Chicago Classification update (V4.0): Technical review on diagnostic criteria for ineffective esophageal motility and absent contractility

Abstract

Esophageal hypomotility disorders manifest with abnormal esophageal body contraction vigor, breaks in peristaltic integrity, or failure of peristalsis in the context of normal lower esophageal sphincter relaxation on esophageal high‐resolution manometry (HRM). The Chicago Classification version 4.0 recognizes two hypomotility disorders, ineffective esophageal motility (IEM) and absent contractility, while fragmented peristalsis has been incorporated into the IEM definition. Updated criteria for ineffective swallows consist of weak esophageal body contraction vigor measured using distal contractile integral (DCI, 100–450 mmHg·cm·s), transition zone defects >5 cm measured using a 20 mmHg isobaric contour, or failure of peristalsis (DCI < 100 mmHg·cm·s). More than 70% ineffective swallows and/or ≥50% failed swallows are required for a conclusive diagnosis of IEM. When the diagnosis is inconclusive (50%–70% ineffective swallows), supplementary evidence from multiple rapid swallows (absence of contraction reserve), barium radiography (abnormal bolus clearance), or HRM with impedance (abnormal bolus clearance) could support a diagnosis of IEM. Absent contractility requires 100% failed peristalsis, consistent with previous versions of the classification. Consideration needs to be given for the possibility of achalasia in absent contractility with dysphagia despite normal IRP, and alternate complementary tests (including timed upright barium esophagram and functional lumen imaging probe) are recommended to confirm or refute the presence of achalasia. Future research to quantify esophageal bolus retention on stationary HRM with impedance and to understand contraction vigor thresholds that predict bolus clearance will provide further refinement to diagnostic criteria for esophageal hypomotility disorders in future iterations of the Chicago Classification.

How Updates in Chicago Classification Impact Clinical Practice

“…In addition to "upgrading" IEM and fragmented peristalsis from minor motility disorders (CC v4.0 does not differentiate between major and minor motility disorders), CC v4.0 combines these entities and applies more stringent criteria for an IEM diagnosis (Figure 5). 12 Specifically, CC v4.0 requires ≥70% of swallows to be ineffective (DCI < 450 mmHg•s•cm) or fragmented (>5 cm break in the 20 mmHg isobaric contour of for swallows with DCI >450 mmHg•s•cm) for an IEM diagnosis. Alternatively, ≥50% failed swallows (DCI < 100 mmHg•s•cm) also constitutes IEM.…”

Novedades acerca de los trastornos motores del esófago tras la reciente clasificación de chicago 4.0

“…2 En ella, se incorporaron modificaciones al protocolo de estudio, que incluyen la realización de degluciones con el paciente en decúbito y en sedestación y el uso de maniobras de provocación para mejorar la sensibilidad y especificidad de los hallazgos (Tabla 1). 3 Otra modificación relevante consiste en el reconocimiento de que los patrones manométricos pueden no ser específicos, estableciéndose categorías diagnósticas conclusivas y no conclusivas. También, se modificaron los criterios diagnósticos de los trastornos por hipomotilidad y la obstrucción de salida de la unión esofagogástrica (EGJOO, según sus siglas en inglés), siendo estos los cambios que se abordarán en esta revisión.…”

“…Además, la PF es una entidad muy infrecuente. 3 La PF no fue eliminada pues los defectos peristálticos > 5 cm demostraron asociación con atrapamiento del bolo deglutido 7 y con clearance alterado del reflujo, usando el tiempo de exposición ácida (TEA) en monitoreo ambulatorio. 8…”

“…38,52 Los agentes procinéticos convencionales por vía oral (metoclopramida, domperidona) no han demostrado eficacia en la hipomotilidad esofágica ni mejoría de los síntomas. 3,26 Tampoco hay evidencia de un aumento del vigor contráctil ni en el control de síntomas con agonistas 5-HT4 como Mosapride y Reverexepride. [53][54][55] Respecto del Prucalopride, hay evidencia muy limitada de mejoría del TEA y de los síntomas esofágicos en cuatro pacientes con ERGE en tratamiento por estreñimiento concomitante.…”

The Relevance of Ineffective Esophageal Motility to Surgical Practice

“…With the widespread uptake of highresolution esophageal manometry, definitions evolved to reference the distal contractile integral (DCI), such as DCI <450 mmHg-s-cm with ≥50% ineffective swallows representing IEM, 5 though the 95th percentile DCI value in healthy volunteers has been reported to be as low as 200 mmHg-cm-s. 6 In 2021, the Chicago Classification version 4.0 introduced some subtlety into the diagnosis of IEM, differentiating between "conclusive" and "inconclusive" diagnoses, to allow for greater sensitivity in predicting incomplete bolus transit in symptomatic patients. 7 A conclusive diagnosis of IEM now requires >70% ineffective swallows or at least 50% failed swallows (DCI <100mmHg-cm-s). 8 An inconclusive diagnosis allows for 50% to 70% ineffective swallows, though this definition is not as strongly supported by the expert consensus opinion of the Chicago Classification 4.0 working group.…”