Retrospective Study
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Aug 14, 2022; 28(30): 4163-4173
Published online Aug 14, 2022. doi: 10.3748/wjg.v28.i30.4163
Changes in the esophagogastric junction outflow obstruction manometric feature based on the Chicago Classification updates
Yue-Yuan Li, Wen-Ting Lu, Jian-Xiang Liu, Li-Hong Wu, Meng Chen, Hong-Mei Jiao
Yue-Yuan Li, Wen-Ting Lu, Meng Chen, Hong-Mei Jiao, Department of Geriatrics, Peking University First Hospital, Beijing 100034, China
Jian-Xiang Liu, Li-Hong Wu, Department of Gastroenterology and Hepatology, Peking University First Hospital, Beijing 100034, China
Author contributions: Li YY and Lu WT contributed equally to this work; Li YY, Lu WT, and Jiao HM conception and designed of research; Li YY and Lu WT analyzed data; Lu WT and Chen M performed the HRM and provided clinical information; Li YY, Liu JX, and Jiao HM interpreted of research; Li YY drafted manuscript; Jiao HM revised manuscript and approved the final version of manuscript; all authors approved the final version of the article.
Supported by the China Central Health Research Fund, No. W2013BJ29; and the Interdisciplinary Clinical Research Project of Peking University First Hospital, No.2019CR40.
Institutional review board statement: This study was reviewed and approved by the Institutional Review Board of the Peking University First Hospital, No. 2022-099.
Informed consent statement: A waiver of informed consent was granted by our Institutional Review Board because our retrospective analysis used completely anonymized data.
Conflict-of-interest statement: All authors have declared no conflicts of interest.
Data sharing statement: Data sharing available, please require through email.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Hong-Mei Jiao, MD, Chief Physician, Department of Geriatrics, Peking University First Hospital, No. 8 Xishiku Street, Xicheng District, Beijing 100034, China.
Received: March 10, 2022
Peer-review started: March 10, 2022
First decision: April 11, 2022
Revised: April 21, 2022
Accepted: July 18, 2022
Article in press: July 18, 2022
Published online: August 14, 2022
Processing time: 152 Days and 16.5 Hours

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.


To evaluate the esophageal motility characteristics of patients with EGJOO and select valuable parameters for confirming the diagnosis of EGJOO.


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.


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.


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.

Keywords: Esophagogastric junction outflow obstruction, High-resolution manometry, Esophageal motility disorders, Upper esophageal sphincter, Proximal esophagus

Core Tip: This is a retrospective study to evaluate the motility features of esophagogastric junction outflow obstruction (EGJOO). This is the first detailed study of EGJOO based on the latest Chicago Classification. Patients with EGJOO showed more substantial abnormalities at the esophagogastric junction than patients who met the previous criteria, and the motility disorder of EGJOO is implicated in the proximal esophagus. Additionally, the upper esophageal sphincter nadir pressure, proximal esophageal contractile integral, proximal esophageal length, lower esophageal sphincter resting pressure, and integrated relaxation pressure on rapid drink challenge contribute to confirming the diagnosis of EGJOO.