Esophageal motility disorders on high-resolution manometry: Chicago classification version 4.0©

Published on Jan 1, 2021in Neurogastroenterology and Motility2.946
· DOI :10.1111/NMO.14058
Rena Yadlapati18
Estimated H-index: 18
(UCSD: University of California, San Diego),
Peter J. Kahrilas122
Estimated H-index: 122
(NU: Northwestern University)
+ 49 AuthorsJohn E. Pandolfino79
Estimated H-index: 79
(NU: Northwestern University)
Chicago Classification v4.0 (CCv4.0) is the updated classification scheme for esophageal motility disorders using metrics from high-resolution manometry (HRM). Fifty-two diverse international experts separated into seven working subgroups utilized formal validated methodologies over two-years to develop CCv4.0. Key updates in CCv.4.0 consist of a more rigorous and expansive HRM protocol that incorporates supine and upright test positions as well as provocative testing, a refined definition of esophagogastric junction (EGJ) outflow obstruction (EGJOO), more stringent diagnostic criteria for ineffective esophageal motility and description of baseline EGJ metrics. Further, the CCv4.0 sought to define motility disorder diagnoses as conclusive and inconclusive based on associated symptoms, and findings on provocative testing as well as supportive testing with barium esophagram with tablet and/or functional lumen imaging probe. These changes attempt to minimize ambiguity in prior iterations of Chicago Classification and provide more standardized and rigorous criteria for patterns of disorders of peristalsis and obstruction at the EGJ.
#1Daniel Sifrim (QMUL: Queen Mary University of London)H-Index: 70
#2Sabine Roman (University of Lyon)H-Index: 59
Last. C. Prakash Gyawali (WashU: Washington University in St. Louis)H-Index: 29
view all 30 authors...
Objective Limitations of existing impedance-pH thresholds include small sample size of normative studies, inclusion of artefactual pH drops and incorrect identification of impedance reflux events. We aimed to obtain new impedance-pH thresholds from expert consensus analysis of tracings from a large number of healthy subjects. Design Of 541 studies performed worldwide using two different systems (Diversatek, USA, and Laborie, Netherlands), 150 tracings with oesophageal diagnoses, behavioural diso...
16 CitationsSource
#1Benjamin D. Rogers (WashU: Washington University in St. Louis)H-Index: 8
#2Arvind Rengarajan (WashU: Washington University in St. Louis)H-Index: 7
Last. C. Prakash Gyawali (WashU: Washington University in St. Louis)H-Index: 29
view all 26 authors...
BACKGROUND Esophagogastric junction contractile integral (EGJ-CI) and EGJ morphology are high-resolution manometry (HRM) metrics that assess EGJ barrier function. Normative data standardized across world regions and HRM manufacturers are limited. METHODS Our aim was to determine normative EGJ metrics in a large international cohort of healthy volunteers undergoing HRM (Medtronic, Laborie, and Diversatek software) acquired from 16 countries in four world regions. EGJ-CI was calculated by the same...
4 CitationsSource
#1Amanda J. Krause (NU: Northwestern University)H-Index: 2
#2Hui Su (Capital Medical University)H-Index: 3
Last. Dustin A. Carlson (NU: Northwestern University)H-Index: 23
view all 8 authors...
BACKGROUND Esophagogastric junction outflow obstruction (EGJOO) as defined by Chicago Classification of esophageal motility disorders (CCv3.0) encompasses a broad range of diagnoses, thus posing clinical challenges. Our aims were to evaluate multiple rapid swallow (MRS) and rapid drink challenge (RDC) during high-resolution manometry (HRM) to aid identifying clinically relevant EGJOO. METHODS Patients with a HRM diagnosis of EGJOO based on CCv3.0 that also completed MRS and RDC during HRM and ba...
4 CitationsSource
#1Santosh Sanagapalli (St. Vincent's Health System)H-Index: 6
#2Joshua McGuire (UCLH: University College Hospital)H-Index: 1
Last. Rami Sweis (UCLH: University College Hospital)H-Index: 18
view all 14 authors...
INTRODUCTION Esophagogastric junction outflow obstruction (EGJOO) defined on high-resolution esophageal manometry (HRM) poses a management dilemma given marked variability in clinical manifestations. We hypothesized that findings from provocative testing (rapid drink challenge and solid swallows) could determine the clinical relevance of EGJOO. METHODS In a retrospective cohort study, we included consecutive subjects between May 2016 and January 2020 with EGJOO. Standard HRM with 5-mL water swal...
7 CitationsSource
#1Farhan Quader (WashU: Washington University in St. Louis)H-Index: 6
#2Benjamin D. Rogers (WashU: Washington University in St. Louis)H-Index: 8
Last. C. Prakash Gyawali (WashU: Washington University in St. Louis)H-Index: 29
view all 7 authors...
Introduction Ineffective esophageal motility (IEM) is a minor motor disorder with potential reflux implications. Contraction reserve, manifested as augmentation of esophageal body contraction after multiple rapid swallows (MRS), may affect esophageal acid exposure time (AET) in IEM. Methods Esophageal high-resolution manometry (HRM) and ambulatory reflux monitoring studies were reviewed over 2 years to identify patients with normal HRM, IEM (≥50% ineffective swallows), and absent contractility (...
7 CitationsSource
#1Arvind Rengarajan (WashU: Washington University in St. Louis)H-Index: 7
#2Benjamin D. Rogers (WashU: Washington University in St. Louis)H-Index: 8
Last. Chandra Prakash Gyawali (WashU: Washington University in St. Louis)H-Index: 26
view all 25 authors...
ABSTRACT Objective High-resolution manometry (HRM) is the current standard for characterization of esophageal body and esophagogastric junction (EGJ) function. We aimed to examine the prevalence of abnormal esophageal motor patterns in health, and to determine optimal thresholds for software metrics across HRM systems. Design Manometry studies from asymptomatic adults were solicited from motility centers worldwide, and were manually analyzed using integrated relaxation pressure (IRP), distal lat...
4 CitationsSource
#1Joseph R. Triggs (UPenn: University of Pennsylvania)H-Index: 3
#2Dustin A. Carlson (NU: Northwestern University)H-Index: 23
Last. John E. Pandolfino (NU: Northwestern University)H-Index: 79
view all 6 authors...
Abstract: Background & Aims The etiologies of esophagogastric junction outflow obstruction (EGJOO) vary, as do their therapeutic implications. We aimed to identify patients with EGJOO most likely to benefit from achalasia-type treatment, based on findings from functional luminal imaging probe (FLIP) panometry. Methods We performed a retrospective study of 34 patients who received a diagnosis of EGJOO from January 2015 through July 2017. Our analysis included patients who had been evaluated with ...
25 CitationsSource
#1Arash Babaei (MCW: Medical College of Wisconsin)H-Index: 5
#2Sadaf Shad (MCW: Medical College of Wisconsin)H-Index: 4
Last. Benson T. Massey (MCW: Medical College of Wisconsin)H-Index: 25
view all 3 authors...
BACKGROUND: Absent esophageal contractility (AC) is distinguished from type 1 achalasia (ACH1) during high-resolution manometry (HRM) on the basis of normal or elevated deglutitive integrated relaxation pressure (IRP) values. However, IRP measurements are subject to pressure recording error. We hypothesized that distinctive responses to pharmacologic provocation using amyl nitrite (AN) and cholecystokinin (CCK) could reliably distinguish AC patients from those with ACH1. AIM: To compare esophage...
6 CitationsSource
#1Sara Philonenko (University of Paris)H-Index: 1
#2Sabine RomanH-Index: 59
Last. Benoit Coffin (University of Paris)H-Index: 53
view all 14 authors...
BACKGROUND/AIMS Jackhammer esophagus (JE) is a hypercontractile esophageal motor disorder defined by at least two swallows with a distal contractile integral (DCI) >8000 mm during high-resolution manometry (HRM). The relationship between symptoms and hypercontractility and the response to therapies have been poorly evaluated. The aim of this study was to determine the clinical presentation, manometric diagnosis, and therapeutic results in a large cohort of JE patients. METHODS Patients w...
6 CitationsSource
#1Claire Beveridge (HUP: Hospital of the University of Pennsylvania)H-Index: 3
#1Claire A. Beveridge (HUP: Hospital of the University of Pennsylvania)H-Index: 1
Last. Kristle L. Lynch (HUP: Hospital of the University of Pennsylvania)H-Index: 8
view all 6 authors...
: Esophagogastric junction outflow obstruction (EGJOO) is an abnormal finding on high-resolution manometry (HRM) characterized by an elevated median integrated relaxation pressure with some intact peristalsis.1 EGJOO is associated with heterogeneous symptoms, disease course, and response to treatment.1-4 It can be idiopathic or secondary with causes including malignancy, infiltrative disease, or structural etiology.1,3 Therefore, Chicago Classification of Esophageal Motility Disorders version 3....
10 CitationsSource
Cited By40
#1Rena Yadlapati (UCSD: University of California, San Diego)H-Index: 18
#2Peter J. Kahrilas (NU: Northwestern University)H-Index: 122
#1Amir Mari (BIU: Bar-Ilan University)H-Index: 6
#2Fadi Abu Baker (Hillel Yaffe Medical Center)H-Index: 7
Last. Tawfik Khoury (BIU: Bar-Ilan University)H-Index: 11
view all 0 authors...
Achalasia is a rare neurodegenerative disorder causing dysphagia and is characterized by abnormal esophageal motor function as well as the loss of lower esophageal sphincter (LES) relaxation. The assessment and management of achalasia has significantly progressed in recent years due to the advances in high-resolution manometry (HRM) technology along with the improvements and innovations of therapeutic endoscopy procedures. The recent evolution of HRM technology with the inclusion of an adjunctiv...
#1Dustin A. Carlson (NU: Northwestern University)H-Index: 23
#2Alexandra J. Baumann (NU: Northwestern University)H-Index: 5
Last. John E. Pandolfino (NU: Northwestern University)H-Index: 79
view all 9 authors...
INTRODUCTION High-resolution manometry (HRM) is generally considered the primary method to evaluate esophageal motility; functional luminal imaging probe (FLIP) panometry represents a novel method to do so and is completed during sedated endoscopy. This study aimed to compare HRM and FLIP panometry in predicting esophageal retention on timed barium esophagram (TBE). METHODS A total of 329 adult patients who completed FLIP, HRM, and TBE for primary esophageal motility evaluation were included. An...
#1Luis Gerardo Alcala-Gonzalez (Autonomous University of Barcelona)
#2Carolina Malagelada (Autonomous University of Barcelona)H-Index: 19
Last. Fernando Azpiroz (Autonomous University of Barcelona)H-Index: 65
view all 6 authors...
BACKGROUND The manometric diagnosis of severe intestinal dysmotility is performed at most institutions using catheters with 2-8 sensors 5-10 cm apart. The recent application of high-resolution manometry catheters with closely spaced sensors to other gut segments has been highly successful. The objective of the present study was to determine the feasibility of a jejunal high-resolution manometry method and to carry out a descriptive analysis of normal jejunal motor function. METHODS A 36-channel ...
#1Qianjun Zhuang (SYSU: Sun Yat-sen University)
#2Niandi Tan (SYSU: Sun Yat-sen University)H-Index: 2
Last. Yinglian Xiao (SYSU: Sun Yat-sen University)H-Index: 9
view all 6 authors...
BACKGROUND The updated Chicago Classification version 4.0 (CCv4.0) establishes a more stringent criteria to diagnose ineffective esophageal motility (IEM). This study aims to investigate the clinical significance of IEM in CCv4.0 in the context of gastroesophageal reflux disease (GERD). METHODS A retrospective study was conducted among suspected GERD patients who had heartburn and/or regurgitation as their chief complaints and completed esophageal function tests in our center from 2017 to 2019. ...
#1Daniel Cisternas (Universidad del Desarrollo)H-Index: 5
#2Tiffany Taft (NU: Northwestern University)H-Index: 16
Last. C Bilder (Fundación Favaloro)H-Index: 4
view all 18 authors...
INTRODUCTION Grading dysphagia is crucial for clinical management of patients. The Eckardt score (ES) is the most commonly used for this purpose. We aimed to compare the ES with the recently developed Brief Esophageal Dysphagia Questionnaire (BEDQ) in terms of their correlation and discriminative capacity for clinical and manometric findings and evaluate the effect of gastroesophageal reflux symptoms on both. METHODS Symptomatic patients referred for high-resolution manometry (HRM) were prospect...
#1Gaurav Bhasker Nigam (University of Oxford)
#2Dipesh H. VasantH-Index: 10
Last. Anjan DharH-Index: 18
view all 3 authors...
Dysphagia is a common presentation in gastroenterology practice and the diagnosis and management requires a comprehensive knowledge of diverse range of aetiologies, with a systematic approach for assessment of symptoms, selection of investigations and appropriate treatment to relieve symptoms. In this curriculum review, the suggested diagnostic approach highlights the importance of thorough clinical assessment in order to guide the selection of investigations. This article discusses the utility ...
#1Véronique Vitton (AMU: Aix-Marseille University)H-Index: 24
#2Marc Barthet (AMU: Aix-Marseille University)H-Index: 25
Last. JM Gonzalez (AMU: Aix-Marseille University)H-Index: 1
view all 3 authors...
#1Kazuto Tsuboi (Jikei University School of Medicine)H-Index: 13
#2Fumiaki Yano (Jikei University School of Medicine)H-Index: 13
Last. Hideyuki KashiwagiH-Index: 19
view all 10 authors...
Peptic esophagitis can occur as a complication of laparoscopic Heller-Dor surgery (LHD) among patients with esophageal achalasia. The goal of this study was to identify the characteristics of patients who have developed peptic esophagitis following LHD surgery along with the risk factors associated with the occurrence of peptic esophagitis. Among the 447 cases consisting of esophageal achalasia patients who underwent LHD as the primary surgery, we compared the patient background, pathophysiology...
#1Mentore Ribolsi (Università Campus Bio-Medico)H-Index: 20
Last. Michele CicalaH-Index: 35
view all 7 authors...
INTRODUCTION The clinical management of chronic cough patients is challenging, and their response to proton pump inhibitors (PPIs) is considered as unsatisfactory. Few data concerning the association between impedance-pH variables and PPI response in these patients are available. Mean nocturnal baseline impedance (MNBI) and postreflux swallow-induced peristaltic wave (PSPW) index increase the diagnostic yield of impedance-pH in gastroesophageal reflux disease. METHODS Demographic, clinical, and ...