Changes in the Treatment of Primary Esophageal Motility Disorders Imposed by the New Classification for Esophageal Motility Disorders on High Resolution Manometry (Chicago Classification 4.0)

Abstract

The Chicago Classification is the most used classification for primary esophageal motility disorders (PEMD). This classification was recently updated to the 4.0 version. This opinion piece focuses on the possible implications for the treatment of PMED determined by the new classification. Chicago Classification 4.0 included two new concepts for the diagnosis of achalasia: (1) type III achalasia diagnosis demands 100% absent peristalsis defined as either failed peristalsis or spasm; (2) ''inconclusive diagnosis of achalasia'' was added as a possibility. Both may decrease unnecessary treatment. Esophagogastric junction outflow obstruction, distal esophageal spasm, and hypercontractile esophagus were only considered clinically significant when correlated to supportive testing and relevant clinical symptoms and in the absence of gastroesophageal reflux disease. This may decrease the surge of treatment, especially peroral endoscopic myotomy, based solely on manometric diagnosis.

The Relevance of Ineffective Esophageal Motility to Surgical Practice

“…7 Even when IEM exists with dysphagia, no specific treatment exists to target the IEM directly. 31 Diagnosis of severe hypomotility, particularly without contraction reserve, in the preoperative patient with GERD may influence the surgical techniques for antireflux operations although currently available data do not explicitly support this practice. Persistent dysphagia remains a problem after all forms of anti-reflux surgery.…”

Spastic Motility Disorders: Diagnosis and Management in the Era of the Chicago Classification

“…GERD may be present in up 35% of the patients with esophageal hypercontractility. 13 Despite this evolution in definition, however, no association with symptomatology was rationalized. Hypercontractile esophagus is no longer synonymous with jackhammer esophagus, as 3 phenotypes of hypercontractile esophagus can be observed: single-peaked hypercontractile swallows, jackhammer, and hypercontractile swallows with a vigorous LES after-contraction.…”

“…7 While the jackhammer phenotype is most likely reflective of pathology, these patterns cannot be of prognostic value or tailor treatment yet, because of the lack of studies mostly due to the rarity of the disease. 13 An overall recommendation of a cautious approach to these patients is therefore mandatory. In fact, the available data about the clinical presentation of these manometric abnormalities are scarce and controversial, and several authors have failed to report any significant correlation of hypercontractile esophageal peristaltic waves with clinical symptoms.…”

Chicago 4.0, dispepsia funcional en niños, fibra en trastornos funcionales intestinales, y genética y genómica en SII

“…Otro aspecto importante es que los diagnósticos se clasifican en conclusivos y no conclusivos. Es así como en acalasia, la CCv4.0 indica que debe haber un 100% de aperistalsis o estaríamos ante un diagnóstico no conclusivo de acalasia 3 . Y en cuanto a la obstrucción del flujo de la unión esofagogástrica, los trastornos espásticos y el esófago hipercontráctil no tendrían significancia sin la presencia de pruebas de apoyo y manifestaciones clínicas 3,4 .…”

“…Es así como en acalasia, la CCv4.0 indica que debe haber un 100% de aperistalsis o estaríamos ante un diagnóstico no conclusivo de acalasia 3 . Y en cuanto a la obstrucción del flujo de la unión esofagogástrica, los trastornos espásticos y el esófago hipercontráctil no tendrían significancia sin la presencia de pruebas de apoyo y manifestaciones clínicas 3,4 . Por supuesto, la clasificación no es completa y aún tiene limitantes, incluso ante hallazgos de alteraciones que no pueden ser clasificadas en las actualmente aceptadas, principalmente lo que antes denominábamos trastornos funcionales inespecíficos o los trastornos espásticos del esófago, pero como decíamos, este es un trabajo en progreso y futuras versiones deberán refinar aún más estos diagnósticos, con base en los hallazgos de la investigación.…”