Table 2.

Disorders of Esophagogastric Junction Outflow

Achalasia

Type I: Abnormal IRP and absent contractility (100% failed peristalsis)

Type II: Abnormal IRP and absent contractility with panesophageal pressurization in 20% or more swallows

Type III: Abnormal IRP and evidence of spasm (20% or more swallows with premature contraction) with no peristalsis

Cutoff of spasm in 20% of swallows is arbitrary; confidence for Type III achalasia is increased with higher number of premature swallows

Inconclusive diagnosis of achalasia is best resolved with a TBE with a 13-mm barium tablet and/or FLIP in patients with dysphagia

Opioids are associated with Type III achalasia, and patients should be studied off opioid medication, if possible. Timing of discontinuation is based on drug half-life

EGJOO

Manometric diagnosis of EGJOO is always considered clinically inconclusive

Manometric diagnosis requires an elevated median IRP in both the supine and upright positions, increased intrabolus pressure, and evidence of peristalsis

Clinically relevant symptoms of EGJOO include dysphagia (usually solid foods) and/or noncardiac chest pain

Definitive diagnosis of EGJOO requires supportive evidence of obstruction by TBE with a barium tablet and/or FLIP

Bold text indicates important new criteria in Chicago Classification version 4.0.

EGJOO, esophagogastric junction outflow obstruction; FLIP, functional lumen imaging planimetry; IRP, integrated relaxation pressure; TBE, timed barium esophagram.