Chicago classification version 4.0^© technical review: Update on standard high‐resolution manometry protocol for the assessment of esophageal motility

Abstract

The Chicago Classification v4.0 (CCv4.0) is the updated classification scheme for esophageal motility disorders using metrics from high‐resolution manometry (HRM). A key feature of CCv.4.0 is the more rigorous and expansive protocol that incorporates single wet swallows acquired in different positions (supine, upright) and provocative testing, including multiple rapid swallows and rapid drink challenge. Additionally, solid bolus swallows, solid test meal, and/or pharmacologic provocation can be used to identify clinically relevant motility disorders and other conditions (eg, rumination) that occur during and after meals. The acquisition and analysis for performing these tests and the evidence supporting their inclusion in the Chicago Classification protocol is detailed in this technical review. Provocative tests are designed to increase the diagnostic sensitivity and specificity of HRM studies for disorders of esophageal motility. These changes attempt to minimize ambiguity in prior iterations of Chicago Classification, decrease the proportion of HRM studies that deliver inconclusive diagnoses and increase the number of patients with a clinically relevant diagnosis that can direct effective therapy. Another aim in establishing a standard manometry protocol for motility laboratories around the world is to facilitate procedural consistency, improve diagnostic reliability, and promote collaborative research.

British Society of Gastroenterology (BSG) and British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) joint consensus guidelines on the diagnosis and management of eosinophilic oesophagitis in children and adults

“…109 This technique has now been included as a standard in the most recent iteration of the Chicago Classification of motility disorders. 110 The GDG recommends that full evaluation of persistent, refractory dysphagia in patients with EoE with apparently normal endoscopic findings should include oesophageal physiological testing and barium swallow studies where appropriate, as described in the BSG guidelines on oesophageal manometry and reflux monitoring 111 and the Chicago classification. 96 Solid swallows during HRM should be considered in order to replicate the presenting symptoms of EoE.…”

How provocative tests in addition to wet swallows during high-resolution manometry can direct clinical management

“…Median duration to complete a 200 g STM is 6 min, and a consumption time of >8 min is considered abnormal (some patients with motility disorders do not complain of dysphagia but eat very slowly) [7]. Pathological thresholds that define motility disorders have been described, and these can be applied to diagnose motility disorders using the CCv4.0 [5 ▪ ,21]. Serial diagnostic studies have shown that inclusion of a meal can increase the diagnostic sensitivity and specificity of motor disorders including spasm, hypercontractile motility and EGJ outlet obstruction.…”

Towards a more precise classification of esophageal motility disorders in patients with systemic sclerosis

“…The use of HRM classification scheme termed as the Chicago Classification further increases the performance and the reliability of the test 24,25 . Finally, many studies have shown that the use of adjunctive tests enable to improve the diagnostic yield of HRM in different clinical conditions because applying a physiologic challenge increases the esophageal workload and the sensitivity of the investigation 26 . The most frequently adopted provocative maneuvers are represented by multiple rapid swallows (MRS), rapid challenge test and various test meals.…”