Classification and definition of manometric disorders

Classification	Disorder	Definition
Disorders of EGJ outflow	Type I achalasia	Abnormal median IRP & 100% failed peristalsis
	Type II achalasia	Abnormal median IRP, 100% failed peristalsis, & ≥20% swallows with panesophageal pressurization
	Type III achalasia*	Abnormal median IRP & ≥20% swallows with premature/spastic contraction and no evidence of peristalsis
	EGJ outflow obstruction^¶^Δ	Abnormal median IRP (supine and upright), ≥20% elevated intrabolus pressure (supine), and not meeting criteria for achalasia
Disorders of peristalsis	Absent contractility	Normal median IRP (supine and upright) & 100% failed peristalsis
	Distal esophageal spasm^Δ	Normal median IRP & ≥20% swallows with premature/spastic contraction
	Hypercontractile esophagus^Δ	Normal median IRP & ≥20% hypercontractile swallows
	Ineffective esophageal motility	Normal median IRP, with >70% ineffective swallows or ≥50% failed peristalsis

EGJ: esophagogastric junction; IRP: integrated relaxation pressure; CC: Chicago Classification; EGJOO: esophagogastric junction outflow obstruction.
* CCv4.0 recognizes that the distinction between type III achalasia and conclusive EGJOO can be difficult and was vague in CCv3.0. In CCv4.0, achalasia is defined by 100% absent peristalsis which is inclusive of swallows that are either failed or premature and Type III achalasia should not have evidence of normal peristalsis (normal or ineffective swallows).
¶ Patients with EGJ obstruction and evidence of peristalsis would fulfill strict criteria for EGJOO and may have features suggestive of achalasia or other patterns of peristalsis defined by criteria used for disorders of peristalsis: EGJOO with spastic features (presence of ≥20% premature swallows), EGJOO with hypercontractile features, EGJOO with ineffective motility, or EGJOO with no evidence of disordered peristalsis.
Δ Denote manometric patterns of unclear clinical relevance. A clinically relevant conclusive diagnosis requires additional information which may include clinically relevant symptoms and/or supportive testing.

From: Yadlapati R, Kahrilas PJ, Fox MR, et al. Esophageal motility disorders on high-resolution manometry: Chicago classification version 4.0 ©. Neurogastroenterol Motil 2021; 33(1):e14058. https://onlinelibrary.wiley.com/doi/10.1111/nmo.14058. Copyright © 2020 John Wiley & Sons Ltd. Reproduced with permission of John Wiley & Sons Inc. This image has been provided by or is owned by Wiley. Further permission is needed before it can be downloaded to PowerPoint, printed, shared or emailed. Please contact Wiley's permissions department on [email protected] or use the RightsLink service by clicking on the 'Request Permission' link accompanying this article on Wiley Online Library (http://onlinelibrary.wiley.com).

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Classification and definition of manometric disorders