The Esophageal Symptom Questionnaire (ESQ-30) May Differentiate Achalasia from EGJ Outflow Obstruction

Introduction: The manometric diagnoses of achalasia and esophagogastric junction outflow obstruction (EGJOO) are difficult to differentiate based solely on symptoms. The Esophageal Symptom Questionnaire (ESQ-30) is a standardized outcome measure of the frequency and severity esophageal symptoms and contains the following subscales: globus (ESQ-G), dysphagia (ESQ-D), and reflux symptoms (ESQ-R). Our study aims to elucidate the association between manometric diagnosis and symptoms using the ESQ-30. Methods: Between October 2021 - March 2023, 681 patients (54.5 +/- 14.8 y, 65% female) underwent esophageal manometry and had complete ESQ-30 questionnaires: 379 normal, 109 ineffective esophageal motility, 14 jackhammer esophagus, 20 absent contractility, 14 distal esophageal spasm, 97 EGJOO, 48 achalasia (3 achalasia type 1, 41 achalasia type 2, 4 achalasia type 3). A one-way ANOVA was performed to compare the effect of manometric diagnosis on ESQ-D, ESQ-G and ESQ-R scores. Receiver operating characteristic (ROC) analysis was performed. Results: The one-way ANOVA comparing the effect of manometric diagnosis on ESQ-D, globus ESQ-G and reflux ESQ-R scores showed that there was a statistically significant difference between at least 2 groups in globus (F (8,672) = 2.4, P = .015) and dysphagia (F (8,672) = 15.2, P< .01). Bonferroni test for multiple comparisons found that the mean value of ESQ-D was significantly higher in jackhammer esophagus compared to normal motility (mean difference 19.7, P = .03, 95% CI 1.1-38.2). The mean value of the ESQ-D was significantly higher in type 2 achalasia compared to normal (mean difference 33.3, P< .01, 95% CI 22.2-44.5), ineffective esophageal motility (mean difference 31.3, P< .01 95% CI 18.8-43.7), and EGJOO (mean difference 29.3, P< .01, 95% CI 16.6-42.0). The ESQ-D differentiated between patients with achalasia and EGJOO with an AUC of .812 (.74-.88) (Figure 1). Conclusion: This study compared the ESQ-30 scores for dysphagia, globus, and reflux between patients with different esophageal motility disorders including achalasia and EGJOO. The mean dysphagia impact score (ESQ-D) was significantly different when comparing the achalasia group with both the EGJOO and the normal groups. Differentiating achalasia from non-achalasia EGJOO is of key importance as achalasia has definitive therapy, while the clinical significance of non-achalasia EGJOO is less certain. Our findings suggest that standardized patient symptom scores may play a role in discriminating between these 2 conditions.Figure 1.: Receiver Operator Curve Analysis for ESQ-G, ESQ-D, ESQ-R.