Criteria of normal & abnormal swallows according to Chicago classification v3.0

1. Normal and abnormal swallows
in Chicago classification version 3.0
Samir Haffar M.D.

2. (1) Technical aspects of HRM
(2) Metrics of esophagogastric junction
(3) Metrics of esophageal contraction
(4) Steps to analyze wet swallows
Normal & abnormal swallows in esophageal HRM
Chicago classification version 3.0

3. (1) Technical aspects of esophageal HRM

4. Technical aspects of esophageal HRM
2 phases
• Analysis during rest:
Recording for several minutes in supine position
Allow accommodation to catheter & sensors in SSC to warm
Patient swallow as infrequently as possible & breathe quietly
Markers of UES, upper & lower border of LES & stomach placed
• Analysis during swallow:
Administering ten 5 mL water swallows separated by 30 sec
This should be considered to be the minimum
Bredenoord AJ & Hebbard GS. Neurogastroenterol Motil 2012; 24(Suppl. 1), 5–10.

5. Esophageal HRM at rest
EGJ: esophagogastric junction – LES: lower esophageal sphincter – CD: crural diaphragm
Conklin J et al. ACG Annual Postgraduate Course - October 12-13, 2013
Intra-eophageal pressures decrease in inspiration & increase in expiration
EGJ (LES & CD) in same location (absence of hiatal hernia)
EGJ moves toward stomach & increases in inspiration
EGJ moves toward thorax and decreases in expiration

6. HRM atlas – Medical measurement Systems
Esophageal HRM following a wet swallow
esophageal pressure topography

7. Esophageal HRM following a wet swallow
Clause's segments
Conklin JL. J Neurogastroenterol Motil 2013; 19(3):281-294.
5 ml wet swallow
S1: striated esophageal muscles
Transition zone: pressure between S1 & S2
S2 & S3: proximal & distal smooth muscles
S4: LES repositioning at its resting position

8. Markers for UES, upper & lower borders of LES & stomach are placed
Landmarks of esophageal HRM

9. 200 mmHg150 mmHg100 mmHg
Conklin J, Soffer E, & Pimentel M. Color atlas of high resolution manometry, Springer, 2009.
Changing amplification of HRM system
As with standard manometry systems, amplification can be changed
It is prudent to begin at a standard range (150 mmHg)
Gain can then be changed to show variations in pressures

10. 20 mmHg 40 mmHg 100 mmHg
Conklin J, Soffer E, & Pimentel M. Color atlas of high resolution manometry, Springer, 2009.
Changing isobaric contour lines (ICL)
The pressure is higher inside the contour line and lower outside

11. Chicago classification version 3.0
no previous foregut surgery
Kahrilas PJ et al. Neurogastroenterol Motil 2015; 27:160-174.
• Individual scoring of at least ten 5-ml swallows in supine position
• Esophagogastric junction EGJ morphology at rest
EGJ tone at rest
Integrated relaxation pressure after WS
• Esophageal contraction Contraction vigor
Contraction pattern
Intra-bolus pressure pattern (pressurization)
• Absent in CC v3.0 Contractile front velocity (CFV)
Small break (2 – 5 cm)
No more nutcracker

12. (2) Metrics of esophagogastric junction

13. Metrics of esophagogastric junction
• At rest Esophagogastric junction morphology
Esophagogastric tone
• After wet swallow Integrated relaxation pressure (IRP)

14. EGJ morphology
two main components: LES & crural diaphragm (CD)
RIP: respiration inversion point
Kahrilas PJ et al. Neurogastroenterol Motil 2015; 27:160-174.
• Type I EGJ Complete overlap between LES & CD
normal Single peak on spatial pressure variation plot
• Type II EGJ Slight separation between LES & CD (1-2 cm)
Double-peaked on spatial pressure plot
Nadir pressure between peaks > intra-gastric pressure
• Type III EGJ LES and CD clearly separated (≥ 2 cm)
hiatal hernia Nadir pressure between peak < intra-gastric pressure
RIP proximal to CD (IIIa) & proximal to LES (IIIb)

15. Esophagogastric junction type I
normal
Complete overlap between LES and CD
Single peak on spatial pressure variation plot
Kahrilas PJ et al. Neurogastroenterol Motil 2015; 27:160-174.

16. Esophagogastric junction type II
Minimal but discernible LES-CD separation (1 – 2 cm)
Double-peaked on spatial pressure variation plot
Nadir pressure between peaks > intra-gastric pressure
Kahrilas PJ et al. Neurogastroenterol Motil 2015; 27:160-174.

17. Esophagogastric junction type III
hiatal hernia
Type IIIbType IIIa
LES and CD clearly separated (≥ 2 cm)
Nadir pressure between peak ≤ intra-gastric pressure
RIP proximal at level CD in type IIIa & at level of LES in type IIIb
Kahrilas PJ et al. Neurogastroenterol Motil 2015; 27:160-174.

18. LES-CD separation
Kahrilas PJ et al. Neurogastroenterol Motil 2015; 27:160-174.
Measurement Single peak: LES-CD separation is 0
Double peak: LES-CD separation = distance between peaks
Hiatal hernia Type I: absence of hiatal hernia
Type II: absence of data on the subject
Type III: persistent hiatal hernia
LES-CD separation may fluctuate in course of prolonged HRM study
Report subtype & range of LES-CD separation throughout the study

19. Integrated relaxation pressure (IRP)
• Mean of the 4 sec of maximal deglutitive relaxation in
the10-s window beginning at UES relaxation in reference
to gastric pressure
• Contributing times can be contiguous or non-contiguous
e.g., interrupted by diaphragmatic contraction
Kahrilas PJ et al. Neurogastroenterol Motil 2015; 27:160-174.

20. Carlson DA & Pandolfino JE. Gastroenterol Clin North Am 2013; 42(1): 1–15.
Normal integrated relaxation pressure (IRP)
4 nonconsecutive sec of lowest axial pressure displayed by dashed boxes
IRP: 4.8 mmHg - Nadir LES pressure: 0.3 mmHg above gastric pressure

21. Integrated relaxation pressure (IRP)
Kahrilas PJ et al. Neurogastroenterol Motil 2015; 27:160-174.
• Utilizing median rather than mean minimize the impact of one or
more outlier values that might skew the result (e.g., due to cough)
• Cutoff value for ULN is technology-specific
Ranges from 15 (Sierra design) to 28 mmHg (Unisensor design)
Only rigorously analyzed for Sierra design
Peril of being overly rigid in application of cutoff values

22. (3) Metrics of esophageal peristalsis

23. Metrics of esophageal peristalsis
• Contraction vigor
• Contraction pattern
• Intra-bolus pressure pattern (pressurization)

24. Contraction vigor
based on distal contractile integral (DCI)
Kahrilas PJ et al. Neurogastroenterol Motil 2015; 27:160-174.
• Normal contraction DCI > 450 but < 8000 mmHg.s.cm
• Failed contraction DCI < 100 mmHg.s.cm
• Weak contraction DCI > 100 but < 450 mmHg.s.cm
• Ineffective contraction Failed or weak contraction
• Hypercontractile DCI ≥ 8000 mmHg.s.cm

25. Distal contractile integral (DCI)
normal value: 450 - 8000 mmHg.s.cm
Amplitude x duration x length (mmHg.s.cm) of distal
esophageal contraction exceeding 20 mmHg from transition
zone to proximal margin of LES (contractile segments 2 & 3)
Kahrilas PJ et al. Neurogastroenterol Motil 2015; 27:160-174.

26. Normal distal contractile integral (DCI)
Box from transition zone to proximal aspect of EGJ (yellow dashed line)
The 20 mmHg isobaric contour line is determined (black line)
Calculated by summing pressures from all time/length foci within field
Conklin JL. J Neurogastroenterol Motil 2013; 19(3):281-294.

27. Failed contraction
DCI < 100 mmHg.s.cm
Roman S et al. Gastrointest Endosc Clin N Am 2014; 24(4): 545–561.

28. Weak contraction
DCI 100 - 450 mmHg.s.cm
Roman S et al. Gastrointest Endosc Clin N Am 2014; 24(4): 545–561.

29. Hypercontraction
DCI > 8 000 mmHg.s.cm
Roman S et al. Gastrointest Endosc Clin N Am 2014; 24(4): 545–561.

30. Hypercontraction
occasionally uniquely affects LES & not distal esophagus
Normal esophageal contraction followed by prominent LES contraction
Including EGJ in DCI measurement (white dashed box) results in dg
of hypercontractility
Roman S et al. Gastrointest Endosc Clin N Am 2014; 24(4): 545–561.

31. Contraction pattern
• Premature contraction Distal latency < 4.5 sec
• Fragmented contraction Large break (> 5 cm length)
with DCI > 450 mmHg.s.cm
• Intact contraction Not achieving the above criteria

32. Premature contraction
based on distal latency (DL) < 4.5 sec
Distal latency is the interval between UES relaxation
and contractile deceleration point (CDP)
Kahrilas PJ et al. Neurogastroenterol Motil 2015; 27:160-174.

33. Contractile deceleration point (CDP)
key landmark in assessment of contraction pattern
Inflexion point along 30 mmHg isobaric contour at which
propagation velocity slows, demarcating peristalsis from
ampullary emptying
Kahrilas PJ et al. Neurogastroenterol Motil 2015; 27:160-174.

34. Contractile deceleration point (CDP)
Isobaric contour line (ICL) set at 30 mmHg
2 troughs of peristaltic esophageal contraction: proximal (P) & distal (D)
CDP represents inflexion point in contractile front propagation
CDP localized by fitting 2 tangential lines to initial & terminal portions
Pandolfino JE et al. Neurogastroenterol Motil 2010; 22:395–e90.

35. Normal distal latency (DL)
normal > 4.5 sec
Interval between UES relaxation & contractile deceleration point (CDP)
Roman S et al. Gastroenterol Clin North Am 2011; 40(4): 823-835.

36. CDP in weak contraction & hypercontraction
Weak contraction Hypercontraction
Pandolfino JE et al. Neurogastroenterol Motil 2010; 22:395–e90.
Isobaric contour line at 20 mmHg Isobaric contour line at 50 mmHg

37. Contractile deceleration point (CDP)
Sometimes difficult to localize
Kahrilas PJ et al. Neurogastroenterol Motil 2015; 27:160-174.
• Atypical peristaltic architecture
Must be localized within 3 cm of proximal margin of LES
• Compartmentalized pressurization
Should be localized with the 50 rather than 30 mmHg ICL

38. CDP must be localized to within 3 cm of proximal margin of LES
(between 2 red dotted lines) & prevents miscategorization
Kahrilas PJ et al. Neurogastroenterol Motil 2015; 27:160-174.
Localization of CDP / Atypical peristaltic architecture
2 points can sometimes be identified

39. Localization of CDP / Pressurization
Distal compartmentalized pressurization
2 isobaric contours line (ICL) at 30 & 50 mmHg
The 30- and 50-mmHg ICL are not parallel
CDP & DL measured at 50-mmHg to exclude area of pressurization
Roman S & Kahrilas PJ. Gastroenterol Clin North Am 2011; 40(4): 823-835.

40. Premature contraction
DL < 4.5 cm
Roman S et al. Gastrointest Endosc Clin N Am. 2014; 24(4): 545–561.

41. Contractile front velocity (CFV)
normal value < 9 cm/sec
Slope of the tangent approximating the 30 mm Hg isobaric
contour from the transition zone to the CDP

42. Normal contractile front velocity (CFV)
normal < 9 cm/ sec
Kahrilas PJ et al. J Clin Gastroenterol 2008 ; 42(5): 627-635.

43. Rapid contraction
CFV > 9 cm/s
Unknown clinical relevance of rapid contraction & normal DL
Lack of specificity to define esophageal spasm
Removed from Chicago classification v3.0
Roman S & Mion F. HRM: analyse des données et classification de Chicago. Lyon, France

44. Premature & rapid contraction
DL < 4.5 cm & CFV > 9 cm/s
Roman S et al. Gastrointest Endosc Clin N Am. 2014; 24(4): 545–561.

45. Fragmented contraction
Large break (> 5 cm length) in the 20-mmHg ICL
with DCI > 450 mmHg.s.cm
Kahrilas PJ et al. Neurogastroenterol Motil 2015; 27:160-174.

46. Fragmented contraction
large break > 5 cm & DCI > 450 mmHg.s.cm
Only break > 5 cm in length considered abnormal in
Chicago classification version 3.0
Roman S et al. Gastrointest Endosc Clin N Am. 2014; 24(4): 545–561.

47. Small breaks (2-5 cm)
Small breaks considered normal in Chicago classification version 3.0
Roman S & Mion F. HRM: analyse des données et classification de Chicago. Lyon, France

48. Intra-bolus pressure pattern (pressurization)
determine pressurization with isobaric contour at 30 mmHg
Kahrilas PJ et al. Neurogastroenterol Motil 2015; 27:160-174.
• Pan-esophageal pressurization
Uniform pressurization >30 mmHg from UES to EGJ
• Compartmentalized pressurization
Pressurization >30 mmHg from contractile front to EGJ
• EGJ pressurization
Pressurization between LES & CD with LES-CD separation
• Normal pressurization
No bolus pressurization > 30 mmHg

49. Panesophageal pressurization
extending from UES to EGJ
Hirano I. ACG Regional Postgraduate Course - St. Louis, MO - 2013

50. Compartmentalized pressurization
distal esophageal pressurization from contractile front to EGJ
Hirano I. ACG Regional Postgraduate Course - St. Louis, MO - 2013

51. Esophagogastric junction pressurization
Pressurization between LES & CD in conjunction with hiatal hernia
Pandolfino J & Roman s. Thorac Surg Clin 2011; 21(4): 465–475.

52. ContractionPressurization
Pressurization or contraction?
Using spatial pressure variation plot on right of each EPT plots
Each spatial pressure variation plot identified by white dashed line
Pressurization: intraesophageal pressure not vary between UES & EGJ
Esophageal contraction: pressure variations along esophageal body
Roman S & Kahrilas PJ. Gastroenterol Clin North Am 2013; 42(1): 27–43.

53. (4) Steps to analyze wet swallows

54. Stepwise EPT analysis of individual swallows
Carlson DA et al. Gastroenterol & hepatol 2015; 11(6):374-384.

55. Contraction pattern
Kahrilas PJ et al. Neurogastroenterol Motil 2015; 27:160-174.
• Failed contraction DCI < 100 mmHg·cm·sec or
DCI < 450 mmHg.s.cm + DL < 4.5 sec
• Weak contraction DCI 100 - 450 mmHg.s.cm
• Ineffective contraction Failed or weak contraction
• Hyper-contraction DCI > 8 000 mmHg.s.cm
• Premature contraction DL < 4.5 cm
• Rapid contraction CFV > 9 cm/sec - removed from CC v3.0
• Fragmented contraction Peristaltic break > 5 cm + DCI > 450
• Normal contraction Not achieving any of the above criteria

56. Failed contraction (weak & premature)
DCI 100 - 450 mmHg.s.cm + DL < 4.5 sec
Roman S et al. Gastrointest Endosc Clin N Am. 2014; 24(4): 545–561.

57. Metrics of a normal wet swallow
Roman S et al. Gastrointest Endosc Clin N Am. 2014; 24(4): 545–561.
EGJ morphology type I
Normal EGJ tone
IRP: 0.8 (nl < 15 mmHg)
DCI: 1107 (nl: 450-8000 mmHg.s.cm)
DL: 7.2 (nl > 4.5 s)
Absence of large break
Absence of pressurization

58. Thank You