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Addressing Gaps in the Chicago Classification Version 4.0: Defining an Optimal Intrabolus Pressure Measurement on

Muhammed M Alikhan1, Aidan D Smires1, John E Pandolfino1

  • 1Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.

Neurogastroenterology and Motility
|April 12, 2026
PubMed
Summary
This summary is machine-generated.

A new standardized method for measuring intrabolus pressure (IBP) using 4D high-resolution manometry (HRM) improves the diagnosis of esophagogastric junction outflow obstruction (EGJOO). The 1-second max IBP measure showed the highest accuracy in identifying EGJOO.

Keywords:
dysphagiaesophagusimpedancemanometrymotilityperistalsis

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Area of Science:

  • Gastroenterology
  • Physiology

Background:

  • Intrabolus pressure (IBP) is a key marker for esophagogastric junction (EGJ) outflow resistance.
  • Current methods for measuring IBP lack standardization, limiting the interpretation of high-resolution manometry (HRM) data for diagnosing EGJ outflow obstruction (EGJOO).

Purpose of the Study:

  • To develop and validate a standardized method for measuring IBP using 4D HRM.
  • To assess the diagnostic performance of IBP measures in identifying EGJOO.

Main Methods:

  • Utilized data from three patient cohorts: Controls, Normal Motility, and conclusive EGJOO.
  • Performed 4D HRM analysis blinded to clinical data, assessing IBP on per-swallow and per-patient levels.
  • Employed receiver operating curve (ROC) analysis to evaluate the predictive accuracy of IBP measures for EGJOO.

Main Results:

  • Included 33 controls, 35 normal motility, and 15 conclusive EGJOO patients.
  • Per-swallow analysis revealed significant differences in all ten IBP measures between groups (P < 0.001), with higher IBP in EGJOO.
  • The 1-second max IBP measure demonstrated the highest area under the ROC curve (AUROC).

Conclusions:

  • Standardized IBP measurement using an optimized method (1-s max IBP) within the 4D-HRM framework is a significant advancement.
  • This approach, combined with impedance-confirmed bolus tracking, provides a physiologically grounded and clinically meaningful interpretation of HRIM data.
  • The findings support the clinical utility of this standardized IBP measurement for diagnosing EGJOO.