S4471 FLIP-Assisted Diagnosis and On-the-Spot Dilation of Achalasia With Inconclusive Manometry

Introduction: The functional lumen imaging probe (FLIP) is a novel technology that utilizes high-resolution impedance planimetry during volume-controlled distension to assess esophageal cross-sectional area and distensibility. Endoluminal FLIP (EndoFLIP™) aids in diagnosing motility disorders, while therapeutic FLIP (EsoFLIP™) enables guided dilation. We present a case of achalasia with inconclusive high-resolution impedance manometry, conclusively diagnosed using EndoFLIP™ and treated with EsoFLIP™ in the same session. Case Description/Methods: A 77-year-old man with a history of gastroesophageal reflux disease and remotely cured tonsil cancer presented with progressive dysphagia to solids and liquids. A barium swallow performed on symptom onset 18 months prior showed mild cricopharyngeal narrowing. Speech and swallow evaluation ruled out oropharyngeal dysphagia. Over the past 8 months, his symptoms worsened with 10-pound weight loss. Esophagogastroduodenoscopy revealed a tight esophagogastric junction (EGJ) and punctate esophageal white plaques; biopsy confirmed Candida esophagitis. Symptoms persisted despite antifungal therapy. High-resolution impedance manometry showed absent esophageal pressurization, and no peristalsis but was inconclusive due to undiscernible esophageal sphincters. The patient then underwent EndoFLIP™ evaluation. A 16-cm EndoFLIP™ catheter was inserted with the balloon traversing the EGJ. Standard volumetric distension protocol was used. At successive 10-mL increments, measurements of diameter (mm), distensibility index (DI, mm2/mmHg), and pressure (mmHg) were as follows: 40 mL (4, 1.0, 12.3), 50 mL (6.3, 1.8, 17.8), 60 mL (9.7, 3.0, 24.9), and 70 mL (14.5, 3.8, 43.2). The absence of contractile activity and low EGJ-DI confirmed type I achalasia. Subsequently, an EsoFLIP™ dilation catheter was used, a 30 mm stepwise balloon was introduced, dilating to a diameter of 30 mm. The patient tolerated the procedure well and experienced marked improvement in symptoms. Discussion: FLIP aids in diagnosing esophageal motility disorders diagnosis particularly when manometry is inconclusive and offers additional advantages of immediate therapeutic dilation using EsoFLIP™. Unlike single size pneumatic dilation, EsoFLIP™ allows for real-time, gradual dilation with precision without fluoroscopy, improving safety. This case highlights FLIP’s dual utility and its expanding role in frontline management of esophageal dysphagia and motility disorders.