The conundrum of esophagogastric junction outflow obstruction: Answers to key clinical questions

Esophagogastric junction outflow obstruction (EGJOO) is a heterogeneous disorder characterized by abnormal esophagogastric junction residual pressures in the setting of intact esophageal body peristalsis. This manometric finding is most clinically relevant in patients with dysphagia and chest pain, and may arise from various mechanisms, including structural processes, catheter positioning artifact, and medications. Rarely, manometric EGJOO is a consequence of abnormal relaxation of the lower esophageal sphincter (LES) akin to achalasia. Thus, it is critical in the evaluation of EGJOO to determine if a true pressure gradient exists across the esophagogastric junction (EGJ) that warrants therapy. There are many unanswered questions in EGJOO diagnosis and management, which are addressed in this review in the context of the use of provocative maneuvers during high-resolution manometry, complementary and alternate testing, and therapeutic options.