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The three subtypes of achalasia are all defined by an elevated median IRP and specifically include A) Type 1 Achalasia with 100% failed peristalsis, B) Type 2 Achalasia with 100% failed peristalsis and at least 20% of swallows with panesophageal pressurization, and C) Type 3 Achalasia with at least 20% of swallows with premature contractions and the remainder of the swallows failed or premature. The more stringent criteria for type 3 achalasia is an update in the Chicago Classification version 4.0
Source publication
Purpose of Review
Chicago Classification has standardized clinical approach to primary esophageal motility disorders. With new clinical data and advancing treatments, Chicago Classification has undergone multiple revisions to reflect updated findings and enhance diagnostic accuracy. This review will describe the recently published Chicago Classific...
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Aim: Although nonspecific esophageal motility disorder(NEMD) is the most common diagnosis in manometry, unlike other primary esophageal disorders, it is the least known and least studied disorder in the literature. Studies with a small number of patient groups have been reported in the literature. The aim of this study is to share the demographic a...
Citations
... Moreover, to guide clinical decisions for inconclusive diagnoses on HRM, supportive tests such as timed barium esophagography (TBE) or endoluminal functional lumen imaging probe (FLIP) are strongly recommended in CC v4.0. 5 However, the diagnostic accuracy of CC v4.0 compared with that of CC v3.0 remains unclear. ...
Background/aims:
We aim to investigate the diagnostic accuracy and differences between Chicago classification version 3.0 (CC v3.0) and 4.0 (CC v4.0).
Methods:
Patients who underwent high-resolution esophageal manometry (HRM) for suspected esophageal motility disorders were prospectively recruited between May 2020 and February 2021. The protocol of HRM studies included additional positional change and provocative testing designed by CC v4.0.
Results:
Two hundred forty-four patients were included. The median age was 59 (interquartile range, 45-66) years, and 46.7% were males. Of these, 53.3% (n = 130) and 61.9% (n = 151) were categorized as normalcy by CC v3.0 and CC v4.0, respectively. The 15 patients diagnosed of esophagogastric junction outflow obstruction (EGJOO) by CC v3.0 was changed to normalcy by position (n = 2) and symptom (n = 13) by CC v4.0. In seven patients, the ineffective esophageal motility (IEM) diagnosis by CC v3.0 was changed to normalcy by CC v4.0. The diagnostic rate of achalasia increased from 11.1% (n = 27) to 13.9% (n = 34) by CC v4.0. Of patients diagnosed IEM by CC v3.0, 4 was changed to achalasia based on the functional lumen imaging probe (FLIP) results by CC v4.0. Three patients (2 with absent contractility and 1 with IEM in CC v3.0) were newly diagnosed with achalasia using a provocative test and barium esophagography by CC v4.0.
Conclusions:
CC v4.0 is more rigorous than CC v3.0 for the diagnosis of EGJOO and IEM and diagnoses achalasia more accurately by using provocative tests and FLIP. Further studies on the treatment outcomes following diagnosis with CC v4.0 are needed.
... Typical and atypical (e.g., asthma, coughing, hoarseness) GERD symptoms, weight loss, and vomiting are other attributable symptoms [1][2]. While the association of symptoms to feeding may be helpful, it is not required to diagnose DES [8][9]. ...
Distal esophageal spasm is characterized by premature contractions of the distal esophageal smooth muscle leading to non-obstructive dysphagia and non-cardiac chest pain. Diagnosis requires the presence of symptoms along with evidence of at least 20% premature contractions in the setting of a normal lower esophageal sphincter relaxation on high-resolution manometry. New updates to the Chicago Classification have improved the diagnostic accuracy of this method. Functional lumen imaging probe is a growing diagnostic modality that gives a more complete picture of esophageal motility. Pharmacologic treatment remains inadequate. Endoscopic myotomy might be of benefit for non-achalasia esophageal motility disorders. More research is required to better understand the pathophysiology and develop safe and long-lasting management for this disease.
Ineffective Motility (IM), under the umbrella of the Chicago classification version 3.0 metric, cannot individually define the severity of patient
symptoms and clinical outcomes. In light of this, an updated CCv4.0 protocol is proposed with rapid drink challenge (RDC), an effective
diagnostic tool that entails better results on high-resolution manometric (HRM) findings and helps redefine cases of patients presenting with
IM. We offer a case where a patient with IM, as observed by just manometric findings, was directed for a rapid drink challenge (RDC) test
where pan esophageal pressurization and an increase in integrated relaxation pressure (IRP) of 26 mmHg on HRM color contour was observed.
Thus, it shows that RDC is an efficient test that can be used to differentiate various groups of esophageal motility disorders, and along with that,
it may help medical practitioners diagnose and manage related patients better.
Objective:
Deglutition, speech production, and airway protection are extraordinarily complex, interrelated functions that are coordinated, in large part, by the motor and sensory innervation of CN X. Previous studies assessing the relationship between neurogenic voice disorders and dysphagia have focused on the risk of aspiration due to glottic insufficiency and the association of vocal fold hypomobility (VFH) with systemic neurologic disease. The purpose of this study was to investigate the relationship between VFH disorders and ineffective esophageal motility (IEM).
Methods:
Adult voice patients who underwent laryngeal electromyography (LEMG) and dual 24-hour pH impedance with high-resolution manometry (HRM) testing were included in the study. Subjects were assigned to one of two groups based on the presence or absence of moderate-to-severe RLN and/or SLN VFH (Mo-SLNH/RLNH) using results from six muscle LEMG tests. In subjects with Mo-SLNH/RLNH, there was 0-60% muscle recruitment on LEMG, whereas control subjects in the non-Mo-SLNH/RLNH group demonstrated 61-100% muscle recruitment. Analysis of mild-to-severe VFH (80% muscle recruitment or less) was also performed in a similar manner. The prevalence of IEM, defined using Chicago Classification Version 4.0 (CCv4.0), was compared between groups, as were HRM parameters.
Results:
One hundred sixty-two subjects were included (37.7% male/62.3% female, mean age of 43.88 ± 17.285). No differences in IEM prevalence were found when stratifying for cases of mild-to-severe VFH. However, there was significantly higher percentage of IEM in those with Mo-SLNH/RLNH. Mo-SLNH/RLNH subjects demonstrated higher rates of weak swallows and inefficient swallows, as well as lower IBP and UES residual pressures on HRM.
Conclusions:
Patients with Mo-SLNH/RLNH demonstrated a significantly higher prevalence of IEM. Those with mild-to-severe VFH did not. Higher rates of ineffective and weak swallows, and lower IBP and UES residual pressures among Mo-SLNH/RLNH subjects suggest a possible connection between Mo-SLNH/RLNH and IEM disorders. These manometric differences were more prominent with sub-stratification of the Mo-SLNH/RLNH group by IEM. Additional research is advised.
