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Evaluation of Esophageal Motility and Lessons from Chicago Classification version 4.0

  • Neurogastroenterology and Motility Disorders of the Gastrointestinal Tract (S Rao, Section Editor)
  • Published:
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Abstract

Purpose of Review

Chicago Classification has standardized clinical approach to primary esophageal motility disorders. With new clinical data and advancing treatments, Chicago Classification has undergone multiple revisions to reflect updated findings and enhance diagnostic accuracy. This review will describe the recently published Chicago Classification version 4.0 (CCv4.0), which aimed to enhance diagnostic characterization and limit overdiagnosis of inconclusive esophageal motility diagnoses.

Recent Findings

Key revisions outlined in CCv4.0 include (1) a modified standardized HRM study protocol performed in supine and upright positions, (2) recommended ancillary testing and manometric provocation for inconclusive manometric diagnoses (3) the required presence of obstructive symptoms for conclusive diagnoses of esophagogastric junction outflow obstruction, distal esophageal spasm and hypercontractile esophagus, and (4) requirement of confirmatory testing for esophagogastric junction outflow obstruction.

Summary

These key modifications aim to improve diagnostic accuracy and consistency of clinically relevant esophageal motility disorders, and subsequently clinical outcomes.

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Fig. 1
Fig. 2

Adapted from the Chicago Classification version 4.0 ©. Hypercontractile Esophagus is defined by a normal median IRP and at least 20% or more swallows as hypercontractile (DCI ≥ 8000 mmHg-s-cm). In the Chicago Classification update hypercontractile esophagus is no longer synonymous with Jackhammer esophagus but rather may indicate one of three phenotypes: A) single peak hypercontractile swallow (the most common), B) jackhammer esophagus with repetitive prolonged contractions, or a new entity defined by a C) hypercontractile lower esophageal sphincter

Fig. 3

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Abbreviations

HRM:

High-resolution manometry

CCv4.0:

Chicago Classification version 4.0

EPT:

Esophageal pressure topography

CCv1.0:

Chicago Classification version 1.0

CCv2.0:

Chicago Classification version 2.0

CCv3.0:

Chicago Classification version 3.0

EGJ:

Esophagogastric junction

EGJOO:

Esophagogastric junction outflow obstruction

DCI:

Distal contractile integral

IEM:

Ineffective esophageal motility

IRP:

Integrated relaxation pressure

LES:

Lower esophageal sphincter

MRS:

Multiple rapid swallow

RDC:

Rapid drink challenge

TBE:

Timed barium esophagram

FLIP:

Functional lumen imaging probe

OIED:

Opioid-induced esophageal dysfunction

DL:

Distal latency

DES:

Distal esophageal spasm

GERD:

Gastroesophageal reflux disease

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Funding

RY is supported by NIH K23 DK125266 (PI: Yadlapati).

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Authors and Affiliations

  1. Department of Medicine, University of California, San Diego, La Jolla, CA, USA

    Priya Sharma

  2. Division of Gastroenterology, University of California, San Diego, ACTRI, Building 1W517, 9500 Gilman Drive MC 0956, La Jolla, CA, 92093, USA

    Rena Yadlapati

Authors
  1. Priya Sharma
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  2. Rena Yadlapati
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Contributions

PS and RY: Literature review, drafting of manuscript, critical revision of manuscript, final approval of manuscript to be published.

Corresponding author

Correspondence to Rena Yadlapati.

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Conflicts of Interest

Rena Yadlapati: Institutional Consulting Agreement: Medtronic, Ironwood Pharmaceuticals, Diversatek; Consultant: Phathom Pharmaceuticals; Research support: Ironwood Pharmaceuticals; Advisory Board with Stock Options: RJS Mediagnostix; Priya Sharma: None.

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Sharma, P., Yadlapati, R. Evaluation of Esophageal Motility and Lessons from Chicago Classification version 4.0. Curr Gastroenterol Rep 24, 10–17 (2022). https://doi.org/10.1007/s11894-022-00836-7

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