Algorithm for Applying the Chicago Classification of Esophageal Motor Disorders - Flowchart
Algorithm for Applying the Chicago Classification of Esophageal Motor Disorders - Flowchart Achalasia Achalasia
«Flowchart»

Step 1: Perform 10 wet swallows (Primary position)

Step 1: Perform 10 wet swallows (Primary position)

Step 1: Perform 10 wet swallows (Primary position)

Step 1

End

End

End

EGJ Outflow Obstruction


Achalasia variant versus mechanical obstruction

EGJ Outflow Obstruction


Achalasia variant versus mechanical obstruction

EGJ Outflow Obstruction


Achalasia variant versus mechanical obstruction


Achalasia variant versus mechanical obstruction Achalasia variant versus mechanical obstruction Achalasia variant versus mechanical obstruction

Absent Peristalsis

Distal esophageal spasm


≥20% of swallows with reduced DL (<4.5 s)

Jackhammer esophagus


!!getq!!20% of swallows with DCI >8000 mm Hg-s-cm and normal DL

Absent Peristalsis

Distal esophageal spasm


≥20% of swallows with reduced DL (<4.5 s)

Jackhammer esophagus


!!getq!!20% of swallows with DCI >8000 mm Hg-s-cm and normal DL

Absent Peristalsis

Distal esophageal spasm


≥20% of swallows with reduced DL (<4.5 s)


≥20% of swallows with reduced DL (<4.5 s) ≥

Jackhammer esophagus


!!getq!!20% of swallows with DCI >8000 mm Hg-s-cm and normal DL


!!getq!!20% of swallows with DCI >8000 mm Hg-s-cm and normal DL

Rapid contraction


≥20% of swallows with rapid CFV (>9 cm/s) and normal DL

Hypertensive Peristalsis


≥20% of swallows with DCI >5000 mm Hg-s-cm and normal DL

Weak Peristalsis


≥30% of swallows with small (2-5 cm) breaks in the 20-mm Hg IBC
≥20% of swallows with large (>5 cm) breaks in the 20-mm Hg IBC

Frequent Failed Peristalsis


≥30% of absent swallows

Rapid contraction


≥20% of swallows with rapid CFV (>9 cm/s) and normal DL

Hypertensive Peristalsis


≥20% of swallows with DCI >5000 mm Hg-s-cm and normal DL

Weak Peristalsis


≥30% of swallows with small (2-5 cm) breaks in the 20-mm Hg IBC
≥20% of swallows with large (>5 cm) breaks in the 20-mm Hg IBC

Frequent Failed Peristalsis


≥30% of absent swallows

Rapid contraction


≥20% of swallows with rapid CFV (>9 cm/s) and normal DL


≥20% of swallows with rapid CFV (>9 cm/s) and normal DL ≥

Hypertensive Peristalsis


≥20% of swallows with DCI >5000 mm Hg-s-cm and normal DL


≥20% of swallows with DCI >5000 mm Hg-s-cm and normal DL ≥

Weak Peristalsis


≥30% of swallows with small (2-5 cm) breaks in the 20-mm Hg IBC
≥20% of swallows with large (>5 cm) breaks in the 20-mm Hg IBC


≥30% of swallows with small (2-5 cm) breaks in the 20-mm Hg IBC ≥
≥20% of swallows with large (>5 cm) breaks in the 20-mm Hg IBC ≥

Frequent Failed Peristalsis


≥30% of absent swallows


≥30% of absent swallows ≥

Normal

Normal

Normal

CFV, contractile front velocity; DCI, distal contractile interval; DL, distal latency; EGJ, esophagogastric junction; IBC, isobar contour; IRP, integrated relaxation pressure

CFV, contractile front velocity; DCI, distal contractile interval; DL, distal latency; EGJ, esophagogastric junction; IBC, isobar contour; IRP, integrated relaxation pressure

CFV, contractile front velocity; DCI, distal contractile interval; DL, distal latency; EGJ, esophagogastric junction; IBC, isobar contour; IRP, integrated relaxation pressure

CFV DCI DL EGJ IBC IRP

IRP ≥ upper limit of normal AND some instances of intact or weak peristalsis

IRP ≥ upper limit of normal AND some instances of intact or weak peristalsis

IRP ≥ upper limit of normal AND some instances of intact or weak peristalsis

≥ AND

Yes

Yes

Yes

No

No

No

IRP is normal AND absent peristalsis OR reduced distal latency OR DCI >8000 mm Hg-cm-s

IRP is normal AND absent peristalsis OR reduced distal latency OR DCI >8000 mm Hg-cm-s

IRP is normal AND absent peristalsis OR reduced distal latency OR DCI >8000 mm Hg-cm-s

AND OR OR

Yes

Yes

Yes

No

No

No

IRP is normal AND minor peristaltic abnormalities

IRP is normal AND minor peristaltic abnormalities

IRP is normal AND minor peristaltic abnormalities

AND

Yes

Yes

Yes

No

No

No

Abnormal median IRP

Abnormal median IRP

Abnormal median IRP

Step 2: (if not done) Wet swallows in secondary position + MRS/RDC

Step 2: (if not done) Wet swallows in secondary position + MRS/RDC

Step 2: (if not done) Wet swallows in secondary position + MRS/RDC

Step 2 (if not done)

100% absent peristalsis all swallows are either failed or premature!!Image!!

100% absent peristalsis all swallows are either failed or premature!!Image!!

100% absent peristalsis all swallows are either failed or premature!!Image!!

!!Image!!

Yes

Yes

Yes

No

No

No

Disorders of EGJ outflow

Achalasia I

Disorders of EGJ outflow

Achalasia I

Disorders of EGJ outflow

Achalasia I

Disorders of EGJ outflow

Achalasia II

Disorders of EGJ outflow

Achalasia II

Disorders of EGJ outflow

Achalasia II

Disorders of EGJ outflow

Achalasia III

Disorders of EGJ outflow

Achalasia III

Disorders of EGJ outflow

Achalasia III

100% failed peristalsis without PEP

100% failed peristalsis without PEP

100% failed peristalsis without PEP

100% failed peristalsis with PEP in ≥20% swallows

100% failed peristalsis with PEP in ≥20% swallows

≥ 100% failed peristalsis with PEP in ≥20% swallows ≥

≥20% swallows with premature contractions. Failed peristalsis ± PEP may be present

≥20% swallows with premature contractions. Failed peristalsis ± PEP may be present

≥ ≥20% swallows with premature contractions. Failed peristalsis ± PEP may be present ≥

<Next Node>

<Next Node>

<Next Node>

<Next Node>

Abnormal TBE or FLIP

Abnormal TBE or FLIP

Abnormal TBE or FLIP

Disorders of EGJ outflow

EGJOO*†

Disorders of EGJ outflow

EGJOO*†

Disorders of EGJ outflow

EGJOO*†

*†

No evidence of EGJ outflow obstruction

No evidence of EGJ outflow obstruction

No evidence of EGJ outflow obstruction

No evidence of EGJ outflow obstruction

Yes

Yes

Yes

No

No

No

<Next Node>

<Next Node>

<Next Node>

<Next Node>

Yes

Yes

Yes

No

No

No

Step 2: Wet swallows in secondary position + MRS/RDC

Step 2: Wet swallows in secondary position + MRS/RDC

Step 2: Wet swallows in secondary position + MRS/RDC

Step 2

Elevated LES IRP in varying positions ± elevated IBP/PEP

Elevated LES IRP in varying positions ± elevated IBP/PEP

Elevated LES IRP in varying positions ± elevated IBP/PEP

Yes

Yes

Yes

No

No

No

Disorders of peristalsis

Absent contractility

Disorders of peristalsis

Absent contractility

Disorders of peristalsis

Absent contractility

100% failed peristalsis

100% failed peristalsis

100% failed peristalsis

Yes

Yes

Yes

No

No

No

Disorders of peristalsis

Distal esophageal spasm*

Disorders of peristalsis

Distal esophageal spasm*

Disorders of peristalsis

Distal esophageal spasm*

*

≥20% swallows with premature contractions

≥20% swallows with premature contractions

≥20% swallows with premature contractions

≥

Yes

Yes

Yes

No

No

No

<Next Node>

<Next Node>

<Next Node>

<Next Node>

Disorders of peristalsis

Hypercontractile esophagus*

Disorders of peristalsis

Hypercontractile esophagus*

Disorders of peristalsis

Hypercontractile esophagus*

*

Disorders of peristalsis

Ineffective esophageal motility

Disorders of peristalsis

Ineffective esophageal motility

Disorders of peristalsis

Ineffective esophageal motility

No evidence of disorder of peristalsis

No evidence of disorder of peristalsis

No evidence of disorder of peristalsis

No evidence of disorder of peristalsis

>70% ineffective or ≥50% failed swallows

>70% ineffective or ≥50% failed swallows

>70% ineffective or ≥50% failed swallows

≥

Yes

Yes

Yes

No

No

No

Consider meal challenges based an symptom!!Image!!

Consider meal challenges based an symptom!!Image!!

Consider meal challenges based an symptom!!Image!!

Consider meal challenges based an symptom!!Image!! !!Image!!

≥20% swallows with hypercontractility

≥20% swallows with hypercontractility

≥20% swallows with hypercontractility

≥

Yes

Yes

Yes

No

No

No

Elevated LES IRP persists in varying positions + elevated IBP/PEP‡

Elevated LES IRP persists in varying positions + elevated IBP/PEP‡

Elevated LES IRP persists in varying positions + elevated IBP/PEP‡

‡

Yes

Yes

Yes

No

No

No