背景:食管胃结合部流出道梗阻(EGJOO)的关键诊断标准发表在最新的芝加哥分类4.0版(CCv4.0)中。除了先前的标准[仰卧位时积分松弛压(IRP)升高],EGJOO的测压诊断需要满足直立湿吞时中位IRP升高和代谢内压升高的标准。然而,随着诊断标准的修改,EGJOO的测压特征变化尚不清楚。
目的:评估EGJOO患者的食管运动特征,并选择有价值的参数来确认EGJOO的诊断。
方法:我们对370例患者进行了回顾性分析,这些患者接受了5mL水吞咽×10仰卧位的高分辨率测压,×5直立姿势,2016年11月至2021年11月在北京大学第一医院使用200mL水进行快速饮用挑战(RDC)。纳入51例仰卧位综合IRP升高且有蠕动证据的患者,作为EGJOO组,24例符合更新的EGJOO测压诊断(CCv4.0),27例未符合更新的EGJOO标准的患者作为孤立仰卧IRP升高组(直立体位的IRP中位数正常或IBP升高的仰卧吞下者少于20%)。收集46例具有正常测压特征的患者作为正常高分辨率测压(HRM)组。食管上括约肌(UES),食道体,比较各组食管下括约肌(LES)参数。
结果:与正常人力资源管理组相比,EGJOO(CCv4.0)患者的近端食管收缩积分(PECI)和近端食管长度(PEL)显着降低,RDC上IRP升高(每次比较P<0.05),而孤立仰卧IRP升高的患者没有这样的特征。EGJOO患者在食管胃交界处也比孤立仰卧IRP升高患者有更显著的异常,包括更高的LES静息压力(LESP),代谢压力,正中仰卧IRP,正中IRP,和RDC上的IRP(每次比较P<0.05)。在仰卧IRP升高的51人中,吞咽困难的患者的PECI和PEL明显低于无吞咽困难的患者。进一步的多变量分析显示,PEL,LESP,和RDC上的IRP是与EGJOO相关的因素。接收器工作特性分析显示UES最低点压力,PEL,PECILESP,RDC上的IRP和IRP是支持确认EGJOO诊断的参数。
结论:基于CCv4.0,EGJOO患者有更严重的食管胃连接部功能障碍,并与近端食管有关。此外,几个参数支持确认EGJOO的诊断。
BACKGROUND: The critical diagnostic criteria for esophagogastric junction outflow obstruction (EGJOO) were published in the latest Chicago Classification version 4.0 (CCv4.0). In addition to the previous criterion [elevated integrated relaxation pressure (IRP) in supine position], manometric diagnosis of EGJOO requires meeting the criteria of elevated median-IRP during upright wet swallows and elevated intrabolus pressure. However, with the diagnostic criteria modification, the change in manometric features of EGJOO remained unclear.
OBJECTIVE: To evaluate the esophageal motility characteristics of patients with EGJOO and select valuable parameters for confirming the diagnosis of EGJOO.
METHODS: We performed a retrospective analysis of 370 patients who underwent high-resolution manometry with 5 mL water swallows × 10 in supine, × 5 in upright position and the rapid drink challenge (RDC) with 200 mL water from November 2016 to November 2021 at Peking University First Hospital. Fifty-one patients with elevated integrated supine IRP and evidence of peristalsis were enrolled, with 24 patients meeting the updated manometric EGJOO diagnosis (CCv4.0) as the EGJOO group and 27 patients not meeting the updated EGJOO criteria as the isolated supine IRP elevated group (either normal median IRP in upright position or less than 20% of supine swallows with elevated IBP). Forty-six patients with normal manometric features were collected as the normal high-resolution manometry (HRM) group. Upper esophageal sphincter (UES), esophageal body, and lower esophageal sphincter (LES) parameters were compared between groups.
RESULTS: Compared with the normal HRM group, patients with EGJOO (CCv4.0) had significantly lower proximal esophageal contractile integral (PECI) and proximal esophageal length (PEL), with elevated IRP on RDC (P < 0.05 for each comparison), while isolated supine IRP elevated patients had no such feature. Patients with EGJOO also had more significant abnormalities in the esophagogastric junction than isolated supine IRP elevated patients, including higher LES resting pressure (LESP), intrabolus pressure, median supine IRP, median upright IRP, and IRP on RDC (P < 0.05 for each comparison). Patients with dysphagia had significantly lower PECI and PEL than patients without dysphagia among the fifty-one with elevated supine IRP. Further multivariate analysis revealed that PEL, LESP, and IRP on RDC are factors associated with EGJOO. The receiver-operating characteristic analysis showed UES nadir pressure, PEL, PECI, LESP, and IRP on RDC are parameters supportive for confirming the diagnosis of EGJOO.
CONCLUSIONS: Based on CCv4.0, patients with EGJOO have more severe esophagogastric junction dysfunction and are implicated in the proximal esophagus. Additionally, several parameters are supportive for confirming the diagnosis of EGJOO.