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Chicago 4.0 is the new classification for esophageal motility disorders based on high-resolution manometry. Previous classification may have caused overtreatment of specific manometric patterns. Chicago 4.0 defined criteria for clinically relevant specific manometric patterns.

Fragmented peristalsis is characterized by the presence of large pressure breaks in the peristaltic contractions in the esophagus. Weak contractions impair clearance of refluxed gastric contents and chronic excessive acid exposure leads to weakening of peristaltic function.

Motility disorders beyond achalasia with the current classification are: esophagogastric junction outflow obstruction, major disorders of peristalsis (distal esophageal spasm, hypercontractile esophagus, absent contractility) and minor disorders of peristalsis (ineffective esophageal motility, fragmented peristalsis).

Chicago Classification v4. 0 (CCv4. 0) is the updated classification scheme for esophageal motility disorders using metrics from high-resolution manometry (HRM). Fifty-two diverse international experts separated into seven working subgroups utilized formal validated methodologies over two-years to develop CCv4.

The Chicago classification is a hierarchical classification scheme. The initial step is to evaluate the relaxation of the esophagogastric junction upon swallowing by using the IRP. If elevated, patients should be classified as having achalasia or EGJ outflow obstruction, depending on the peristalsis.

EGJ was classified as: Type I, no separation between the lower esophageal sphincter (LES) and crural diaphragm (CD); Type II, minimal separation (>1 and <2 cm); Type III, ? 2 cm separation.

4.0 is the more rigorous and expansive protocol that incorporates single wet swallows acquired in different positions (supine, upright) and provocative testing, including multiple rapid swallows and rapid drink challenge.