Provocative testing spots treatment responders in oesophagogastric junction outflow obstruction

During high-resolution oesophageal manometry (HRM), provocative testing has been shown to accurately detect clinically relevant oesophagogastric junction outflow obstruction (OGJOO) that benefits from therapy, indicating its advantage when routinely performed as part of the manometric protocol, according to a study.

The authors included 121 consecutive patients with OGJOO between May 2016 and January 2020 in this retrospective cohort study. Standard HRM with 5-mL water swallows was followed by provocative testing. Barium oesophagography findings were then obtained.

Patients with structural obstruction were separated from those with functional OGJOO, who were classified as either symptom-positive or -negative. Only symptom-positive patients were considered for achalasia-type therapies. Finally, the authors calculated sensitivity and specificity for clinically relevant OGJOO during 5-mL water swallows, provocative testing, and barium.

Of the patients, 76 percent and 25 percent had dysphagia and holdup on barium, respectively; ninety-seven (84 percent) had functional OGJOO. Those with symptom-positive OGJOO were more likely to show abnormal motility and pressurization patterns and to reproduce symptoms during provocative testing, but not with 5-mL water swallows.

Twenty-nine (30 percent) functional OGJOO patients underwent achalasia-type therapy, of whom 26 (90 percent) had a symptomatic response. Forty-eight (49 percent) functional OGJOO patients were managed conservatively, of whom 78 percent showed symptom remission.

While specificity was similar, provocative testing exhibited superior sensitivity in identifying treatment responders from spontaneously remitting OGJOO (85 percent) relative to both 5-mL water swallows (54 percent; p<0.01) and barium oesophagography (54 percent; p=0.02).