Esophagogastric junction outflow obstruction: advances in diagnosis and clinical management

Esophagogastric junction outflow obstruction (EGJOO) is an esophageal motility disorder characterized by incomplete lower esophageal sphincter relaxation, with at least partially preserved peristalsis. Recognition of this entity has evolved with the Chicago Classification version 4.0, which has refined diagnostic criteria by incorporating clinical correlation and confirmatory testing, thereby reducing the overdiagnosis observed with previous versions. Diagnosis is based on high-resolution esophageal manometry, identifying elevated integrated relaxation pressure of the lower esophageal sphincter in both supine and upright positions, as well as intrabolus pressurization. However, those findings may lack clinical relevance, prompting the performance of complementary studies, such as timed barium esophagram, functional lumen imaging probe, and provocative maneuvers during manometry, to confirm clinically significant obstruction. Therapeutic options include pharmacologic therapy, botulinum toxin type A injection, pneumatic dilation, peroral endoscopic myotomy, and surgical myotomy, with growing evidence supporting lower esophageal sphincter-targeted interventions in patients with confirmed obstruction. Additionally, opioid use is an important modifying factor, influencing both motor phenotype and therapeutic response. The current understanding of EGJOO highlights the need for a multimodal diagnostic approach and personalized therapeutic strategies. Nevertheless, there are still important gaps regarding the prediction of clinical progression and the standardization of emerging diagnostic tools.