P0321 - Clinical Characteristics of Patients With Ineffective Esophageal Motility by Chicago Classification 4.0 Compared to Chicago Classification 3.0

Syed Ahmad Adil, MD¹, Michael Kurin, MD¹, Sofi Damjanovska, MD¹, Samuel Tanner, MD², Katarina Greer, MD^3
1University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH; ²University Hospitals Cleveland Medical Center, Cleveland, OH; ³Louis Stokes Cleveland VA Medical Center, Cleveland, OH

Introduction: Under Chicago 4.0 Classification (CCv4.0), ineffective esophageal motility (IEM) has more stringent diagnostic criteria. Whether this translates to more significant clinical findings is unclear. We investigate the real-world implications of this change on the prevalence and clinical characteristics of patients diagnosed with IEM.

Methods: Single-center retrospective analysis of all high resolution esophageal manometries (HREMs) performed at an academic medical center from 2014 to 2021. All patients with IEM by CCv4.0 criteria and/or CCv3.0 criteria were identified. Two cohorts were created: Chicago 3.0 classification alone (CC3 group), and both Chicago 3.0 and 4.0 Classification (CC3&4 group). The two cohorts were compared on the basis of demographics, comorbidities, manometric and reflux parameters, and clinical outcomes.

Results: After analyses of 594 HREMs, a 2-expert panel confirmed the diagnosis of IEM in 66 (11.1%) patients, 25 of whom met criteria for CCv3.0 only (CC3 group) and 41 who met criteria for both CCv3.0 and CCv4.0 (CC3&4 group). The two groups were similar in terms of age, gender, race, BMI, and substance use history. There were no significant differences between the two groups in prevalence of GERD, eosinophilic esophagitis, Barrett’s esophagus, hiatal hernia, prior foregut surgeries, prior medical therapies for GERD, or indications for HREM. Except for a difference in the distal contractile integral, there was no difference in other HREM parameters or bolus clearance by impedance (Table 1). Among patients assessed for peristaltic reserve, those in the CC3&4 group had significantly less peristaltic reserve compared to those in the CC3 group (22% vs. 88%; p < .05). The CC3&4 group had significantly higher supine acid exposure time (AET) and higher Demeester scores compared to the CC3 group (Table 1). Though there was no difference in medical or surgical therapies for GERD offered after HREM, patients in the CC3&4 group were more likely to have symptoms that did not improve over time, compared to the CC3 group (37% vs. 12%; p < .05).

Discussion: We found a 38% absolute reduction in diagnosis of IEM under CCv4.0. The diagnosis of IEM under CCv4.0 is associated with more severe reflux parameters, less adequate peristaltic reserve, and lower likelihood of improvement over time, compared to CCv3.0, giving the diagnosis more clinical significance. However, impairment in bolus transit did not increase under CCv4.0.

Results of pH Testing	Chicago 3.0 (median, interquartile range)	Chicago 3.0 & 4.0 (median, interquartile range)	P value
AET (%)	4.0 (1.2-8.2)	9.4 (2.3-12.9)	0.23
Supine AET (%)	1.0 (0-2.6)	12 (4.8-23.4)	0.004
Total reflux events	37.3 (10-50.8)	33.8 (16.4-58.3)	NS
Acid reflux events	38 (16.5-55.8)	26 (13.1-34.5)	NS
Supine reflux events	2 (1-5.3)	22 (5.9-24.8)	0.02
Upright reflux events	30.5 (6-42)	26.3 (17.3-41.8)	NS
Reflux events >5min	3.8 (1-7.8)	4.3 (1.8-7.8)	NS
Longest reflux event (min)	8.9 (4.8-30.8)	20.9 (9.0-41.2)	NS
Demeester score	17.9 (7.6-24.8)	39.2 (21.3-51.1)	0.05
Manometric Findings	Chicago 3.0 (median, interquartile range)	Chicago 3.0 & 4.0 (median, interquartile range)	P value
Median IRP (mmHg)	7 (5-10)	7.5 (5-11)	NS
Baseline LESP (mmHg)	14 (8-24)	16 (8-23)	NS
Baseline UESP (mmHg)	81 (58-121)	60.5 (43-97)	NS
Mean DCI (mmHg*s*cm)	495 (408-666)	253.5 (177-319)	< 0.0001
Distal latency (s)(mean; std)	8.2 +/- 1.4	8.0 +/- 2.7	NS
Ineffective swallows (%)	57 (50-60)	90 (80-100)	n/a
Failed swallows (%)	20 (10-30)	36 (18-60)	n/a
Premature swallows (%)	0 (0-0)	0 (0-0)	NS
Fragmented swallows (%)	0 (0-10)	0 (0-0)	NS
Impedance bolus clearance liquid (%)	43 (30-70)	50 (20-62)	NS
Impedance bolus clearance viscous (%)	50 (40-65)	40 (20-57)	NS

Table: Top Portion: Results of pH Testing,
Bottom Portion: Manometric Findings

Key:
AET: Acid Exposure Time,
IRP: Integrated Relaxation Pressure,
LESP: Lower Esophageal Sphincter Pressure,
UESP: Upper Esophageal Sphincter Pressure,
DCI: DIstal Contractile Integral



Disclosures:
Syed Ahmad Adil indicated no relevant financial relationships.
Michael Kurin indicated no relevant financial relationships.
Sofi Damjanovska indicated no relevant financial relationships.
Samuel Tanner indicated no relevant financial relationships.
Katarina Greer indicated no relevant financial relationships.


Syed Ahmad Adil, MD¹, Michael Kurin, MD¹, Sofi Damjanovska, MD¹, Samuel Tanner, MD², Katarina Greer, MD³. P0321 - Clinical Characteristics of Patients With Ineffective Esophageal Motility by Chicago Classification 4.0 Compared to Chicago Classification 3.0, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.