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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1033_Библиотеки_им_академика_М_И_Перельмана
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Fig. 11.8 Distal contractile integral (DCI). DCI value is calculated as the
product of the mean amplitude of contraction in the distal esophagus (mmHg)
times the duration of contraction (seconds) times the length of the distal
oesophageal segment (cm) exceeding 20mmHg for the region spanning from
the transition zone to the proximal aspect of the lower esophageal sphincter
Step 3: Review Pressurization Patterns
Each swallow should be evaluated using the IBC (isobaric contour) tool to document isobaric pressurization >30 mmHg.
Pressurization occurs when the swallowed liquid becomes trapped
between two contracting segments of the esophagus and is identied by a vertical isobaric pressure band. Pressurization of
>30mmHg that spans from the UES to the EGJ is termed pane-
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Fig. 11.9 Distal latency (DL) measures objectively the time frame of the
wave from the beginning of the swallow (upper esophageal relaxation) to the
contractile deceleration point (CDP)
M. R. Youssef et al.
sophageal pressurization, compartmentalized (from the deglutitive
contractile front to the esophagogastric junction [EGJ]), or EGJ
pressurization (between the LES and the diaphragm in conjunction with a hiatal hernia).
The Chicago Classication v3.0
The Chicago Classication (CC) was developed to standardize
the interpretation of high-resolution esophageal manometry studies. The CC categorizes esophageal motility disorders utilizing
high-resolution manometry (HRM) imaged with pressure topography plots. This classication is intended for patients with no
previous surgeries compromising the esophagus or the EGJ. It
utilizes a hierarchical approach, sequentially prioritizing (a) disorders of the esophagogastric junction (EGJ) outow, (b) major
disorders of peristalsis, and (c) minor disorders of peristalsis [4].
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Fig. 11.10 Chicago Classication v3.0
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It is worth it to remark that there are technology-specic normal
and abnormal values, especially for the IRP. The practitioner analyzing the study should be aware of the cutoff values according to
their device. For the purpose of this chapter, we will be focusing
on the Medtronic technology.
After the detailed analysis of the 10 wet swallows, the Chicago
Classication is utilized to analyze data from HRM to determine
the manometric diagnosis. The presence or absence of outow
obstruction, represented by an IRP of >15-mmHg, is the initial
assessment used in the hierarchical algorithm for the interpretation of HRM studies with the CC v3.0 (Fig.11.10).
1. Esophageal Motility Disorders with Elevated IRP
(a) Achalasia: It is a condition characterized by aperistalsis
and failure of the LES to relax. The Chicago Classication
has identied three subtypes of achalasia through esophageal HRM that are all associated with incomplete LES
relaxation (IRP >15mmHg) but with different pressurization patterns.
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M. R. Youssef et al.
Type I: IRP >15mmHg, and aperistalsis with no pressure waves recorded (Fig.11.11).
Type II: IRP >15mmHg, panesophageal pressurization
>30 mmHg in at least 20% of swallows, and 100%
failed swallows (Fig.11.12).
Fig. 11.11 Type 1 achalasia (classic achalasia) is diagnosed when there are
100% aperistalsis, elevated mean IRP (>15mmHg Medtronic), and DCI less
than 100mHg-sec-cm. Even if aperistalsis is present and IRP is at the upper
limit of normal, achalasia should still be taken into consideration as a potential diagnosis
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Fig. 11.12 Type 2 achalasia, elevated median IRP (>15mmHg*), 100%
failed peristalsis, and panesophageal pressurization with ≥20% of swallows.
Contractions may be masked by esophageal pressurization and DCI should
not be calculated
Type III: (spastic achalasia) It is associated with IRP
≥15mmHg and premature (spastic) contractions with
or without periods of compartmentalized pressurization in ≥20% of swallows (Fig.11.13).
(b) EGJ Outow Obstruction (EGJOO): It is dened as failure
of the LES to relax (IRP >15mmHg) with intact or weak
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M. R. Youssef et al.
Fig. 11.13 Type 3 achalasia, elevated median IRP (>15mmHg*), no normal
peristalsis, premature (spastic) contractions with DCI > 450 mmHg-s-cm
with ≥20% of swallows. May be mixed with panesophageal pressurization
peristalsis not meeting criteria for achalasia as being an
EGJ outow obstruction (Fig.11.14). This is a heterogeneous diagnosis with a differential diagnosis that includes
early, evolving, or incomplete achalasia, mechanical
obstruction, hiatal hernia, and pressure artifacts. In this
situation, patients will need additional diagnostic studies
such as barium swallow and/or endoscopy.
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Fig. 11.14 EGJ obstruction is characterized by an altered IRP in the absence
of other criteria for achalasia. Manometry in a patient with dysphagia after
Nissen fundoplication
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(c) Esophageal Motility Disorders with Normal IRP—
major disorders of peristalsis (not encountered in normal
subjects).
Diffuse Esophageal Spasm: ≥20% premature contractions (DL<4.5s) with DCI>450, physiologically representing an impairment of deglutitive inhibition, thus
showing incomplete inhibition in the esophageal body
during multiple rapid swallows (MRS). Some normal
peristalsis (segmental spasm) and normal EGJ relaxation may be present. Most patients with a distal latency
of <4.5 are eventually diagnosed with distal esophageal
spasm or type III achalasia (Fig.11.15).
Hypercontractile Esophagus (Jackhammer esophagus):
It is characterized by DCI>8000mmHg/sec/cm in at
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M. R. Youssef et al.
Fig. 11.15 Diffuse esophageal spasm (DES) is dened as normal median
IRP and ≥20% premature contractions (DL<4.5s) with DCI>450mmHgs- cm*. Some normal peristalsis may be present. This disorder may be attributable not only to a primary esophageal dysmotility but also secondary to
reux disease. Further workup of the patient’s symptoms is warranted
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Fig. 11.16 Hypercontractile esophagus (Jackhammer esophagus): at least
20% of propagated swallow-induced contraction with a DCI of >8000mmHgs- cm, as that value is extremely rare in asymptomatic subjects. This patient’s
study was characterized by contraction amplitudes of >200mmHg in the distal esophagus, and average DCI (contraction vigor) of 14,919. Patients with
these disorders may present with dysphagia and/or noncardiac chest pain
least 20% of swallows and normal
DL.Hypercontractility may be involved, or even be
localized to the LES. DCI > 8000 is never seen in
asymptomatic controls. The occurrence of a multipeaked contraction seems to be of limited relevance
(Fig.11.16).
Absent Contractility: It is characterized by aperistalsis
(100% failed swallows) in the setting of normal LES
relaxation (IRP <15 mmHg). This motility pattern is
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Fig. 11.17 Aperistaltic esophagus and low LES resting pressure. This type
of HRM may be seen in patients with connective tissue disorders such as
scleroderma. It is a common nding in absent contractility (major motility
disorder) and occasionally can be seen in ineffective esophageal motility
(minor motility disorder). Hypomotility disorders carry an increased risk of
GERD due to delayed esophageal clearance. In addition, unexplained dysphagia can be seen in patients with normal GE junction relaxation
M. R. Youssef et al.
classically seen in patients with systemic scleroderma
(Fig.11.17).
(d) Esophageal Motility Disorders with Normal IRP—
Minor Disorders of Peristalsis.
Ineffective esophageal motility: It is diagnosed when
>50% of swallows are ineffective, determined as either
failed (DCI < 100 mmHg cm s) or weak (DCI 100–
450mmHgcms) (Fig.11.18).
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