{"id":2374,"date":"2022-03-26T09:00:39","date_gmt":"2022-03-26T12:00:39","guid":{"rendered":"https:\/\/gastropedia.pub\/pt\/classificacao-de-chicago-4-0-o-que-ha-de-novo-na-manometria-de-alta-resolucao\/"},"modified":"2023-08-26T19:53:19","modified_gmt":"2023-08-26T22:53:19","slug":"classificacao-de-chicago-4-0-o-que-ha-de-novo-na-manometria-de-alta-resolucao","status":"publish","type":"post","link":"https:\/\/gastropedia.pub\/pt\/gastroenterologia\/esofago\/classificacao-de-chicago-4-0-o-que-ha-de-novo-na-manometria-de-alta-resolucao\/","title":{"rendered":"Classifica\u00e7\u00e3o de Chicago 4.0: o que h\u00e1 de novo na manometria de alta resolu\u00e7\u00e3o?"},"content":{"rendered":"<div class=\"pdfprnt-buttons pdfprnt-buttons-post pdfprnt-top-right\"><a href=\"https:\/\/gastropedia.pub\/pt\/wp-json\/wp\/v2\/posts\/2374?print=pdf\" class=\"pdfprnt-button pdfprnt-button-pdf\" target=\"_blank\" ><img decoding=\"async\" src=\"https:\/\/gastropedia.pub\/pt\/wp-content\/plugins\/pdf-print\/images\/pdf.png\" alt=\"image_pdf\" title=\"Ver PDF\" \/><\/a><a href=\"https:\/\/gastropedia.pub\/pt\/wp-json\/wp\/v2\/posts\/2374?print=print\" class=\"pdfprnt-button pdfprnt-button-print\" target=\"_blank\" ><img decoding=\"async\" src=\"https:\/\/gastropedia.pub\/pt\/wp-content\/plugins\/pdf-print\/images\/print.png\" alt=\"image_print\" title=\"Conte\u00fado de impress\u00e3o\" \/><\/a><\/div><p><span style=\"font-weight: 400;\">A <\/span><a href=\"https:\/\/endoscopiaterapeutica.com.br\/assuntosgerais\/manometria-esofagica-de-alta-resolucao\/\"><span style=\"font-weight: 400;\">Classifica\u00e7\u00e3o de Chicago<\/span><\/a><span style=\"font-weight: 400;\"> (CC) busca padronizar a interpreta\u00e7\u00e3o da manometria de alta resolu\u00e7\u00e3o (MAR) definindo um fluxograma para classificar os dist\u00farbios motores do es\u00f4fago. A primeira vers\u00e3o completa foi publicada em 2009, sendo recentemente atualizada para a 4\u00aa vers\u00e3o. A classifica\u00e7\u00e3o anterior (3.0 de 2015) j\u00e1 havia sido discutida previamente neste <a href=\"https:\/\/endoscopiaterapeutica.com.br\/assuntosgerais\/manometria-esofagica-de-alta-resolucao\">site<\/a><\/span><span style=\"font-weight: 400;\">.<\/span><\/p>\n<p><span style=\"font-weight: 400;\">Mas o que muda, de fato, nessa nova atualiza\u00e7\u00e3o?<\/span><\/p>\n<h2>1. Mudan\u00e7a de protocolo para realiza\u00e7\u00e3o da MAR<\/h2>\n<p><span style=\"font-weight: 400;\">A CC 4.0 preconiza a realiza\u00e7\u00e3o de degluti\u00e7\u00f5es tanto em posi\u00e7\u00e3o supina como em posi\u00e7\u00e3o vertical, bem como de manobras adicionais, como m\u00faltiplas degluti\u00e7\u00f5es r\u00e1pidas (MDR, ou <\/span><i><span style=\"font-weight: 400;\">multiple rapid swallows \u2013 MRS<\/span><\/i><span style=\"font-weight: 400;\">) e desafio de bebida r\u00e1pida (DBR, <\/span><i><span style=\"font-weight: 400;\">rapid drink challenge \u2013 RDC<\/span><\/i><span style=\"font-weight: 400;\">).<\/span><\/p>\n<p><span style=\"font-weight: 400;\">A recomenda\u00e7\u00e3o preferencial \u00e9 pelo sistema de estado s\u00f3lido, mas sabemos que o seu custo \u00e9 elevado e que, no Brasil, o sistema de perfus\u00e3o \u00e9 muito mais dispon\u00edvel. A classifica\u00e7\u00e3o de CC 4.0 pode tamb\u00e9m ser utilizada com o sistema de perfus\u00e3o, desde que valores normativos tenham sido determinados. Nesse caso, por\u00e9m, devem-se realizar apenas as degluti\u00e7\u00f5es supinas e manobras que sejam poss\u00edveis nessa posi\u00e7\u00e3o.<\/span> <span style=\"font-weight: 400;\">Na pr\u00e1tica, caso usemos o sistema de perfus\u00e3o no nosso dia a dia, seguimos com 10 degluti\u00e7\u00f5es \u00famidas na posi\u00e7\u00e3o supina, mas recomenda-se realizar pelo menos 1 sequ\u00eancia de MDR.<\/span><\/p>\n<p><span style=\"font-weight: 400;\">O Quadro 1 detalha o protocolo padronizado pela CC 4.0 para realiza\u00e7\u00e3o de MAR.<\/span><\/p>\n<p><span style=\"font-weight: 400;\">Quadro 1: Protocolo para manometria de alta resolu\u00e7\u00e3o padronizado conforme CC 4.0<\/span><\/p>\n<h3>Protocolo MAR \u2013 CC 4.0<\/h3>\n<ul>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Jejum de 4 horas;<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Assinar termo de consentimento.<\/span><\/li>\n<\/ul>\n<h3>Estudo inicial em posi\u00e7\u00e3o supina<\/h3>\n<ul>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">60 segundos para adapta\u00e7\u00e3o;<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Documentar posi\u00e7\u00e3o com pelo menos 3 inspira\u00e7\u00f5es profundas;<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">30 segundos de linha de base;<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">10 degluti\u00e7\u00f5es \u00famidas (5 mL) supinas;<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">1 sequ\u00eancia MDR (deve ser repetida at\u00e9 3x se tentativa falha ou resposta anormal).<\/span><\/li>\n<\/ul>\n<h3>Mudar posi\u00e7\u00e3o para vertical (apenas se sistema de estado s\u00f3lido)<\/h3>\n<ul>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">60 segundos para adapta\u00e7\u00e3o;<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Documentar posi\u00e7\u00e3o com pelo menos 3 inspira\u00e7\u00f5es profundas;<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">30 segundos de linha de base;<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">5 degluti\u00e7\u00f5es \u00famidas (5 mL) verticais;<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">1 DBR.<\/span><\/li>\n<\/ul>\n<h3>Se n\u00e3o encontrar nenhum dist\u00farbio motor, considerar:<\/h3>\n<ul>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Se alta probabilidade de OFJEG: testes com degluti\u00e7\u00f5es s\u00f3lidas ou provoca\u00e7\u00e3o farmacol\u00f3gica, se dispon\u00edvel;<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Se suspeita de rumina\u00e7\u00e3o: realizar, se poss\u00edvel, imped\u00e2ncia p\u00f3s-prandial.<\/span><\/li>\n<\/ul>\n<h3>Se achados amb\u00edguos ou se existe suspeita de obstru\u00e7\u00e3o que n\u00e3o preenche crit\u00e9rios para acal\u00e1sia, considerar outros testes complementares:<\/h3>\n<ul>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Esofagograma baritado cronometrado;<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">EndoFLIP.<\/span><\/li>\n<\/ul>\n<h2>2. N\u00e3o h\u00e1 mais diferencia\u00e7\u00e3o entre dist\u00farbios maiores e menores da peristalse<\/h2>\n<p><span style=\"font-weight: 400;\">A CC 4.0 n\u00e3o distingue mais entre dist\u00farbios de motilidade maiores e menores, mas simplesmente separa dist\u00farbios de obstru\u00e7\u00e3o da JEG dos dist\u00farbios de peristalse.<\/span><\/p>\n<p><span style=\"font-weight: 400;\">A Figura 1 resume a an\u00e1lise hier\u00e1rquica da motilidade esof\u00e1gica conforme CC 4.0.<\/span><\/p>\n<div id=\"attachment_11772\" style=\"width: 910px\" class=\"wp-caption aligncenter\"><img fetchpriority=\"high\" decoding=\"async\" aria-describedby=\"caption-attachment-11772\" class=\"wp-image-11772 size-full\" src=\"https:\/\/gastropedia.pub\/pt\/wp-content\/uploads\/2021\/03\/fluxograma_endoscopia.png\" alt=\"\" width=\"900\" height=\"500\" \/><p id=\"caption-attachment-11772\" class=\"wp-caption-text\">Figura 1: Fluxograma para diagn\u00f3stico de dist\u00farbios motores esof\u00e1gicos segundo Classifica\u00e7\u00e3o de Chicago 4.0. Integral da press\u00e3o de relaxamento (IRP &#8211; integrated relaxation pressure); Jun\u00e7\u00e3o esofagog\u00e1strica (JEG); M\u00faltiplas degluti\u00e7\u00f5es r\u00e1pidas (MDR); Desafio de bebida r\u00e1pida (DBR); Obstru\u00e7\u00e3o ao fluxo da JEG (OFJEG).<\/p><\/div>\n<h2>3. <b>Subtipos de acal\u00e1sia seguem o padr\u00e3o da classifica\u00e7\u00e3o anterior<\/b><\/h2>\n<h2>4. <b>Defini\u00e7\u00e3o mais criteriosa sobre obstru\u00e7\u00e3o ao fluxo da jun\u00e7\u00e3o esofagog\u00e1strica (OFJEG)<\/b><\/h2>\n<p><span style=\"font-weight: 400;\">Apesar de uma propor\u00e7\u00e3o de OFJEG poder evoluir para <a href=\"https:\/\/endoscopiaterapeutica.com.br\/assuntosgerais\/poem-miotomia-endoscopica-peroral-no-tratamento-da-acalasia\/\" target=\"_blank\" rel=\"noopener\">acal\u00e1sia<\/a> ou mesmo representar uma variante de acal\u00e1sia, observou-se que mais de um ter\u00e7o desses casos s\u00e3o clinicamente irrelevantes ou relacionados a etiologias benignas, como efeitos mec\u00e2nicos, uso de opioide ou artefatos. Para evitar tratamentos desnecess\u00e1rios, a CC 4.0 foi mais criteriosa nesse tema.<\/span><\/p>\n<p><span style=\"font-weight: 400;\">O diagn\u00f3stico manom\u00e9trico de OFJEG \u00e9 definido pela eleva\u00e7\u00e3o da IRP (integral da press\u00e3o de relaxamento, <\/span><i><span style=\"font-weight: 400;\">integrated relaxation pressure<\/span><\/i><span style=\"font-weight: 400;\">) em duas posi\u00e7\u00f5es + 20% degluti\u00e7\u00f5es com press\u00e3o intrabolus elevada na posi\u00e7\u00e3o supina, com evid\u00eancia de peristalse. A suspeita inicial para o diagn\u00f3stico de OFJEG ocorre quando a IRP \u00e9 alterada, mas n\u00e3o h\u00e1 crit\u00e9rios para acal\u00e1sia, isto \u00e9, h\u00e1 contra\u00e7\u00f5es perist\u00e1lticas.<\/span><\/p>\n<p><span style=\"font-weight: 400;\">Por outro lado, o diagn\u00f3stico de OFJEG clinicamente relevante requer: diagn\u00f3stico manom\u00e9trico + sintomas relevantes (disfagia ou dor tor\u00e1cica n\u00e3o card\u00edaca) + investiga\u00e7\u00f5es adicionais para obstru\u00e7\u00e3o (esofagograma ou endoFLIP). Voc\u00ea pode conhecer mais sobre endoFLIP neste outro <a href=\"https:\/\/endoscopiaterapeutica.com.br\/assuntosgerais\/endoluminal-functional-lumen-imaging-probe-endofliptm-conhecendo-tecnologia-e-seus-potenciais-usos\/\">artigo do Endoscopia Terap\u00eautica<\/a><\/span><span style=\"font-weight: 400;\">.<\/span><\/p>\n<h2>5. <b>De nada adianta achado manom\u00e9trico sem cl\u00ednica compat\u00edvel<\/b><\/h2>\n<p><span style=\"font-weight: 400;\">Alguns padr\u00f5es manom\u00e9tricos podem ser incidentais, n\u00e3o indicando patologia cl\u00ednica e n\u00e3o justificando uma interven\u00e7\u00e3o. Portanto, uma das principais prioridades na CC 4.0 foi distinguir entre patologia e achados manom\u00e9tricos inespec\u00edficos. Optou-se por manter o esquema de classifica\u00e7\u00e3o estabelecido com base na fisiologia esof\u00e1gica, mas a OFJEG, o espasmo esof\u00e1gico distal e o es\u00f4fago hipercontr\u00e1til passam a ser considerados padr\u00f5es com relev\u00e2ncia cl\u00ednica obscura. Um diagn\u00f3stico clinicamente relevante desses dist\u00farbios requer achados manom\u00e9tricos conclusivos e sintomas relevantes (disfagia e\/ou dor tor\u00e1cica n\u00e3o card\u00edaca).<\/span><\/p>\n<h2>6. <b>Jackhammer<\/b> <b>passa a ser considerado um subtipo de es\u00f4fago hipercontr\u00e1til<\/b><\/h2>\n<p><span style=\"font-weight: 400;\">A CC 4.0 manteve os crit\u00e9rios da CC 3.0 de \u2265 20% de degluti\u00e7\u00f5es hipercontr\u00e1teis, mas revisou a nomenclatura para mudar o Jackhammer para um subtipo e renomear o dist\u00farbio como es\u00f4fago hipercontr\u00e1til. Essa altera\u00e7\u00e3o considerou a heterogeneidade dos padr\u00f5es de motilidade que atendem \u00e0 defini\u00e7\u00e3o, com a identifica\u00e7\u00e3o de tr\u00eas subgrupos: Jackhammer (britadeira) com contra\u00e7\u00f5es prolongadas repetitivas, degluti\u00e7\u00f5es hipercontr\u00e1teis de pico \u00fanico e degluti\u00e7\u00f5es hipercontr\u00e1teis com uma vigorosa p\u00f3s-contra\u00e7\u00e3o do esf\u00edncter inferior do es\u00f4fago. Entre os tr\u00eas padr\u00f5es, o Jackhammer \u00e9, normalmente, o mais sintom\u00e1tico e com a maior probabilidade de responder \u00e0 interven\u00e7\u00e3o.<\/span><\/p>\n<h2>7. <b>Defini\u00e7\u00e3o de motilidade esof\u00e1gica ineficaz (MEI) passou a ser mais rigorosa<\/b><\/h2>\n<p><span style=\"font-weight: 400;\">A defini\u00e7\u00e3o da CC 4.0 de MEI \u00e9 mais rigorosa, exigindo mais de 70% das contra\u00e7\u00f5es como ineficazes (em vez de, pelo menos, 50% em classifica\u00e7\u00f5es anteriores) ou \u2265 50% das contra\u00e7\u00f5es falhas. A defini\u00e7\u00e3o de uma contra\u00e7\u00e3o ineficaz tamb\u00e9m passa a abranger degluti\u00e7\u00f5es fragmentadas, sendo que o peristaltismo fragmentado n\u00e3o \u00e9 mais um dist\u00farbio motor.<\/span><\/p>\n<h3>Como citar este artigo<\/h3>\n<p><span style=\"font-weight: 400;\">Lages RB. Classifica\u00e7\u00e3o de Chicago 4.0: o que h\u00e1 de novo na manometria de alta resolu\u00e7\u00e3o?. Gastropedia 2022. Dispon\u00edvel em: <a href=\"https:\/\/gastropedia.pub\/pt\/gastroenterologia\/esofago\/classificacao-de-chicago-4-0-o-que-ha-de-novo-na-manometria-de-alta-resolucao\/\" target=\"_blank\" rel=\"noopener\">https:\/\/gastropedia.pub\/pt\/gastroenterologia\/esofago\/classificacao-de-chicago-4-0-o-que-ha-de-novo-na-manometria-de-alta-resolucao\/<\/a><\/span><\/p>\n<h3>Refer\u00eancias<\/h3>\n<ol>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Yadlapati R, Kahrilas PJ, Fox MR, Bredenoord AJ, Prakash Gyawali C, Roman S, et al. Esophageal motility disorders on high-resolution manometry: Chicago classification version 4.0\u00a9. Neurogastroenterol Motil 2021; 33(1):e14058. doi:10.1111\/nmo.14058.<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Yadlapati R, Pandolfino JE, Fox MR, Bredenoord AJ, Kahrilas PJ. What is new in Chicago Classification version 4.0? Neurogastroenterol Motil 2021;33(1):1\u20137. doi:10.1111\/nmo.14053.<\/span><\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"<p>A Classifica\u00e7\u00e3o de Chicago (CC) busca padronizar a interpreta\u00e7\u00e3o da manometria de alta resolu\u00e7\u00e3o (MAR) definindo um fluxograma para classificar os dist\u00farbios motores do es\u00f4fago. A primeira vers\u00e3o completa foi&hellip;<\/p>\n","protected":false},"author":4165,"featured_media":2205,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[19,18],"tags":[],"ano":[43],"tipo":[121],"volume":[57],"class_list":["post-2374","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-esofago","category-gastroenterologia","ano-43","tipo-assuntos-gerais","volume-volume-i"],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v27.2 (Yoast SEO v27.3) - https:\/\/yoast.com\/product\/yoast-seo-premium-wordpress\/ -->\n<title>Classifica\u00e7\u00e3o de Chicago 4.0: o que h\u00e1 de novo na manometria de alta resolu\u00e7\u00e3o? - Gastropedia<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/gastropedia.pub\/pt\/gastroenterologia\/esofago\/classificacao-de-chicago-4-0-o-que-ha-de-novo-na-manometria-de-alta-resolucao\/\" \/>\n<meta property=\"og:locale\" content=\"pt_BR\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Classifica\u00e7\u00e3o de Chicago 4.0: o que h\u00e1 de novo na manometria de alta resolu\u00e7\u00e3o?\" \/>\n<meta property=\"og:description\" content=\"A Classifica\u00e7\u00e3o de Chicago (CC) busca padronizar a interpreta\u00e7\u00e3o da manometria de alta resolu\u00e7\u00e3o (MAR) definindo um fluxograma para classificar os dist\u00farbios motores do es\u00f4fago. 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