of anatomic or mechanical causes, such as cancer, outcomes are generally favorable. Individuals with minimal or no symptoms often experience resolution of the EGJOO, even without treatment. Epidemiology
The overall prevalence of EGJOO is unclear. The prevalence of EGJOO among all patients undergoing high resolution manometry was up to 10 percent. The diagnostic criteria were later adjusted to distinguish relevant (symptomatic) EGJOO from isolated manometric findings of EGJOO without symptoms.Individuals diagnosed with EGJOO based on Chicago 3.0 classification have an average age of 56–57 years. EGJOO more commonly affects women (51-88%). The average BMI is between 25 and 30. == References ==