FLIP Panometry IDs Clinically Relevant Esophagogastric Junction Outflow Obstruction

FLIP panometry can serve as a complement to HRM per Chicago Classification v4.0 esophagogastric junction outflow obstruction diagnosis for clarifying clinical significance.

Functional luminal imaging probe (FLIP) panometry provides conclusive findings that help direct treatment decisions for optimal outcomes in patients with esophagogastric junction outflow obstruction (EGJOO), according to study findings published in the American Journal of Gastroenterology.

High-resolution manometry (HRM) confirms the presence of EGJOO; however, these findings remain clinically inconclusive. The Chicago Classification version 4.0 requires additional testing using FLIP panometry or a barium esophagram to clarify clinical significance.

FLIP panometry produces high-resolution assessment of the mechanical characteristics of the upper gastrointestinal tract wall, especially the esophagogastric junction (EGJ), allowing for identification of patients with clinically relevant EGJOO.

Researchers at Northwestern University conducted an observational study analyzing data from a previous cohort study on 139 adult patients (women, 57%) treated for esophageal symptoms at the Esophageal Center of Northwestern between November 2012 and December 2019.

Defining ‘conclusive EGJOO’ by the complementary finding of EGJ obstruction on FLIP Panometry, 77% of such patients reported significant clinical improvement following achalasia-type treatments.

Following diagnosis of EGJOO based upon HRM findings, these patients also underwent FLIP panometry during endoscopy, rapid drink challenge on HRM, and a timed barium esophagram to inform the treatment plan.

Selected treatments consisted of either achalasia-type treatments or nonachalasia-type treatments. Achalasia-type treatments included pneumatic dilation, peroral endoscopic myotomy, laparoscopic Heller’s myotomy, or Botox injections. Nonachalasia-type treatments included acid suppressive therapy, GI-focused cognitive behavioral therapy, endoscopic dilation, off-label use of smooth muscle relaxants for the esophagus, reassurance/observation, and hiatal hernia repair using Toupet fundoplication.

Researchers evaluated clinical outcomes using the Eckardt score (ES), where anything lower than a 3 reflected a good outcome.

Following FLIP panometry, 33 (77%) of 43 patients with conclusive EGJOO receiving achalasia-type treatments demonstrated good clinical outcomes, while none of the 12 patients with conclusive EGJOO who received nonachalasia-type treatments had good clinical outcomes.

In contrast, only a third of the patients with normal EGJ opening on FLIP panometry had good outcomes with achalasia-type treatments, while 90% of the patients in this category fared better clinically if they received the more conservative, nonachalasia-type treatments.

FLIP panometry, rapid drink challenge on HRM, and timed barium esophagram testing all correlated with treatment outcomes, proving their utility as complementary evaluation tools during comprehensive esophageal motility testing.

The study authors concluded that the findings “suggest that motility assessment with FLIP Panometry provides a means to identify clinically relevant EGJOO and guide management in these challenging patients. Defining ‘conclusive EGJOO’ by the complementary finding of EGJ obstruction on FLIP Panometry, 77% of such patients reported significant clinical improvement following achalasia-type treatments.”

Limitations include the observational study design; lack of randomization or blinding, introducing potential bias, missing data points, especially due to patients lost to follow-up; heterogeneity of treatment approaches; and use of the ES as the primary outcome measure.

Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.


Carlson DA, Schauer JM, Kou W, Kahrilas PJ, Pandolfino JE. FLIP Panometry helps identify clinically relevant esophagogastric junction outflow obstruction per Chicago Classification v4.0. Am J Gastroenterol. Published online August 23, 2022. doi:10.14309/ajg.0000000000001980