Esophagogastric Junction Morphology is Associated with Ambulatory Reflux Monitoring Phenotypes in Patients Evaluated for Gastroesophageal Reflux Disease

Abstract

Aim: To evaluate whether high-resolution manometry-defined esophagogastric junction (EGJ) morphology is associated with objective reflux burden in adults evaluated for suspected gastroesophageal reflux disease. Materials and Methods: Consecutive adults evaluated between January 2021 and December 2025 were retrospectively screened. After exclusions, 243 patients who completed 36-channel high-resolution manometry and off-proton-pump-inhibitor pH-metry were included. Abnormal acid exposure time (AET) was defined as AET >6%. Associations were assessed using non-parametric tests and logistic regression adjusted for age, sex, hiatal hernia size, and lower esophageal sphincter pressure. Results: Mean age was 42.0 years and 146 patients (60.1%) were male. EGJ morphology was Type I in 111 patients, Type II in 81, and Type III in 51. Abnormal AET occurred in 38.7%, 22.2%, and 78.4% of Types I, II, and III, respectively (p<0.001). Median AET was 3.66%, 3.75%, and 10.79% (p<0.001). In the extended model, Type III remained associated with abnormal AET compared with Type I (OR 5.08, 95% CI 1.21-21.24; p=0.026). Conclusion: Type III EGJ morphology was associated with higher objective reflux burden, whereas Type II showed a heterogeneous pattern. EGJ morphology may complement, but should not replace, ambulatory reflux testing.

Keywords

• gastroesophageal reflux disease
• esophagogastric junction
• high-resolution manometry
• acid exposure time
• pH monitoring

References

1. 1. Vakil N, van Zanten SV, Kahrilas P, Dent J, Jones R. The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus. Am J Gastroenterol. 2006;101:1900–1920. https://doi.org/10.1111/j.1572-0241.2006.00630.x
2. 2. Katz PO, Dunbar KB, Schnoll-Sussman FH, Greer KB, Yadlapati R, Spechler SJ. ACG Clinical Guideline for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2022;117:27–56. https://doi.org/10.14309/ajg.0000000000001538
3. 3. Yadlapati R, Gyawali CP, Pandolfino JE, et al. AGA Clinical Practice Update on the personalized approach to the evaluation and management of GERD. expert review. Clin Gastroenterol Hepatol. 2022;20(5):984–994. e1. https://doi.org/10.1016/j.cgh.2022.01.025
4. 4. Gyawali CP, Kahrilas PJ, Savarino E, et al. Modern diagnosis of GERD. the Lyon Consensus. Gut. 2018;67:1351–1362. https://doi.org/10.1136/gutjnl-2017-314722
5. 5. Gyawali CP, Yadlapati R, Fass R, et al. Updates to the modern diagnosis of GERD. Lyon Consensus 2. 0. Gut. 2024;73:361–371. https://doi.org/10.1136/gutjnl-2023-330616
6. 6. Yadlapati R, Kahrilas PJ, Fox MR, et al. Esophageal motility disorders on high-resolution manometry: Chicago Classification version 4. 0. Neurogastroenterol Motil. 2021;33:e14058. https://doi.org/10.1111/nmo.14058
7. 7. Pandolfino JE, Kim H, Ghosh SK, Clarke JO, Zhang Q, Kahrilas PJ. High-resolution manometry of the EGJ. an analysis of crural diaphragm function in GERD. Am J Gastroenterol. 2007;102(5):1056–1063. https://doi.org/10.1111/j.1572-0241.2007.01138.x
8. 8. Tolone S, de Cassan C, de Bortoli N, Roman S, Galeazzi F, Salvador R, et al. Esophagogastric junction morphology is associated with a positive impedance-pH monitoring in patients with GERD. Neurogastroenterol Motil. 2015;27(8):1175–1182. https://doi.org/10.1111/nmo.12606

9. 9. Koseki M, Seltzer ES, Cavaliere K, Luo Y, Jodorkovsky D. Implications of the updated Lyon Consensus 2. 0 in clinical practice. Foregut. 2025;5(1):3–11. https://doi.org/10.1177/26345161241277568
10. 10. Kayali S, Calabrese F, Pasta A, Marabotto E, Bodini G, Furnari M, et al. Effect of hiatal hernia and esophagogastric junction morphology on esophageal motility: evidence from high-resolution manometry studies. Neurogastroenterol Motil. 2024;36(12):e14929. https://doi.org/10.1111/nmo.14929
11. 11. Voulgaris T, Hoshino S, Yazaki E. Is there a direct relationship between hiatal hernia size, esophageal body hypomotility and symptomatic perception of gastroesophageal reflux episodes? Ann Gastroenterol. 2023;36(6):599–604. https://doi.org/10.20524/aog.2023.0830
12. 12. Vespa E, Barchi A, Altieri G, et al. Assessment of esophagogastric junction integrity by high-resolution manometry identifies upright and recumbent predominant reflux phenotypes. Neurogastroenterol Motil. 2026;38(2):e70262. https://doi.org/10.1111/nmo.70262
13. 13. Sifrim D, Zerbib F. Diagnosis and management of patients with reflux symptoms refractory to proton pump inhibitors. Gut. 2012;61(9):1340–1354. https://doi.org/10.1136/gutjnl-2011-301897
14. 14. Bredenoord AJ, Weusten BLAM, Smout AJPM. Symptom association analysis in ambulatory gastro-oesophageal reflux monitoring. Gut. 2005;54(12):1810–1817. https://doi.org/10.1136/gut.2005.072629
15. 15. Zerbib F, Roman S, Ropert A, et al. Esophageal pH-impedance monitoring and symptom analysis in GERD. a study in patients off and on therapy. Am J Gastroenterol. 2006;101(9):1956–1963. https://doi.org/10.1111/j.1572-0241.2006.00711.x
16. 16. Nguyen AD, Carlson DA, Patel A, Gyawali CP. AGA Clinical Practice Update on incorporating functional lumen imaging probe into esophageal clinical practice: expert review. Gastroenterology. 2025;169(4):726–736. e1. https://doi.org/10.1053/j.gastro.2025.05.011