Chicago classification v4.0 protocol improves specificity and accuracy of diagnosis of oesophagogastric junction outflow obstruction

Abstract

Summary Background Chicago classification version 4.0 (CCv4.0) introduced stringent diagnostic criteria for oesophagogastric junction outflow obstruction (EGJOO), in order to increase the clinical relevance of the diagnosis, although this has not yet been demonstrated. Aims To determine the prevalence of EGJOO using CCv4.0 criteria in patients with CCv3.0‐based EGJOO, and to assess if provocative manoeuvres can predict a conclusive CCv4.0 diagnosis of EGJOO. Methods Clinical presentation, high resolution manometry (HRM) with rapid drink challenge (RDC), and timed barium oesophagogram (TBE) data were extracted for patients diagnosed with EGJOO as per CCv3.0 between 2018 and 2020. Patients were then re‐classified according to CCv4.0 criteria, using clinically relevant symptoms (dysphagia and/or chest pain), and abnormal barium emptying at 5 min on TBE. Receiver operating characteristic (ROC) analyses identified HRM predictors of EGJOO. Results Of 2010 HRM studies, 144 (7.2%) fulfilled CCv3.0 criteria for EGJOO (median age 61 years, 56.9% female). Upon applying CCv4.0 criteria, EGJOO prevalence decreased to 1.2%. On ROC analysis, integrated relaxation pressure during RDC (RDC‐IRP) was a significant predictor of a conclusive EGJOO diagnosis by CCv4.0 criteria (area under the curve: 96.1%). The optimal RDC‐IRP threshold of 16.7 mm Hg had 87% sensitivity, 97.1% specificity, 95.7% negative predictive value and 91.3% positive predictive value for a conclusive EGJOO diagnosis; lower thresholds (10 mmHg, 12 mmHg) had better sensitivity but lower specificity. Conclusion CCv4.0 criteria reduced the prevalence of EGJOO by 80%, thereby refining the diagnosis and identifying clinically relevant outflow obstruction. Elevated RDC‐IRP can predict conclusive EGJOO per CCv4.0.

Editorial: reducing false alarms with oesophagogastric junction outflow obstruction

“…They also demonstrated that a higher median rapid drink challenge (RDC)-IRP, specifically 16.7 mmHg, is predictive of conclusive EGJOO by CCv4.0 criteria. 10 These data highlight the many ways that the updated HRM protocol and definition of EGJOO are a large leap forward in minimising 'false alarms' (Figure 1). Importantly, these updates in CCv4.0 promote a higher level of rigour and confidence in the manometric…”

“…4 Visaggi et al examined the impact of these new diagnostic requisites on the prevalence of EGJOO. 10 They identified that CCv4.0 diagnostic criteria (HRM metrics with the addtion of obstructive symptoms and supportive TBE findings) yield higher specificity for EGJOO with an impressive six-fold reduction (from 7.2% to 1.2%) of EGJOO prevalence. Further, they identified a lack of abnormal TBE in those without obstructive symptoms, justifying the requirement for obstructive symptoms for EGJOO in CCv4.0.…”

“…Further, they identified a lack of abnormal TBE in those without obstructive symptoms, justifying the requirement for obstructive symptoms for EGJOO in CCv4.0. They also demonstrated that a higher median rapid drink challenge (RDC)‐IRP, specifically 16.7 mmHg, is predictive of conclusive EGJOO by CCv4.0 criteria 10 …”

“…Visaggi et al examined the impact of these new diagnostic requisites on the prevalence of EGJOO 10 . They identified that CCv4.0 diagnostic criteria (HRM metrics with the addtion of obstructive symptoms and supportive TBE findings) yield higher specificity for EGJOO with an impressive six‐fold reduction (from 7.2% to 1.2%) of EGJOO prevalence.…”

Esophageal dysmotility in patients with eosinophilic esophagitis: pathogenesis, assessment tools, manometric characteristics, and clinical implications

“…A standard HRM protocol requires at least ten 5 mL water swallows, obtained in both supine and sitting position. Provocative tests (i.e., multiple rapid swallows—MRS and rapid drinking challenge—RDC) were included to investigate the peristaltic reserve and outflow obstruction [ 38 , 39 ]. According to CCv4.0, the esophagogastric junction (EGJ) morphology and LES relaxation should be assessed first.…”