The Functional Lumen Imaging Probe Detects Esophageal Contractility Not Observed With Manometry in Patients With Achalasia

Abstract

Background & Aims The functional lumen imaging probe (FLIP) could improve characterization of achalasia subtypes by detecting non-occlusive esophageal contractions not observed with standard manometry. We aimed to evaluate for esophageal contractions during volumetric distention in patients with achalasia using FLIP topography. Methods Fifty one treatment-naïve patients with achalasia, defined and sub-classified by high-resolution esophageal pressure topography, and 10 asymptomatic individuals (controls) were evaluated with the FLIP during endoscopy. During stepwise distension, simultaneous intra-bag pressures and 16 channels of cross-sectional areas were measured; data were exported to software that generated FLIP topography plots. Esophageal contractility was identified by noting periods of reduced luminal diameter. Esophageal contractions were further characterized by propagation direction, repetitiveness, and based on whether they were occluding or non-occluding. Results Esophageal contractility was detected in all 10 controls: 8/10 had repetitive, antegrade, contractions and 9/10 had occluding contractions. Contractility was detected in 27% (4/15) of patients with type I achalasia and 65% (18/26, including 9 with occluding contractions) of patients with type II achalasia. Contractility was detected in all 10 patients with type III achalasia; 8 of these patients had a pattern of contractility not observed in controls (repetitive, retrograde contractions). Conclusions Esophageal contractility not observed with manometry can be detected in patients with achalasia using FLIP topography. The presence and patterns of contractility detected with FLIP topography may represent variations in pathophysiology, such as mechanisms of pan-esophageal pressurization in patients with type II achalasia. These findings could have implications for additional sub-classification to supplement prediction of the achalasia disease course.

Advances in the management of oesophageal motility disorders in the era of high-resolution manometry: a focus on achalasia syndromes

“…In support of this hypothesis, post-myotomy peristalsis in the Roman et al study was usually characterized as weak with low DCI values 34 . Along the same lines, FLIP detected non-occluding or occluding contractions in 10 of 10 patients with type III achalasia, two-thirds of the 26 patients with type II achalasia tested and one-third of the 15 patients with type I achalasia 42 .…”

Functional Lumen Imaging Probe for the Management of Esophageal Disorders: Expert Review From the Clinical Practice Updates Committee of the AGA Institute

“…The benefits of FLIP topography are the ability to define EGJ distensibility and function while simultaneously obtaining information regarding the contractile activity and distensibility of the esophageal body. This approach has been utilized to better characterize the motor activity in the body of the esophagus in achalasia subtypes where patients were categorized based on three distinct body patterns that consisted of repetitive antegrade contractions (RACs), repetitive retrograde contractions (RRCs) or absence of activity (Figure 2) 11, 12 .…”

Achalasia: It Is Not All Black and White

“…In a study performed by Carlson et al, esophageal body contractility including propagating contractions were observed in a proportion of patients with all subtypes of achalasia during catheter bag distension. Often, this contractility was of an abnormal pattern, including repetitive retrograde contractions that were never observed in controls [79]. The significance of these propagating contractions is yet to be seen, but further study is certainly warranted to determine if their presence carry pathophysiologic or prognostic implications.…”