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Review
. 2020 Sep;49(3):427-435.
doi: 10.1016/j.gtc.2020.04.002. Epub 2020 Jun 14.

EndoFLIP in the Esophagus: Assessing Sphincter Function, Wall Stiffness, and Motility to Guide Treatment

Erica N Donnan  1 , John E Pandolfino  2
Affiliations
Review

EndoFLIP in the Esophagus: Assessing Sphincter Function, Wall Stiffness, and Motility to Guide Treatment

Erica N Donnan et al. Gastroenterol Clin North Am. 2020 Sep.

Abstract

The functional luminal imaging probe (FLIP) uses high-resolution planimetry to provide a three-dimensional image of the esophageal lumen by measuring diameter, volume, and pressure changes. Literature surrounding use of FLIP has demonstrated its clinical utility as a diagnostic tool and as a device to guide and measure response to therapy. FLIP can assess and guide treatments for esophageal disease states including gastroesophageal reflux disease, achalasia, and eosinophilic esophagitis. FLIP may become the initial test for patients with undifferentiated dysphagia at their index endoscopy. This article summarizes use of FLIP in assessing sphincter function, wall stiffness, and motility to guide treatments.

Keywords: Achalasia; Dysphagia; EndoFLIP; FLIP; Gastroesophageal reflux; Impedance.

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Conflict of interest statement

Disclosure J.E. Pandolfino holds shared intellectual property rights and ownership surrounding FLIP panometry systems, methods, and apparatus with Medtronic Inc. J.E. Pandolfino discloses Crospon, Inc (stock options), Given Imaging (Consultant, Grant, Speaking), Sandhill Scientific (Consulting, Speaking), Takeda (Speaking), Astra Zeneca (Speaking), Medtronic (Speaking, Consulting), Torax (Speaking, Consulting), Ironwood (Consulting), and Impleo (Grant). E.N. Donnan has nothing to disclose.

Figures

Figure 1:
Figure 1:
Diagram of catheter and placement through the EGJ. The FLIP 2.0 display provides real-time measurement of the EGJ-DI that is measured as the narrowest CSA [green arrow] divided by the simultaneous pressure. The pattern represents a normal response to volumetric distention and is defined as repetitive antegrade contractions (RACs). Courtesy of the Esophageal Center at Northwestern, Chicago, IL.
Figure 2:
Figure 2:
Motility patterns in response to volumetric distention. The top panel is the high-resolution manometry image and the bottom panel is the FLIP topography image of the representative patient. Panel A is a normal subject with a RAC pattern. Panel B is a patient with Type I achalasia and the FLIP depicts an absent contractile response and a poorly relaxing sphincter. Panel C is type II achalasia and the FLIP suggests that there are disordered non-occluding contractions in the body of the esophagus and the sphincter does not open. Panel D is a patient with type III achalasia and the FLIP topography reveals an abnormal pattern where the contractions are retrograde and rapid in terms of the rate of contractions. Courtesy of the Esophageal Center at Northwestern, Chicago, IL.
Figure 3:
Figure 3:
Representative swallows on HRM (left panel), FLIP panometry (middle panel) and esophagram (right panel) for three patients diagnosed with EGJOO based on IRP > 15 mmHg. Patient A is a true-EGJOO (achalasia) with a FLIP DI <2 mm2/mmHg. Patient B has a borderline abnormal manometry with some early compartmentalized pressurization during the swallow. However, the FLIP topography suggests a true EGJOO with FLIP DI <2 mm2/mmHg and erratic contractions that are disordered and retrograde. This is more consistent with what is seen on the esophagram (rosary beads and corkscrew). Patient C is a false positive EGJOO on HRM as the FLIP reveals a normal RAC pattern and a normal EGJ-DI. The esophagram supports normal emptying. Courtesy of the Esophageal Center at Northwestern, Chicago, IL.
Figure 4:
Figure 4:
Two representative FLIP 2.0 images of the distal and proximal esophagus. Note the sphincter landmark in each. They had a narrow caliber esophagus with a dominant EGJ stricture around 10 mm (green arrow) and another distal body stricture (purple arrow) around 12mm. Note the tear in the esophagus after a balloon dilation to 13.5 mm. Courtesy of the Esophageal Center at Northwestern, Chicago, IL.
See this image and copyright information in PMC

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