Korean J Gastroenterol.  2022 Feb;79(2):66-71. 10.4166/kjg.2022.016.

Chicago Classification ver. 4.0: Diagnosis of Peristaltic Disorder

• Choi SI

• KMID: 2526793
• DOI: http://doi.org/10.4166/kjg.2022.016

Abstract

The Chicago Classification is being revised continuously for the accurate diagnosis of esophageal peristaltic disorders in which the etiology is unclear, and the disease behavior is heterogeneous. The ver. 4.0 was recently updated. A representative change in the diagnosis of esophageal peristaltic disorders of the ver. 4.0 showed that the distinction between major and minor disorders was eliminated and was divided into the following four diagnoses: absent contractility, distal esophageal spasm (DES), hypercontractile esophagus (HE), and ineffective esophageal motility. Compared to the ver. 3.0, it recommended a more detailed protocol of high-resolution esophageal manometry and methods of interpreting manometric. In addition, it emphasized the clinically relevant symptoms in diagnosing DES and HE, and presented provocative tests (e.g., multiple rapid swallow and rapid drinking challenge), as well as additional testing, including impedance, timed barium esophagogram and functional lumen imaging probe, which may provide more standardized and rigorous criteria for peristaltic patterns and to minimize the ambiguity in diagnosis. Although it will take time and effort to apply this revised Chicago Classification in clinical practice, it may help diagnose and manage patients with esophageal peristalsis disorder in the future.

Keyword

Esophageal motility disorders; Manometry; Diagnosis; Chicago Classification

Reference

1. Yadlapati R, Kahrilas PJ, Fox MR, et al. 2021; Esophageal motility disorders on high-resolution manometry: Chicago Classification version 4.0^©. Neurogastroenterol Motil. 33:e14058. DOI: 10.1111/nmo.14058. PMID: 33373111. PMCID: PMC8034247.

2. Kahrilas PJ, Bredenoord AJ, Fox M, et al. 2015; The Chicago Classification of esophageal motility disorders, v3.0. Neurogastroenterol Motil. 27:160–174. DOI: 10.1111/nmo.12477. PMID: 25469569. PMCID: PMC4308501.

3. Gyawali CP, Zerbib F, Bhatia S, et al. 2021; Chicago Classification update (V4.0): technical review on diagnostic criteria for ineffective esophageal motility and absent contractility. Neurogastroenterol Motil. 33:e14134. DOI: 10.1111/nmo.14134. PMID: 33768698.

4. Hasak S, Brunt LM, Wang D, Gyawali CP. 2019; Clinical characteristics and outcomes of patients with postfundoplication dysphagia. Clin Gastroenterol Hepatol. 17:1982–1990. DOI: 10.1016/j.cgh.2018.10.020. PMID: 30342262.

5. Roman S, Hebbard G, Jung KW, et al. 2021; Chicago Classification update (v4.0): technical review on diagnostic criteria for distal esophageal spasm. Neurogastroenterol Motil. 33:e14119. DOI: 10.1111/nmo.14119. PMID: 33666299.

6. Pandolfino JE, Roman S, Carlson D, et al. 2011; Distal esophageal spasm in high-resolution esophageal pressure topography: defining clinical phenotypes. Gastroenterology. 141:469–475. DOI: 10.1053/j.gastro.2011.04.058. PMID: 21679709. PMCID: PMC3626105.

7. Lin Z, Pandolfino JE, Xiao Y, et al. 2012; Localizing the contractile deceleration point (CDP) in patients with abnormal esophageal pressure topography. Neurogastroenterol Motil. 24:972–975. DOI: 10.1111/j.1365-2982.2012.01959.x. PMID: 22726890. PMCID: PMC3602322.

8. De Schepper HU, Ponds FA, Oors JM, Smout AJ, Bredenoord AJ. 2016; Distal esophageal spasm and the Chicago Classification: is timing everything? Neurogastroenterol Motil. 28:260–265. DOI: 10.1111/nmo.12721. PMID: 26553751.

9. Campo S, Traube M. 1992; Manometric characteristics in idiopathic and reflux-associated esophageal spasm. Am J Gastroenterol. 87:187–189. PMID: 1734695.

10. Hayashi H, Mine K, Hosoi M, et al. 2003; Comparison of the esophageal manometric characteristics of idiopathic and reflux-associated esophageal spasm: evaluation by 24-hour ambulatory esophageal motility and pH monitoring. Dig Dis Sci. 48:2124–2131. DOI: 10.1023/B:DDAS.0000004514.91064.7f. PMID: 14705816.

11. Sifrim D, Janssens J, Vantrappen G. 1994; Failing deglutitive inhibition in primary esophageal motility disorders. Gastroenterology. 106:875–882. DOI: 10.1016/0016-5085(94)90745-5. PMID: 8143993.

12. Hernandez PV, Valdovinos LR, Horsley-Silva JL, Valdovinos MA, Crowell MD, Vela MF. 2020; Response to multiple rapid swallows shows impaired inhibitory pathways in distal esophageal spasm patients with and without concomitant esophagogastric junction outflow obstruction. Dis Esophagus. 33:doaa048. DOI: 10.1093/dote/doaa048. PMID: 32566945.

13. Marin I, Serra J. 2016; Patterns of esophageal pressure responses to a rapid drink challenge test in patients with esophageal motility disorders. Neurogastroenterol Motil. 28:543–553. DOI: 10.1111/nmo.12749. PMID: 26686375.

14. Ang D, Hollenstein M, Misselwitz B, et al. 2017; Rapid Drink Challenge in high-resolution manometry: an adjunctive test for detection of esophageal motility disorders. Neurogastroenterol Motil. 29:e12902. DOI: 10.1111/nmo.12902. PMID: 27420913.

15. Ang D, Misselwitz B, Hollenstein M, et al. 2017; Diagnostic yield of high-resolution manometry with a solid test meal for clinically relevant, symptomatic oesophageal motility disorders: serial diagnostic study. Lancet Gastroenterol Hepatol. 2:654–661. DOI: 10.1016/S2468-1253(17)30148-6. PMID: 28684262.

16. Herregods TV, Smout AJ, Ooi JL, Sifrim D, Bredenoord AJ. 2017; Jackhammer esophagus: observations on a European cohort. Neurogastroenterol Motil. 29:e12975. DOI: 10.1111/nmo.12975. PMID: 27753176.

17. Philonenko S, Roman S, Zerbib F, et al. 2020; Jackhammer esophagus: clinical presentation, manometric diagnosis, and therapeutic results-results from a multicenter French cohort. Neurogastroenterol Motil. 32:e13918. DOI: 10.1111/nmo.13918. PMID: 32510747.

18. Roman S, Damon H, Pellissier PE, Mion F. 2010; Does body position modify the results of oesophageal high resolution manometry? Neurogastroenterol Motil. 22:271–275. DOI: 10.1111/j.1365-2982.2009.01416.x. PMID: 19814774.

19. Chen JW, Savarino E, Smout A, et al. 2021; Chicago Classification update (v4.0): technical review on diagnostic criteria for hypercontractile esophagus. Neurogastroenterol Motil. 33:e14115. DOI: 10.1111/nmo.14115. PMID: 33729642.

20. Woo M, Andrews CN, Buresi M. 2019; Reversible jackhammer esophagus in a patient with a gastric band. Neurogastroenterol Motil. 31:e13572. DOI: 10.1111/nmo.13572. PMID: 30843357.

21. Sloan JA, Mulki R, Sandhu N, Samuel S, Katz PO. 2019; Jackhammer esophagus: symptom presentation, associated distal contractile integral, and assessment of bolus transit. J Clin Gastroenterol. 53:295–297. DOI: 10.1097/MCG.0000000000001021. PMID: 29521727.

22. Quader F, Reddy C, Patel A, Gyawali CP. 2017; Elevated intrabolus pressure identifies obstructive processes when integrated relaxation pressure is normal on esophageal high-resolution manometry. Am J Physiol Gastrointest Liver Physiol. 313:G73–G79. DOI: 10.1152/ajpgi.00091.2017. PMID: 28408642. PMCID: PMC5538833.

23. Biasutto D, Roman S, Garros A, Mion F. 2018; Esophageal shortening after rapid drink test during esophageal high-resolution manometry: a relevant finding? United European Gastroenterol J. 6:1323–1330. DOI: 10.1177/2050640618796752. PMID: 30386605. PMCID: PMC6206544.

24. Quader F, Mauro A, Savarino E, et al. 2019; Jackhammer esophagus with and without esophagogastric junction outflow obstruction demonstrates altered neural control resembling type 3 achalasia. Neurogastroenterol Motil. 31:e13678. DOI: 10.1111/nmo.13678. PMID: 31310444.

25. Wahba G, Bouin M. 2020; Jackhammer esophagus: a meta-analysis of patient demographics, disease presentation, high-resolution manometry data, and treatment outcomes. Neurogastroenterol Motil. 32:e13870. DOI: 10.1111/nmo.13870. PMID: 32406556.

26. Rengarajan A, Rogers BD, Wong Z, et al. 2022; High-resolution manometry thresholds and motor patterns among asymptomatic individuals. Clin Gastroenterol Hepatol. 20:e398–e406. DOI: 10.1016/j.cgh.2020.10.052. PMID: 33144149.

27. Rogers BD, Rengarajan A, Mauro A, et al. 2020; Fragmented and failed swallows on esophageal high-resolution manometry associate with abnormal reflux burden better than weak swallows. Neurogastroenterol Motil. 32:e13736. DOI: 10.1111/nmo.13736. PMID: 31574208.

28. Zerbib F, Marin I, Cisternas D, et al. 2020; Ineffective esophageal motility and bolus clearance. A study with combined high-resolution manometry and impedance in asymptomatic controls and patients. Neurogastroenterol Motil. 32:e13876. DOI: 10.1111/nmo.13876. PMID: 32394518.

29. Rengarajan A, Bolkhir A, Gor P, Wang D, Munigala S, Gyawali CP. 2018; Esophagogastric junction and esophageal body contraction metrics on high-resolution manometry predict esophageal acid burden. Neurogastroenterol Motil. 30:e13267. DOI: 10.1111/nmo.13267. PMID: 29266647.

30. Chugh P, Collazo T, Dworkin B, Jodorkovsky D. 2019; Ineffective esophageal motility is associated with impaired bolus clearance but does not correlate with severity of dysphagia. Dig Dis Sci. 64:811–814. DOI: 10.1007/s10620-018-5384-x. PMID: 30535781.

31. Martinucci I, Savarino EV, Pandolfino JE, et al. 2016; Vigor of peristalsis during multiple rapid swallows is inversely correlated with acid exposure time in patients with NERD. Neurogastroenterol Motil. 28:243–250. DOI: 10.1111/nmo.12719. PMID: 26661383.