Research Articlea Adv Res Gastroentero Hepatol Volume 16 Issue 1 - October 2020 Copyright © All rights are reserved by Steven B Clayton DOI: 928 10.19080/ARGH.2020.16.555 Mechanical Etiologies Associated with the Diagnosis of Esophageal Outflow Obstruction on High Resolution Manometry Brian E Jones and Steven B Clayton* Assistant Professor of Internal Medicine, Wake Forest University Baptist Medical Center, USA Submission: October 01, 2020; Published: October 09, 2020 *Corresponding author: Steven B Clayton, Assistant Professor of Internal Medicine, Wake Forest University Baptist Medical Center, Medical Center Blvd. Winston-Salem, NC 27157, USA Abstract Background and Aims: Esophageal anatomic obstruction has been associated with the manometric diagnosis of esophagogastric junction outflow obstruction (EGJOO). Endoscopic evaluation is usually the initial step to evaluate dysphagia in adults; however, many high-resolution impedance manometries (HRIM) are being ordered prior to endoscopy especially in open access settings. The aim of this study was to analyze and describeMaterials anatomic and Methods: findings associated with the manometric diagnosis of EGJOO. A retrospective chart review was performed on all patients receiving HRIM. Clinical presentation, diagnostic testing, and treatment findings were recorded. Patients were categorized as having anatomic versus idiopathic etiologies using all available records.Results: The subgroups were described and evaluated. 72 of 114 patients were identified as having anatomic EGJOO. The most common anatomic findings associated EGJOO were hiatal tohernia directed (59.7%), treatment. esophagitis (31.9%), strictures/webs/Schatzki’s rings (26.4%) and fundoplication (26.4%). 21.9% of patients with HRIM findings consistent with EGJOO had history of prior relevant surgery. Most patients with an identified anatomic etiology had symptom response Conclusions: Anatomic findings, such as hiatal hernias and post-surgical changes, are commonly associated with EGJOO on HRIM. Post- surgical HRIM findings consistent with EGJOO, likely secondary to anatomic changes (e.g. following fundoplication), represent a higher portion of our studied population than previously described in the literature. Other than EGD diagnostic test are not able to significantly distinguish between anatomic and idiopathic EGJOO. EGD should continue to be performed prior to HRIM and if not already performed, on any patient with theKeywords: diagnosis of EGJOO. Endoscopy; Digestive System; Esophageal Diseases; Dilation; Hernia, Hiatal; Manometry Introduction Considerable clinical ambiguity exists over the relevance, optimal evaluation, and treatment of the manometric diagnosis of guidelines acknowledge both EGD and HRIM as preoperative variability among surgeons on which test are performed and the evaluations among other test and admit that there is significant esophagogastric junction outflow obstruction (EGJOO). Additional order they are obtained [9]. complexity arises as the manometric diagnosis of EGJOO, can esophageal strictures, hiatal hernia, prior fundoplication, Anatomic EGJOO has been associated with the following: be caused by either anatomic (also known as mechanical in the adjustable gastric band surgery, eosinophilic esophagitis, and medical literature) esophageal etiologies or a poorly relaxing evaluation is performed to evaluate dysphagia in adults prior to lower esophageal sphincter (LES) [1-8]. Ideally, endoscopic malignancy [1]. The idiopathic form of EGJOO is defined as an elevated median integrated relaxation pressure (IRP) (≥15mmHg) high-resolution impedance manometry (HRIM); but many times achalasia are not met but no anatomic esophageal obstruction HRIM is completed prior to endoscopic evaluation. This may be with preserved peristalsis on HRIM, such that the criteria of non-gastroenterology providers. For example, current Society a result of centers allowing open access ordering of HRIM by exists.(7, 8, 10) Many studies have focused on the idiopathic form of American Gastrointestinal and Endoscopic Surgeons (SAGES) of EGJOO but few have performed an in-depth examination of the Adv Res Gastroentero Hepatol 16(1): ARGH.MS.ID.555928 (2020) 001 Advanced Research in Gastroenterology & Hepatology diagnosis. esophageal anatomic findings associated with the manometric 3-minute baseline period and at least ten 5-ml water swallows, using ManoView software in the high-resolution esophageal color each separated by 30-second intervals. All data were analyzed The aim of this study was to analyze and describe anatomic metric data were recorded, including lower esophageal sphincter topography mode to standardize data analysis. All pertinent findings associated with the manometric diagnosis of EGJOO. Secondary aims were to evaluate clinical presentation, HRIM, liquid basal pressure, intrabolus pressure (IBP), IRP, distal contractile impedance analysis and other radiologic findings on standard integral (DCI), large breaks, contractile frontal velocity, and distal barium esophagram (SBE) and timed barium esophagram (TBE) latency (DL) [10-12]. The Chicago Classification version 3.0 that distinguish between anatomic versus idiopathic EGJOO. Materials and Methods criteria were used to establish the diagnosis of EGJOO and classify All high-resolution impedance manometries, including open Identificationesophageal dysmotility of Anatomic [10]. Versus Idiopathic Etiology access studies, performed over a two-year period at large tertiary All available records were reviewed to identify anatomic academic system were analyzed. Inclusion criteria were adult esophageal obstruction versus an idiopathic etiology. The EGD patients (≥18 years old) with EGJOO as defined by the Chicago in esophageal disease who assigned each record to anatomic and findings were reviewed by a gastroenterologist with experience Classification v3.0 (IRP median over 10 swallows ≥15.0 mmHg with intact peristalsis) [10]. An extensive chart review recorded idiopathic subcategories based on EGD findings. Records with patient demographics, clinical presentation, HRIM parameters, EGD findings including the following, except for in cases where a incomplete bolus clearance on impedance analysis, TBE results, rosette was also identified, were placed in the anatomic subgroup: SBE findings, esophagogastroduodenoscopy (EGD) findings, gastroesophageal reflux disease with erosive esophagitis, relevant surgical history, history of gastroesophageal reflux eosinophilic esophagitis, fundoplication, varices, esophageal information was approved without the need for waiver of consent stricture/web/ring, esophageal diverticulum, esophageal ulcer, disease (GERD), and opioid use. Review of protected medical given low risk nature of the study by the institutional review board nodules, and hiatal hernia. All other patients were identified as having idiopathic EGJOO. of Greenville Health System (now Prisma Health). Treatment methodologies, treatment sequence, and patient’s subjective In addition to endoscopy, hiatal hernias were identified via response to treatment were recorded. A patient’s response to barium esophagram or HRIM. Hiatal hernia size was defined as symptoms documented in the medical record. impression on endoscopy, the distance of abdominal contents the distance from the gastric folds to the diaphragmatic hiatus/ treatment was defined as a subjective improvement in presenting through the esophageal hiatus of the diaphragm into the thoracic Timed Barium Esophagram Protocol cavity on esophagram, and/or the distance between the LES pressure zone and the crural diaphragm pressure zone on HRIMs TBE was obtained using a standardized protocol. The patient present. was administered 240ml (8oz.) of low-density barium in the where a double pressure zone distally on the Clouse plot was standing position; spot films were obtained at 1 minute and Statistical Methods 5 minutes to assess liquid emptying. Barium column height as the column was recorded. Next, the esophagus was cleared with measured from the gastroesophageal (GE) junction to the top of Descriptive statistics (means and standard deviations for passage was evaluated after 5 minutes with abnormal test being water followed by ingestion of a 13-mm barium tablet. Tablet continuous factors, frequencies and percentages for categorical factors) were computed by etiology type (anatomic versus barium height at 1 and 5 minutes in centimeters, barium width at in means between the groups were assessed using two-group tablet retention. The following parameters were recorded: idiopathic). For continuous factors, statistical tests for differences 1 and 5 minutes in centimeters, and tablet retention. t-tests. For categorical factors, differences in proportions between High Resolution Manometry Protocol groups were assessed using chi-square tests or Fisher’s exact test in cases of 2×2 tables where expected cell counts were small (i.e., <5). Instances of low expected cell counts when Fisher’s exact test The esophageal motor function of all patients was studied the results. No adjustment of p-values for propagation of type I circumferential sensors at 1 cm intervals and intra-luminal could not be used because the table was not square are noted in with a 36-channel solid-state catheter system with high fidelity error due to multiple hypothesis testing was performed, thus manometry catheter was placed transnasally and positioned to impedance (Medtronic, Inc., Minneapolis, MN, USA). The with that caveat in mind. All analyses were performed