S4295 Dilate, Paralyze, Relieve: Multimodal Management of EGJOO in an Elderly Patient

Introduction: Esophagogastric junction outflow obstruction (EGJOO) is a primary esophageal motility disorder characterized by the impaired relaxation of the esophagogastric junction in conjunction with elevated intrabolus pressure while preserving some degree of normal peristalsis that does not fit with achalasia criteria. The EGJOO is detected in up to 14% of high-resolution manometry studies, predominantly affecting women with an age range of 51 to 69 years old. Case Description/Methods: A 72-year-old woman with past medical history of restless leg syndrome, hypertension, hypothyroidism, and breast cancer with breast lumpectomy, presented with a 5-month history of dysphagia, odynophagia, and nocturnal nausea. Her symptom persisted despite empiric treatment with omeprazole, hyoscyamine, and diazepam. Initial evaluation with barium esophagram demonstrated mild to moderate focal narrowing in the midthoracic esophagus. Episodes of esophageal spasm were observed distal to the narrowing. Esophageal manometry revealed an elevated integrated relaxation pressure of 18.7 mmHg. Contractile activity was detected in the mid and lower segments of the esophagus. Subsequent esophagogastroduodenoscopy revealed a hypertonic lower esophageal sphincter, diminished peristaltic activity, and normal mucosa in the entire esophagus. She was managed with sildenafil, endoscopic balloon dilation of the entire esophagus. Besides, the patient underwent 2 botulinum toxin injections targeting the lower and distal one-third of esophageal sphincter. During follow-up, the patient reported modest symptom relief and improved tolerance of oral intake. Discussion: The diagnosis of EGJOO was established based on clinical presentation, esophagram findings, and manometric evidence. Pharmacologic therapies, the first-line treatment of EGJOO, may offer symptomatic relief but do not correct the underlying esophageal motility disorder. Interventions targeting esophageal dysmotility include botulinum toxin injection, Pneumatic balloon dilation, laparoscopic Heller myotomy with Dor fundoplication, and peroral endoscopic myotomy. This case highlights the complexity and individualized nature of managing EGJOO, underscoring the need for further research to generate evidence-based recommendations for optimal treatment selection. A personalized treatment strategy and shared decision-making play a critical role in guiding the management of this condition.