Editorial: reducing false alarms with oesophagogastric junction outflow obstruction

As a society dependent on technology and information, “false alarms” have become commonplace. Smoke detectors, invaluable as they are, alarm just the same whether there is burnt toast or a blazing housefire. In the medical field, incidental detection of, for instance, a pancreatic cyst can be found in 40–50% of persons undergoing abdominal imaging, fortunately often being a “false alarm”.¹ A similar story has unfolded with high-resolution manometry (HRM). According to Chicago Classification version 3.0 (CCv3.0), an elevated lower oesophageal sphincter (LES) median integrated relaxation pressure (IRP) in the setting of preserved oesophageal body peristalsis on HRM met diagnosis for oesophagogastric junction (EGJ) outflow obstruction (EGJOO).^2–4 Under this definition, 5–24% of all comers undergoing HRM met criteria for EGJOO.^4–9 However, akin to shortcomings of a smoke detector, HRM as a single diagnostic test cannot reliably distinguish between true dysfunction across the LES with clinically meaningful and actionable EGJOO from those without. In fact, 32–94% of those who met CCv3.0 criteria for EGJOO but did not undergo treatment or intervention experienced symptomatic improvement over time.^5–9 However, some patients with manometric EGJOO underwent invasive therapy when unneeded or not indicated.

These limitations were a key impetus for reframing EGJOO and the HRM protocol in CC version 4.0 (CCv4.0). The standard protocol in CCv4.0 moves beyond sole evaluation of deglutitive LES relaxation in the supine position to also evaluating the IRP in an upright position as well as with provocation. According to CCv4.0, the manometric diagnosis of EGJOO requires an elevated IRP in both supine and upright positions along with intrabolus pressurization. However, and also according to CCv4.0, manometric EGJOO is always inconclusive and requires additional data points including presence of clinical symptoms of obstruction as well as corroboration of LES obstruction on a non-HRM test such as timed barium oesophagram (TBE) or functional lumen imaging probe.⁴

Visaggi and colleagues examined the impact of these new diagnostic requisites on the prevalence of EGJOO.¹⁰ They identified that CCv4.0 diagnostic criteria (HRM metrics, symptoms, and TBE findings) yield higher specificity for EGJOO with an impressive 6-fold reduction (from 7.2% to 1.2%) of EGJOO prevalence. Further, they identified a lack of abnormal TBE in those without obstructive symptoms, justifying the requirement for obstructive symptoms for EGJOO in CCv4.0. They also demonstrated that a higher median rapid drink challenge (RDC)-IRP, specifically 16.7 mmHg, is predictive of conclusive EGJOO by CCv4.0 criteria.¹⁰

These data highlight the many ways that the updated HRM protocol and definition of EGJOO are a large leap forward in minimizing “false alarms”. Importantly, these updates in CCv4.0 promote a higher level of rigour and confidence in the manometric assessment of LES relaxation, and challenge us to think beyond the manometry study, particularly before intervention. Visaggi et al have further highlighted the potential for RDC-IRP as a surrogate for TBE, which may reduce requirements for additional testing for clinically conclusive EGJOO in future iterations of CC.

Figure.

Reframing the definition of EGJOO to Reduce False Alarms. The updates in CCv4.0 including increased data points to assess for LES obstruction on HRM, requirement of obstructive symptoms and corroboration of LES obstructive physiology on a non-HRM test have led to less “false alarms” of EGJOO diagnosis.

Abbreviations:

HRM

High resolution manometry

LES

Lower esophageal Sphincter

CC

Chicago Classification

IRP

Integrated relaxation pressure

EGJ

Esophagogastric junction

EGJOO

EGJ outflow obstruction

TBE

Timed barium esophagram

RDC

Rapid drink challenge