Esophagogastric junction contractile integral (EGJ‐CI) complements reflux disease severity and provides insight into the pathophysiology of reflux disease

Abstract

AbstractBackgroundEsophagogastric junction contractile integral (EGJ‐CI) has not come into routine use due to methodological discrepancies and its unclear clinical utility. We aimed to determine which method of calculating EGJ‐CI was best at discriminating between common reflux disease states.MethodsHigh‐resolution manometry (HRM) and pH‐Impedance measurements were acquired for 100 patients; 25 Barrett's esophagus (>3 cm/acid exposure time (AET) > 6), 25 endoscopy‐negative reflux disease (ENRD; AET >6), 25 borderline reflux (AET 4–6), 25 functional heartburn (FH; AET <4), constituting the developmental cohort. EGJ‐CI was calculated at 20 mmHg, 2 mmHg, and 0 mmHg isobaric contour. Empirical associations, univariable, multivariable and ROC analyses were performed between EGJ‐CI and manometric/pH‐impedance metrics. A validation cohort (n = 25) was used to test the new EGJ‐CI cutoff.Key ResultsSignificant correlations with AET were observed when EGJ‐CI was calculated with an isobaric threshold of 20 mmHg (p < 0.001). Significant differences in EGJ‐CI were observed between patients with FH and Barrett's esophagus (p = 0.004) and with ENRD (p = 0.01); however, LES basal pressure was unable to differentiate between these disease states (p = 0.09, p = 0.25, respectively). ROC analysis on the developmental cohort found that EGJ‐CI 21.2 mmHg.cm demonstrated sensitivity 72% and specificity 72% between patients with reflux (Barrett's esophagus/ENRD) and FH. In the validation cohort, 92.8% with a low EGJ‐CI had good/moderate improvement in symptoms following therapy compared to 54.5% with raised EGJ‐CI (p = 0.026).Conclusions and InferencesThis study re‐affirms EGJ‐CI as a reliable discriminator between reflux disease (Barrett's esophagus/ENRD) and FH. In borderline reflux patients, patients with a lower EGJ‐CI score (<21.2 mmHg) appear to respond better to anti‐reflux therapies compared to those with a higher value.