From Chicago classification v3.0 to v4.0: Diagnostic changes and clinical implications

Abstract

Background:The Chicago Classification (CC) used to define esophageal motility disorders in high-resolution manometry (HRM) has evolved over time. Our aim was to compare the frequency of motility disorders diagnosed with the last two versions (CCv3.0 and CCv4.0) and to evaluate symptoms severity according to the diagnoses. Methods:From June to December 2020, patients who underwent esophageal HRM with swallows in supine and sitting positions were included. HRM studies were retrospectively analyzed using CCv3.0 and CCv4.0. Symptoms severity and quality of life were assessed with validated standardized questionnaires.Key Results: Among the 130 patients included (73 women, mean age 52 years), motility disorder diagnoses remained unchanged in 102 patients (78%) with both CC. The 3 patients with esophago-gastric junction outflow obstruction (EGJOO) with CCv3.0 were EGJOO, ineffective esophageal motility (IEM) and normal with CCv4.0. Twentyfour out of 63 IEM diagnosed with the CCv3.0 (38%) turned into normal motility with the CCv4.0. Whatever the CC used, brief esophageal dysphagia questionnaire score was significantly higher in patients with EGJ relaxation disorders compared to those with IEM (25 (0-34) vs 0 (0-19), p = 0.01). Gastro-Esophageal Reflux disease questionnaire (GERD-Q) score was higher in patients with IEM with both CC compared to those who turned to normal with CCv4.0. Conclusions and Inferences:While motility disorders diagnoses remained mainly unchanged with both CC, IEM was less frequent with CCv4.0 compared to CCv3.0. The higher GERD-Q score in IEM patients with CCv4.0 suggests that CCv4.0 might identify IEM more likely associated with GERD.

Comparing Patients Diagnosed With Ineffective Esophageal Motility by the Chicago Classification Version 3.0 and Version 4.0 Criteria

“…At the time of this study, there had only been one published peer-reviewed study (n = 93) comparing the clinical characteristics of IEM patients by CCv3.0 and CCv4.0, and that study largely examined abnormal acid exposure [ 12 ]. A very recent publication showed that IEM was less frequent with CCv4.0 compared to CCv3.0, which is to be expected given the new criteria [ 13 ]. It also showed that the gastroesophageal reflux disease questionnaire (GerdQ) scores were higher for IEM by CCv4.0, with no difference in the Eckardt score or brief esophageal dysphagia questionnaire (BEDQ) noted.…”

“…The researchers did note an inverse correlation between dysphagia score and bolus clearance among IEM patients, which we were unable to replicate in our retrospective study due to lack of detailed dysphagia characteristics. The recent publication did not report a difference in Eckardt score between IEM patients defined by the CCv4.0 or CCv3.0 criteria [ 13 ].…”

Esophageal motility disorder – has Chicago classification v4.0 simplified our management?

“…Supporting tests like impedance or barium esophagram may be required. The new criteria identified IEM more likely associated with GERD [8,9 ▪ ,10].…”

Major mixed motility disorders: An important subset of esophagogastric junction outflow obstruction

“…A study looking at 132 patients completing a manometry protocol in a seated position found that the frequency of patients meeting criteria for disorders of EGJ relaxation including both EGJOO and achalasia as a single group reduced from 7% to 5%. 15 Larger studies looking at only the change in EGJOO frequency have yet to be conducted.…”

“…Refined and more rigorous CCv4 diagnostic criteria for EGJOO have led to a decrease in frequency of motility disorder diagnoses associated with poor EGJ relaxation. A study looking at 132 patients completing a manometry protocol in a seated position found that the frequency of patients meeting criteria for disorders of EGJ relaxation including both EGJOO and achalasia as a single group reduced from 7% to 5% 15 . Larger studies looking at only the change in EGJOO frequency have yet to be conducted.…”