Chicago Classification Version Research Articles

Elevated Intrabolus Pressure Predicts Abnormal Timed Barium Esophagram in Esophagogastric Junction Outflow Obstruction.

Background/AimsTimed barium esophagram (TBE) is used the classification of esophageal motility disorders and assessing esophageal function. Currently, there are no published studies examining the relationship between high-resolution manometry and TBE in patients with esophagogastric junction outflow obstruction (EGJOO). This study seeks to evaluate this relationship and identify manometric variables that may indicate further evaluation using TBE.MethodsRetrospective review of medical records identified patients with a diagnosis of EGJOO per the Chicago classification version 3.0. TBE was performed using standard protocol. Patients were divided into 2 groups based on complete emptying or persistence of standing barium column at 5 minutes.ResultsEleven patients were identified with EGJOO who underwent both high-resolution manometry and TBE within 3 months. Five patients had no standing barium column at 5 minutes, while 6 patients had a persistent barium column. Mean age of each group was 54.0 years and 57.8 years, respectively. Patients with abnormal TBE were found to have significantly elevated intrabolus pressure (IBP) compared with patients who had a normal TBE.ConclusionsIn our study, we found significant differences in IBP between these patient groups. These findings suggest that patients with EGJOO and elevated IBP may prompt further clinical evaluation with TBE in order to clarify clinical diagnosis and guide therapeutic intervention.

2864 Utility of HRM for Improving Diagnosis and Detection of Esophageal Disorders in a Community Clinic

INTRODUCTION: High resolution manometry (HRM) has improved the ability to diagnosis esophageal motility disorders. HRM has the potential to provide diagnostic clarity to patients who suffer from dysphagia, gastroesophageal reflux disease, unexplained chest pain, and other non-specific symptoms. The purpose of this study is to explore the diagnostic yield of HRM in classifying esophageal dysmotility, specifically in a community clinic setting rather than the tertiary care center. High diagnostic accuracy better serves patients. Ultimately, community-based HRM prevents overload at large hospitals and improves access to care for patients. METHODS: We reviewed motility studies performed for the past 18 months at a satellite office built to serve the community. We reviewed the indications and diagnostic yield of HRM. RESULTS: From the cohort of 90 patients, the most common indication was esophageal dysphagia (45.5%). Refractory heartburn made up 32.3% of indications; unexplained chest pain made up 12.2%. Preoperative and postoperative assessments made up 7.7% and 2.2%, respectively. 3 patients were unable to finish the study. 87 were able to complete it. Diagnosis was based on the Chicago Classification version 3.0. Of those who completed the study, 44.8% were classified as normal; 29.8% of cases were EGJ outflow obstruction; 6.8% of cases classified as achalasia; distal spasm was not found in any patients; 3.4% of patients classified as hypercontractile esophagus; 4.6% of cases had absent contractility; 8% had ineffective motility; 1.1% had fragmented peristalsis; post-Nissen assessment was done for 1 patient. CONCLUSION: In our study population, HRM had a high diagnostic yield with its ability to identify esophageal dysmotility by narrowing down the pathogenesis of symptoms like dysphagia, heartburn, and chest pain.. For most patients in this cohort, HRM was well-tolerated. With careful patient selection, HRM has a high diagnostic yield. Because of the clinic location, we were able to assist patients in the rural community and minimize delay in care delivery. Furthermore, community-based HRM has the potential to reduce patient load at larger hospitals. By providing this resource in the community, providers in small-scale clinics improve patient access to care. Gyawali CP, Roman S, Bredenoord AJ, et al. Classification of esophageal motor findings in gastroesophageal reflux disease: Conclusions from an international consensus group. Neurogastroenterol Motil. 2017;29:e13104.

Opioid Treatment and Excessive Alcohol Consumption Are Associated With Esophagogastric Junction Disorders.

Background/AimsThe influence of external factors such as opioids and alcohol has been extensively investigated for various segments of the gastrointestinal tract. However, the association between their use and the development of esophagogastric junction outflow obstruction disorders (EGJOODs) is unknown. Therefore, the aim of this study is to analyze prevalence and clinical relevance of opioids and alcohol intake in patients with EGJOODs.MethodsIn this single-center, retrospective study, we reviewed clinical and pharmacological data of 375 consecutive patients who had undergone high resolution impedance manometry for EGJOODs. EGJOODs were classified according to the Chicago classification version 3.0 and to recently published normal values for test meals. Demographics, manometric data, and symptoms were compared between different groups using Pearson’s chi-squared test, Fisher’s exact test, and multivariate analysis. A P < 0.05 was considered significant.ResultsEGJOOD was found in 30.7% (115/375) of all analyzed patients. The prevalence of opioids (14.8% vs 4.2%, P = 0.026) was significantly higher in patients with EGJOODs compared to patients without EGJOODs. Additionally, excessive alcohol consumption (12.2% vs 3.5%, P = 0.011) was associated with EGJOODs. Excessive alcohol consumption was especially frequent in the non-achalasia esophagogastric junction outflow obstruction subgroup (16.2%) and opioid use in the achalasia type III subgroup (20.0%).ConclusionsWe found a significant association between EGJOODs and opioid as well as excessive alcohol consumption. This underlines the importance of detailed history taking regarding medication and ethanol consumption in patients with dysphagia. Further prospective studies on mechanisms undelaying esophagogastric junction dysfunction due to opioids or alcohol are warranted.

Jackhammer Esophagus: Symptom Presentation, Associated Distal Contractile Integral, and Assessment of Bolus Transit.

The aim of our study was to characterize jackhammer esophagus symptoms and their relationship with the distal contractile integral (DCI) and bolus transit. Jackhammer esophagus is defined by the Chicago Classification version 3.0. This diagnosis is relatively new, with the most current definition being established in 2014. The forerunners of this diagnosis, nutcracker (or hypercontractile) esophagus, have been associated with noncardiac chest pain (NCCP). A retrospective chart review was performed of motility studies from 2011 to 2016. Studies with a diagnosis of jackhammer esophagus, hypercontractile esophagus, nutcracker, esophagogastric junction outflow obstruction, or hypertensive lower esophageal sphincter were reread using Chicago Classification version 3.0, and were included if they met criteria for jackhammer esophagus. Unpaired t-tests were used for analysis (P≤0.05). In total, 142 studies were identified with the above diagnoses. After excluding 84 studies, 58 remained for analysis and 17 were found to have jackhammer esophagus (29%). The mean age was 54 (28 to 75), 5 (29%) were males and 12 (71%) were females. The primary indications were NCCP (5), dysphagia (8), and other causes (4) (cough, heartburn, or regurgitation). The mean DCIs were 17,245 mm Hg×s×cm (NCCP), 14,669 mm Hg×s×cm (dysphagia), and 11,264 mm Hg×s×cm (other causes). The mean DCIs were compared: NCCP versus dysphagia (P=0.41), and NCCP versus other causes (P=0.05). Fifteen (88%) had normal bolus transit for both liquid and viscous swallows. In our small sample size, dysphagia was frequently the presenting symptom followed by NCCP. Those with NCCP have a trend toward a higher DCI. Bolus transit appeared to be normal in this patient population. More data are needed to further elucidate the genesis of symptoms and how they relate to the degree of contractility.

Clinical Characteristics and Associated Systemic Diseases in Patients With Esophageal "Absent Contractility"-A Clinical Algorithm.

This study was carried out to assess the clinical characteristics and associated systemic diseases seen in patients diagnosed with absent contractility as per the Chicago Classification version 3.0, allowing us to propose a diagnostic algorithm for their etiologic testing. The Chicago Classification version 3.0 has redefined major and minor esophageal motility disorders using high-resolution esophageal manometry. There is a dearth of publications based on research on absent contractility, which historically has been associated with myopathic processes such as systemic sclerosis (SSc). We conducted a retrospective, multicenter study. Data of patients diagnosed with absent contractility were pooled from Cleveland Clinic, Cleveland, OH (January 2006 to July 2016) and Metrohealth Medical Center, Cleveland, OH (July 2014 to July 2016) and included: age, gender, associated medical conditions, surgical history, medications, and specific antibody testing. A total of 207 patients, including 57 male individuals and 150 female individuals, with mean age of 56.1 and 60.0 years, respectively, were included. Disease distribution was as follows: SSc (diffuse or limited cutaneous) 132, overlap syndromes 7, systemic lupus erythematosus17, Sjögren syndrome 4, polymyositis 3, and dermatomyositis 3. Various other etiologies including gastroesophageal reflux disease, postradiation esophagitis, neuromuscular disorders, and surgical complications were seen in the remaining cohort. Most practitioners use the term "absent contractility" interchangeably with "scleroderma esophagus"; however, only 63% of patients with absent contractility had SSc. Overall, 20% had another systemic autoimmune rheumatologic disease and 16% had a nonrheumatologic etiology for absent contractility. Therefore, alternate diagnosis must be sought in these patients. We propose an algorithm for their etiologic evaluation.

Assessment of Esophageal Motor Disorders Using High-resolution Manometry in Esophageal Dysphagia With Normal Endoscopy

Background/AimsThe distribution and esophageal motor characteristics of Chinese patients with esophageal dysphagia who exhibit no structural abnormalities on esophagogastroduodenoscopy remain unclear. Our aim is to assess the esophageal motor patterns using high-resolution manometry (HRM) and classify them according to the Chicago classification version 3.0 (CC v3.0). Furthermore, we compared the CC v3.0 and the previous version 2.0 (CC v2.0) for diagnosis of motor disorders.MethodsTwo hundred thirty-six (mean age 48.4 ± 12.2 years, 61.9% female) patients with esophageal dysphagia were included for analysis of motor function using HRM. All participants were administered a questionnaire to determine Eckardt scores before HRM.ResultsAccording to the CC v3.0, 57 (24.2%) patients showed evidence of esophagogastric junction outflow obstruction and were classified as Group 1. Eighteen (7.6%) patients with major disorders of peristalsis were classified as Group 2. Minor disorders of peristalsis (Group 3) were much more frequent (129 [54.7%] patients). Thirty-two (13.6%) patients had normal esophageal manometry were classified as Group 4. All patients with abnormal pH or pH impedance monitoring (n = 44) had minor motor disorders (ineffective esophageal motility [IEM] = 34, fragmented peristalsis = 10). Based on motor category, the Eckardt score was 4.7 ± 0.1 in Group 1, 4.5 ± 0.3 in Group 2, 3.5 ± 0.1 in Group 3, and 3.9 ± 0.1 in Group 4.ConclusionsIEM was the most common esophageal motor disorder in patients with esophageal dysphagia who showed no structural abnormality on endoscopy. While a high Eckardt score suggests outflow obstruction or a major motor disorder, a low score suggests IEM.

High-Resolution Manometry Diagnosis of Ineffective Esophageal Motility Is Associated With Higher Reflux Burden

Introduction: Ineffective esophageal motility (IEM), defined as distal contractile integral (DCI) < 450 mmHg*s*cm on high resolution manometry (HRM) in ≥ 50% of swallows, is the most commonly diagnosed abnormality on HRM based on the Chicago Classification version 3.0. However, the clinical significance of IEM is unclear. We retrospectively analyzed symptom burden and physiologic reflux metrics in subjects having undergone HRM, aiming to clarify clinical implications of an IEM diagnosis. Methods: 239 consecutive subjects (51.8 ± 1.1 years, 32.6% male) with a diagnosis of IEM on HRM performed over a 3 year period beginning in January 2015 were retrospectively reviewed. Findings were compared with that of 100 subjects with normal HRM (50.6 ± 1.6 years, 28% male). Patient reported outcome (PRO) questionnaires including GERDQ and Brief Esophageal Dysphagia Questionnaire (BEDQ) along with pH testing parameters were compared. Subjects with prior foregut surgery were excluded. Results: Of the 239 IEM subjects, 146 underwent reflux monitoring (128 impedance-pH and 18 pHalone) and 155 had PRO data. IEM subjects were more likely to have elevated total reflux events > 73 compared to normal (27.3% vs. 14.0%, p = 0.02, Table 1). Within the IEM group, higher percentage of failed and weak swallows modestely correlated with acid exposure time (AET, rs=0.16, p=0.05) and total reflux events (rs = 0.22, p = 0.01, Figure 1). A modest inverse correlation was noted with increased GERDQ score (r = - 0.25, p = 0.05) and total reflux events (r = -0.28, p < 0.01) as the mean resting lower esophageal sphincter (LES) pressure decreased in IEM. Including only off-PPI reflux testing (N = 56 for IEM and N = 37 for normal), IEM subjects (Table 2) had significantly higher mean total AET (p = 0.02), DeMeester score (p = 0.01), total reflux events (p = 0.01), and bolus exposure time (p < 0.01). The percentage of weak and failed swallows correlated with AET (rs = 0.30, p = 0.03) in IEM subjects off of PPI. PRO scores were not significantly different between IEM and normal whether on or off of PPI.400_A Figure 1. IEM: Ineffective esophageal motility; AET: Acid exposure timeConclusion: Subjects with HRM diagnosis of IEM are more prone to acid reflux while off of PPI and nonacid reflux while on PPI. Reflux burden appears to be worse in those with higher percentage of weak and failed swallows or diminished LES pressure. Adjunctive medications such as transient-lower-esophageal-sphincter-relaxation inhibitors may be useful in IEM subjects incompletely responsive to PPI.400_B Figure 2 No Caption available.400_C Figure 3. IEM: Ineffective esophageal motility; AET: Acid exposure time

Distal contractile to impedance integral ratio assist the diagnosis of pediatric ineffective esophageal motility disorder.

We investigated the diagnostic utility of distal contractile integral (DCI) to esophageal impedance integral (EII) ratio (DCIIR) in high-resolution impedance manometry (HRIM) of ineffective esophageal motility (IEM) in children. We performed HRIM in 31 children with dysphagia, odynophagia, chronic vomiting, chest pain, or heartburn sensation. Based on the Chicago classification version 3.0, 20 subjects were diagnosed with IEM, and 11 subjects were normal. We analyzed the EII and DCIIR using MATLAB software. The DCIIR calculated at the impedance cutoff at 1500 Ω (DCIIR1500) were significantly lower in IEM group than patients with normal motility (P = 0.007). Receiver operating characteristic (ROC) curve analysis showed that a DCIIR1500 < 0.009 mmHg/Ω best predicted IEM in children (P < 0.001). A DCIIR1500 < 0.008 mmHg/Ω is associated with significant body weight loss > 10% within 6 months in children. (P < 0.001). The calculation of DCIIR1500 may assist the automatic analysis of bolus transit in HRIM study to diagnose IEM in children. An DCIIR1500 < 0.009 mmHg/Ω may assist in the diagnosis of IEM in children, and DCIIR1500 < 0.008 mmHg/Ω correlated with significant body weight loss. The calculation of DCIIR may serve as possible parameters for HRIM.

Gender, medication use and other factors associated with esophageal motility disorders in non-obstructive dysphagia

BackgroundHigh-resolution esophageal manometry (HREM) is the diagnostic test of choice for evaluation of non-obstructive dysphagia. Studies regarding the predictors of esophageal dysmotility are limited. Therefore, our aim was to study the prevalence of and factors associated with esophageal motility disorders in patients with non-obstructive dysphagia.MethodsWe performed a retrospective review of all patients with non-obstructive dysphagia who underwent HREM in a tertiary center between 1 January 2014 and 31 December 2015. After obtaining IRB approval (16–051), clinical records were scrutinized for demographic data, symptoms, medication use, upper endoscopic findings and esophageal pH findings. HREM plots were classified per Chicago Classification version 3.0. Primary outcome was prevalence of esophageal motility disorders; secondary outcomes assessed predictive factors.ResultsIn total, 155 patients with non-obstructive dysphagia (55 ± 16 years old, 72% female) were identified. HREM diagnosis was normal in 49% followed by ineffective esophageal motility in 20%, absent contractility in 7.1%, achalasia type II in 5.8%, outflow obstruction in 5.2%, jackhammer esophagus in 4.5%, distal esophageal spasm in 3.9%, fragment peristalsis in 1.9%, achalasia type I in 1.9%, and achalasia type III in 0.6%. Men were five times more likely to have achalasia than women [odds ratio (OR) 5.3, 95% confidence interval (CI): 2.0–14.2; P = 0.001]. Patients with erosive esophagitis (OR 2.9, 95% CI: 1.1–7.7; P = 0.027) or using calcium channel blockers (OR 3.0, 95% CI: 1.2–7.4; P = 0.015) were three times more likely to have hypomotility disorders.ConclusionFrom this study, we concluded that HREM diagnosis per Chicago Classification version 3.0 was normal in 49% of patients with non-obstructive dysphagia. Male gender, erosive esophagitis and use of calcium channel blockers were predictive of esophageal motility disorders.

“Ineffective Esophageal Motility” Is Associated With Impaired Bolus Clearance but Does Not Correlate With Severity of Dysphagia

Introduction: The most recent Chicago Classification (CC) for esophageal motility disorders simplified the definition of minor motility disorders. Ineffective esophageal motility (IEM) is now defined as a distal contractile integral (DCI) <450 mmHg/s/cm in at least 50% of ten liquid swallows on high resolution esophageal manometry (HREM). It remains unclear whether this definition correlates with degree of dysphagia symptoms. Methods: Between 2013-2016, patients presenting for HREM prospectively rated their symptoms using the Eckardt score (Figure 1). Inclusion criteria were patients with non-obstructive dysphagia, and Eckardt dysphagia score of ≥1. Patients with major motility disorders were excluded. We retrospectively reviewed topography plots in order to classify patients according to CC version 3. Symptom scores between patients with IEM (group A) and patients with normal HREM (group B) were compared using two-tailed t-tests. Spearman's correlation coefficient was calculated to determine correlation between symptoms and % bolus clearance using impedance in both groups.Figure: Moderate inverse correlation between dysphagia score and % bolus clearance.Results: 241 patients were screened for inclusion; 33 patients (26 female) met criteria for Group A and 44 patients (36 female) for Group B. There was no difference between the two groups in mean symptom severity scores for dysphagia (1.63 vs. 1.61, P=0.89), chest pain (0.67 vs. 0.75, P=0.64), regurgitation (1.06 vs. 0.85, P=0.32), or weight loss (0.85 vs. 0.49, P=0.11). The % bolus clearance was significantly lower in group A (46.5% vs. 76.7%, P>0.01). There was a moderate inverse correlation between dysphagia score and % bolus clearance (R=-0.37) in group A, but no correlation between dysphagia score and % bolus clearance in group B (R=0.09), (Figure 2). Conclusion: The definition of IEM has evolved over the years, with the latest classification system simplifying its definition. Theoretically, patients with greater percentage of weak or failed swallows would have greater degrees of dysphagia compared to those with <50%, as the latter is considered a normal motor pattern. In our study, the classification of IEM did not discriminate from normal studies for symptom severity. However, patients with IEM did have a correlation between dysphagia score and bolus clearance whereas those without IEM did not. Therefore, adding impedance information to motor pattern classification increases the yield and should be considered in the assessment of dysphagia severity in minor motility disorders.Table: Eckardt Score.

Trends in diagnoses after implementation of the Chicago classification for esophageal motility disorders (V3.0) for high-resolution manometry studies

To determine trends in the diagnostic distribution of esophageal motility disorders after implementation of the Chicago Classification Version 3.0 (CC V3.0) for interpretation of high-resolution manometry (HRM) studies compared to non-Chicago Classification criteria. Retrospective trends analysis of patients with an HRM study conducted at a single center from January 1, 2013 to September 30, 2015. The implementation of the CC V3.0 for manometry interpretation occurred in September 2014. Patient charts were manually reviewed for data collection including demographics and HRM diagnoses. The prevalence and relative risks (RR) of CC V3.0 diagnostic categories (i.e. normal, indeterminate, achalasia, and EGJ outflow obstruction [EJGOO], and major and minor motility disorders) were calculated before and after CC V3.0 implementation. Four hundred sixty-five HRM studies were included in the study including 268 before and 179 after CC V3.0 implementation. The mean ± SD age was 54±15.4 years and 59.8% were female (n =278). The percentage with indeterminate diagnosis decreased from 35.3% before CC V3.0 implementation to 16.8% after implementation (adjusted RR 0.5, 95%CI 0.30-0.70, p <0.001). The percentage with a major motility disorders decreased from 13.9% to 7.3% (adjusted RR 0.5, 95%CI 0.2-1.0, p <0.001). The percentage with EJGOO and minor diagnoses increased from 1.4% to 14.5% and 11.9% to 22.9%, respectively. The percentage with achalasia and normal diagnosis did not change over the study period. Implementation of CCV3.0 was associated with changes in the distribution of esophageal motility diagnoses in clinical practice. The percentage of indeterminate and major diagnosis decreased and EGJOO and minor diagnoses increased. The decrease in the number of indeterminate studies suggests that the CC V3.0 may clarify the criteria for the interpreting physician. The increase in studies with a diagnosis of EGJ outflow obstruction may reflect the heterogeneity of disorders with clinically relevant outflow obstruction.

Impaired Esophageal Motility and Clearance Post-Lung Transplant: Risk For Chronic Allograft Failure

Objectives:Gastroesophageal reflux is common in patients post-lung transplantation (LTx) and thus considered a risk factor for aspiration and consequently allograft rejection and the development of chronic allograft failure. However, evidence supporting this remains unclear and often contradictory. Our aim was to examine the role played by esophageal motility on gastroesophageal reflux exposure, along with its clearance and that of boluses swallowed, and the relationship to development of obstructive chronic lung allograft dysfunction (o-CLAD).Methods:Patients post-LTx (n=50, 26 female; mean age 55 years (range, 20–73 years)) completed high-resolution impedance manometry and 24-h pH/impedance. Esophageal motility abnormalities were classified based upon the Chicago Classification version 3.0.Results:Esophagogastric junction outflow obstruction alone (EGJOOa) (P=0.01), incomplete bolus transit (IBT) (P=0.006) and proximal reflux (P=0.042) increased the risk for o-CLAD. Patients with EGJOOa were most likely to present with o-CLAD (77%); despite being less likely to exhibit abnormal numbers of reflux events (10%) compared with those with normal motility (o-CLAD: 29%, P<0.05; abnormal reflux events: 64%, P<0.05). Patients with EGJOOa had lower total reflux bolus exposure time than those with normal motility (0.6 vs. 1.5% P<0.05). In addition, poor esophageal clearance documented by abnormal post-reflux swallow-induced peristaltic wave index associated with o-CLAD; inversely correlating with the proportion of reflux events reaching the proximal esophagus (r=−0.251; P=0.052).Conclusions:These observations support esophageal dysmotility, especially EGJOOa, and impaired clearance of swallowed bolus or refluxed contents, more so than just the presence of gastroesophageal reflux alone, as important risk factors in the development of o-CLAD.

The Chicago Classification of esophageal motility disorders, v3.0.

The Chicago Classification (CC) of esophageal motility disorders, utilizing an algorithmic scheme to analyze clinical high-resolution manometry (HRM) studies, has gained acceptance worldwide. This 2014 update, CC v3.0, developed by the International HRM Working Group, incorporated the extensive clinical experience and interval publications since the prior (2011) version. Chicago Classification v3.0 utilizes a hierarchical approach, sequentially prioritizing: (i) disorders of esophagogastric junction (EGJ) outflow (achalasia subtypes I-III and EGJ outflow obstruction), (ii) major disorders of peristalsis (absent contractility, distal esophageal spasm, hypercontractile esophagus), and (iii) minor disorders of peristalsis characterized by impaired bolus transit. EGJ morphology, characterized by the degree of overlap between the lower esophageal sphincter and the crural diaphragm and baseline EGJ contractility are also part of CC v3.0. Compared to the previous CC version, the key metrics of interpretation, the integrated relaxation pressure (IRP), the distal contractile integral (DCI), and the distal latency (DL) remain unchanged, albeit with much more emphasis on DCI for defining both hypo- and hypercontractility. New in CC v3.0 are: (i) the evaluation of the EGJ at rest defined in terms of morphology and contractility, (ii) 'fragmented' contractions (large breaks in the 20-mmHg isobaric contour), (iii) ineffective esophageal motility (IEM), and (iv) several minor adjustments in nomenclature and defining criteria. Absent in CC v3.0 are contractile front velocity and small breaks in the 20-mmHg isobaric contour as defining characteristics. Chicago Classification v3.0 is an updated analysis scheme for clinical esophageal HRM recordings developed by the International HRM Working Group.