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Updated: Oct 25, 2025
Simultaneous Laryngopharyngeal and Conventional Esophageal pH Monitoring
Published on: December 14, 2020
Ineffective esophageal motility in Chicago Classification version 4.0 better predicts abnormal acid exposure
Qian-Jun Zhuang1, Nian-di Tan1, Meng-Yu Zhang1
1Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan II Road, Guangzhou, 510080, China.
Insights
The updated Chicago Classification version 4.0 (CCv4.0) provides stricter criteria for ineffective esophageal motility (IEM). CCv4.0 IEM is a better predictor of abnormal acid exposure in gastroesophageal reflux disease (GERD) patients than CCv3.0 IEM.
Area of Science:
- Gastroenterology
- Esophageal Physiology
- Clinical Diagnostics
Background:
- Gastroesophageal reflux disease (GERD) diagnosis and management involve assessing esophageal motility.
- The Chicago Classification (CC) provides criteria for esophageal motility disorders, with version 4.0 (CCv4.0) introducing more stringent criteria for ineffective esophageal motility (IEM).
Purpose of the Study:
- To investigate the clinical significance of IEM diagnosed using CCv4.0 in patients with suspected GERD.
- To compare the predictive value of CCv4.0 IEM versus CCv3.0 IEM for acid exposure and treatment outcomes.
Main Methods:
- Retrospective analysis of 172 suspected GERD patients undergoing esophageal function tests (2017-2019).
- Patients classified as IEM or normal motility based on CCv3.0 and CCv4.0 criteria.
- Comparison of clinical characteristics, high-resolution manometry, reflux monitoring, and proton pump inhibitor (PPI) efficacy between groups.
Main Results:
- CCv4.0 identified 69 IEM cases, while CCv3.0 identified 93 IEM cases.
- IEM in both versions correlated with elevated acid burden and impaired esophageal clearance.
- CCv4.0 IEM alone predicted abnormal acid exposure (OR=2.66, p<0.01).
- CCv3.0 IEM with low EGJ-CI did not predict increased reflux burden.
- No interaction between IEM and weakened EGJ was found.
- No manometric variable predicted PPI response.
Conclusions:
- The stringent criteria for IEM in CCv4.0 offer improved prediction of abnormal acid exposure compared to CCv3.0.
- CCv4.0 criteria enhance the diagnostic utility of IEM in GERD evaluation.
Background:
The updated Chicago Classification version 4.0 (CCv4.0) establishes a more stringent criteria to diagnose ineffective esophageal motility (IEM). This study aims to investigate the clinical significance of IEM in CCv4.0 in the context of gastroesophageal reflux disease (GERD).
Methods:
A retrospective study was conducted among suspected GERD patients who had heartburn and/or regurgitation as their chief complaints and completed esophageal function tests in our center from 2017 to 2019. Patients were further grouped as "CCv3.0 IEM" and normal motility according to Chicago Classification version 3.0 (CCv3.0), and as "CCv4.0 IEM" and normal motility according to CCv4.0. The clinical characteristics, high-resolution manometry, esophageal reflux monitoring, and proton pump inhibitor (PPI) efficacy were compared between different groups. Multivariate analyses were performed to identify esophageal motility parameters associated with reflux burden and symptom outcome.
Results:
Of 172 subjects included, 93 patients were identified as CCv3.0 IEM, 69 as CCv4.0 IEM. IEM in either version was concomitant with elevated acid burden and impaired esophageal clearance as compared to normal motility in corresponding diagnostic criteria, while the only presence of IEM in CCv4.0 was predictive to abnormal acid exposure (AET > 6%: OR = 2.66, 95% CI [1.27-5.56], p < 0.01). The presence of "CCv3.0 IEM" and low EGJ-CI (EGJ-CI < 39.1 mmHg·cm) had no added value in predicting increased reflux burden. No interaction effect was found between the presence of IEM and a weakened EGJ. None of the manometric variables was capable of predicting PPI response.
Conclusions:
Stringent criteria of IEM in CCv4.0 can better predict abnormal acid exposure as compared to CCv3.0.
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