Esophagogastric Junction Contractile Integral and Morphology: Two High-resolution Manometry Metrics of the Anti-reflux Barrier

Background And Aim: We evaluated associations of esophagogastric junction (EGJ) metrics as an anti-reflux barrier with impedance-pH, endoscopic esophagitis, and lower esophageal sphincter (LES) metrics.

Methods: We reviewed high-resolution manometry data from consecutive patients with gastroesophageal reflux disease (GERD) symptoms who underwent impedance-pH and endoscopy, and asymptomatic volunteers. The EGJ contractile integral (CI) was calculated as the mean contractile integral/second during three respiratory cycles. EGJ morphology was classified according to LES-crural diaphragm (CD) separation.

Results: In total, 137 patients (65 male, age 55 years) and 23 (9 male, age 33 years) controls were enrolled. Twenty-five patients had erosive reflux disease (ERD), 16 had non-erosive reflux disease (NERD), 5 had reflux hypersensitivity, and 91 were not GERD. EGJ-CI were lower in patients with GERD (22.6 [13.8-29.2] mmHg cm) than non-GERD (50.3 [31-69.9] mmHg cm, P < 0.01) and controls (67 [26.7-78.7] mmHg cm). With an EGJ-CI cut-off value of 30 mmHg cm, the area under the curve was 0.814 (0.762-0.896), with 77.8% sensitivity and 81.7% specificity for the prediction of GERD. LES-CD separation was greatest in patients with ERD, followed the NERD, non-GERD, and controls. EGJ morphology type III was associated with a higher DeMeester score (7.9 [1.6-12.6]) than were type II (3.25 [0.9-5.975]) and I (1.75 [0.8-6.2]; P < 0.01). EGJ-CI values were lower in patients with GERD than in others in each EGJ morphology subgroup.

Conclusion: Esophagogastric junction contractile integral showed good diagnostic accuracy with high specificity in predicting GERD. LES-CD separation is associated with an increase in acid reflux, but EGJ-CI was associated more strongly with GERD than was EGJ morphology.