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.

Distal esophageal spasm (DES) is a major motility abnormality that can be associated with dysphagia and/or non-cardiac chest pain. The Chicago Classification (CC) v3.0 defined DES when liquid swallows are followed by at least 20% of premature contractions without impairment of esophago-gastric junction (EGJ) relaxation (normal integrated relaxation pressure (IRP)). 1 With the version 3.0, the distal latency (DL) between swallow and distal contraction was introduced as a new parameter to analyze esophageal high-resolution manometry (HRM). It requires the localization of the contractile deceleration point (CDP) which is the inflexion point in the contractile front propagation velocity in the distal esophagus. 2 Premature contraction is thus defined by the DL measured as the interval from the start of relaxation of the upper esophageal sphincter (UES) to the CDP shorter than 4.5 s. 3 The proposed definition of DES is purely manometric in the CCv3.0. An international process began in 2019 to update the Chicago Classification based on new publications and the experience in using