Combined Multichannel Intraluminal Impedance and High-resolution Manometry Improves Detection of Clinically Relevant Esophagogastric Junction Outflow Obstruction

Abstract

Background/aims: Esophagogastric junction outflow obstruction (EGJOO) is a diagnostically heterogeneous group with variable clinical relevance. We studied whether evaluation of bolus transit by multichannel intraluminal impedance (MII) is useful for discriminating clinically relevant EGJOO.

Methods: A total 169 patients diagnosed as having EGJOO between June 2011 and February 2018 were analyzed. All the patients received a combined MII and high-resolution manometry (CMII-HRM). MII was reported as having abnormal liquid bolus transit (LBT) if ＜ 80% of swallows had complete bolus transit. EGJOO was defined as a median integrated relaxation pressure of ＞ 20 mmHg and when the criteria for achalasia were not met. Patients who progress to achalasia, show significant passage disturbance, or require pneumatic dilatation were defined as having a clinically relevant EGJOO.

Results: Among the patients with EGJOO (n = 169), the clinically relevant group (n = 10) is more likely to have dysphagia (100% vs 25.2%, P ＜ 0.001), compartmentalized pressurization (CP; 90.0% vs 22.0%, P ＜ 0.001), and abnormal LBT (100% vs 66.7%, P = 0.032) compared to the non-relevant group (n = 159). The combination of dysphagia, CP, and abnormal LBT showed the best predictive power for clinically relevant EGJOO (sensitivity 90%, specificity 92.5%, positive predictive value 42.9%, negative predictive value 99.3%, positive likelihood ratio 11.9, and negative likelihood ratio 0.1). When CMII-HRM was used, an additional 8.3% of clinically relevant EGJOO cases were identified as compared with HRM alone.

Conclusion: Clinically relevant EGJOO can be predicted using CMII-HRM.

Keywords: Electric impedance; Esophageal achalasia; Esophagogastric junction; Manometry.

Figure 1

Improved esophageal bolus clearance after peroral endoscopic myotomy (POEM) in a patient with esophagogastric junction outflow obstruction (EGJOO). A 50-year-old woman presented with dysphagia. (A) She was diagnosed as having EGJOO (integrated relaxation pressure, 41 mmHg) and showed abnormal liquid bolus transit (LBT; 0%). POEM was performed because no organic cause was found to explain her abnormal dysphagia. (B) After POEM, her symptoms disappeared completely, and the LBT was normalized as indicated by the purple color in the figure.

Figure 2

Prediction of clinical relevance of esophagogastric junction outflow obstruction (EGJOO) according to the number of predictors. *P < 0.001 vs predictors 0, 1, or 2, each.

Figure 3

Added value of impedance for prediction of clinically relevant esophagogastric junction outflow obstruction. CP, compartmentalized pressurization; CMII-HRM, combined multichannel intra-luminal impedance and high-resolution manometry; HRM, high-resolution manometry.