S4444 U-Turn to Obstruction: A Flipped Case of EGJ Outflow Obstruction

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Introduction: Esophageal motility disorders can be challenging to interpret in the setting of altered anatomy. Large hernias can complicate manometric interpretation by distorting normal pressure patterns. We present a case of esophagogastric junction outflow obstruction (EGJOO) in a patient with significantly altered anatomy, where manometry findings were influenced by these anatomic changes. Case Description/Methods: Seventy-three-year-old man with a history of Barrett’s Esophagus presented with morning regurgitation and chronic cough. Incidentally when evaluated for pulmonary embolism, imaging revealed a large gastric herniation with axial rotation of the stomach causing the greater curvature to compress the esophagus. These anatomic findings are reflected on high-resolution manometry which demonstrates esophagogastric junction outflow obstruction with an elevated median integrated relaxation pressure. A large signal of intrabolus pressure is seen under the peristaltic contraction. This is in line with the fluoroscopic image of the greater curvature compressing the midthoracic esophagus. Striated esophageal contractions are prominent to push past this area of obstruction with intact smooth muscle peristalsis and normal distal latency. The slope of peristalsis, contractile front velocity, is altered from extrinsic gastric compression. The manometry catheter appears to not reach the stomach body and is curled up in the cardiac hernia, resulting in pressure artifacts in a butterfly pattern below the LES which may be overlapped with vascular artifact from the descending aorta. Discussion: This case highlights the importance of interpreting esophageal manometry in the context of the patient’s clinical presentation and anatomy. Despite manometric distortion, clinical context from identifiable altered anatomy demonstrated findings consistent with an EGJOO. Distal latency should be measured from the start of UES relaxation to the contractile deceleration point with an isobar contour of 30 mmHg to avoid premature diagnosis of a spastic swallow. Although EGJOO is often an inconclusive diagnosis, with situational awareness, causes can be identified. For our patient, the presence of intact peristalsis suggests that esophageal clearance is likely preserved. Therefore, postoperative dysphagia may be less of a concern which is a key point to communicate for surgical planning. Manometric data should be interpreted alongside clinical and anatomical context for accurate diagnosis and management.

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