ONLINE ARTICLE: Clinical ReviewEvaluation of the Esophagogastric Junction on High Resolution ManometryRogers, Benjamin D. MD, MS*,†; Gyawali, C. Prakash MD, MRCP* Author Information *Division of Gastroenterology, Washington University School of Medicine, St Louis, MO †Division of Gastroenterology, University of Louisville, Louisville, KY C.P.G.: Consulting: Medtronic, Diversatek, Ironwood, IsoThrive, Quintiles. B.D.R. declares that there is nothing to disclose. Address correspondence to: C. Prakash Gyawali, MD, MRCP, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8124, St Louis, MO 63110 (e-mail: [email protected]). Journal of Clinical Gastroenterology: February 2021 - Volume 55 - Issue 2 - p e8-e18 doi: 10.1097/MCG.0000000000001474 Buy Metrics Abstract The esophagogastric junction (EGJ) is a complex barrier between the thoracic and abdominal luminal gut compartments, comprised primarily of the lower esophageal sphincter (LES) and crural diaphragm. Although closed at rest, the EGJ relaxes to allow antegrade bolus transit and retrograde venting of air. Abnormal relaxation is the hallmark of achalasia spectrum disorders, while increased frequency of transient lower esophageal sphincter relaxations and/or EGJ disruption are seen in gastroesophageal reflux disease. High resolution manometry (HRM) is the modern day gold standard for assessment of EGJ morphology and function, with better performance characteristics compared with endoscopy and barium esophagography. Conventional LES metrics defining EGJ function include resting LES pressure as well as postswallow residual pressures. Newer HRM-based metrics include EGJ contractile integral, which measures static barrier function at rest, and EGJ morphology, which characterizes the relationship between LES and crural diaphragm. Provocative maneuvers assess dynamic EGJ function during physiological or pharmacologic stress. The most useful of these maneuvers, the rapid drink challenge, assesses for latent obstruction, while multiple rapid swallows evaluate adequacy of deglutitive inhibition. Amyl nitrate and cholecystokinin administration can segregate motor from structural obstruction. Newer provocative tests (straight leg raise maneuver, abdominal compression) and novel diagnostic tools (functional lumen imaging probe) complement HRM evaluation of the EGJ. Although current HRM metrics and maneuvers show promise in identifying clinically relevant EGJ abnormalities, future investigations evaluating management outcomes will improve segregation of normal from abnormal EGJ morphology and function. Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.