Characterization and follow-up of esophagogastric junction outflow obstruction detected by high resolution manometry.

BACKGROUND: Esophagogastric junction outflow obstruction (EGJOO) is a newly described diagnostic entity growing in importance due to the use of high resolution manometry (HRM). There is little knowledge regarding its incidence, etiopathogeny, long-term evolution, and most suitable treatment. Our objective was to increase the awareness of EGJOO to optimize the management of these patients. METHODS: We conducted a historical (retrospective and prospective) study of patients diagnosed with EGJOO using HRM combined with multichannel intraluminal impedance, comparing their manometric and impedance characteristics with those of a control group. Symptoms, etiology of obstruction, acid exposure, clinical course (and its associated factors), and response to treatment were also evaluated in the EGJOO group. KEY RESULTS: Forty-four subjects were included (28 patients and 16 controls). Esophagogastric junction outflow obstruction patients presented incomplete esophageal transit more frequently than controls. Patients with structural obstruction had dysphagia more frequently than patients with functional obstruction, and different manometric, impedance, and pH-metric patterns. Over one-third of the EGJOO patients presented a spontaneous resolution of symptoms without EGJOO treatment. In the multivariate analysis, the variables associated with this spontaneous symptomatic resolution included typical symptoms of gastro-esophageal reflux disease or epigastralgia as the main symptom and resting or basal pressure of the upper esophageal sphincter <50 mmHg. CONCLUSIONS & INFERENCES: The majority of EGJOO patients presented intact peristalsis which may compensate for the lack of EGJ relaxation. In the EGJOO patients presenting favorable factors associated with a spontaneous resolution of symptoms, invasive treatments should be considered with special caution. Structural etiologies are more amenable to management, while the remainder may improve without intervention.

Targeted neonatal echocardiography (TnECHO) service in a Canadian neonatal intensive care unit: a 4-year experience.

OBJECTIVE: To characterize the effect of a targeted neonatal echocardiography (TnECHO) program on decision making in a tertiary level unit. STUDY DESIGN: Retrospective cohort study of neonates, admitted between September 2007 and April 2011. Details of the TnECHO, and the clinical decisions within 6 h of the consultation were recorded. RESULT: A total of 199 infants underwent 512 echocardiograms with a median (interquartile range) of 2 (1 to 3) TnECHO studies per infant. The indications included assessment for patent ductus arteriosus (PDA; n=261, 51%), post-PDA ligation assessment (n=101, 19%), pulmonary hemodynamics (n=81, 16%), myocardial performance and systemic blood flow (n=52, 10%), and central venous catheter tip position (n=6, 1%). TnECHO consultation was followed by a change in clinical management in 212 cases (41%) and avoidance of a planned intervention in 112 cases (22%). CONCLUSION: TnECHO may be a useful tool to guide clinical decisions in the neonatal intensive care unit setting. Well-planned prospective studies are needed to assess the impact of TnECHO on outcomes.