What is the preferred diagnostic tool between High-Resolution Manometry (HRM) and EndoFLIP (Endoluminal Functional Lumen Imaging Probe) for evaluating esophageal function and motility?

High Resolution Manometry vs EndoFLIP for Evaluating Esophageal Function and Motility

High Resolution Manometry (HRM) is the preferred diagnostic tool for evaluating esophageal function and motility due to its superior reproducibility, speed of performance, ease of interpretation, and established clinical guidelines supporting its use. 1, 2

Advantages of High Resolution Manometry (HRM)

• HRM is superior to standard manometry in terms of reproducibility, speed of performance, and ease of interpretation, with high-grade evidence supporting this recommendation 1
• HRM provides more accurate measurement of bolus movement through the esophagus and can detect disorders of esophageal peristalsis and abnormalities of the lower esophageal sphincter (LOS) that may be missed with standard manometry 2
• HRM enables classification of achalasia into subtypes (I, II, and III), which has prognostic value and can guide therapeutic decisions 1, 2
• HRM has demonstrated improved diagnostic yield for achalasia compared with conventional manometry, with diagnoses more frequently confirmed in follow-up 3
• HRM results are highly reproducible for key parameters including upper esophageal sphincter function, pressure transition zone length, LOS length and pressure, and LOS relaxation 2

Clinical Applications of HRM

• HRM should be performed in patients with dysphagia after endoscopy with biopsies has ruled out mucosal and structural disorders 1, 4
• HRM is essential before antireflux surgery to rule out LOS dysfunction (achalasia) and major motor disorders of the esophageal body 1, 4
• HRM can provide useful diagnostic information in patients with dysphagia after antireflux surgery that cannot be obtained by standard manometry 1
• HRM is the preferred method to localize the LOS prior to catheter-based pH sensor placement 1, 2
• HRM has demonstrated a higher diagnostic yield (97% vs 84%) compared to conventional manometry in patients with unexplained dysphagia 3

EndoFLIP (Endoluminal Functional Lumen Imaging Probe)

• EndoFLIP provides real-time assessment of esophagogastric junction (EGJ) distensibility and distension-induced contractility during endoscopy 5
• EndoFLIP shows excellent interrater agreement for EGJ distensibility index and maximum diameter measurements 6
• EndoFLIP can detect abnormal esophageal motility, including achalasia, at the endoscopic encounter, potentially providing a point-of-care assessment 5
• Normal motility on EndoFLIP panometry is predictive of a benign HRM result 5
• EndoFLIP shows moderate-to-good agreement in the assignment of EGJ opening classification, contractile response pattern, and motility classification 6

Comparative Analysis and Recommendation

• While EndoFLIP shows promise as a complementary or point-of-care tool, HRM remains the established standard with stronger guideline support 1, 2, 6
• HRM has higher levels of interrater agreement and accuracy (82%) compared to EndoFLIP (78%) for motility classification 6
• The British Society of Gastroenterology provides strong recommendations for HRM use in multiple clinical scenarios, while similar guideline support for EndoFLIP is currently lacking 1
• HRM interpretation is significantly more accurate and faster, particularly when assessing esophageal aperistalsis, hypomotility, and relaxation of the LOS 2, 7

Enhanced Diagnostic Capabilities with Adjunctive Testing

• Adjunctive testing during HRM (larger volumes of water, solid/viscous swallows, or a test meal) can provide additional information and unmask pathology not seen with standard water swallows 1, 2
• These adjunctive tests are more representative of normal swallowing behavior, more likely to induce symptoms, and improve diagnostic yield 2, 8
• The addition of impedance to HRM (HRIM) can help visualize bolus movement and peristalsis effectiveness 1, 2

Important Considerations and Potential Pitfalls

• Normal values for HRM are manufacturer and catheter specific, requiring appropriate reference ranges 1, 2
• Failing to perform endoscopy with biopsies before manometry in patients with dysphagia to rule out mucosal and structural disorders 1, 4
• Not using appropriate adjunctive testing (solid swallows, test meals) which can unmask pathology not seen with standard water swallows 1, 2
• Overall procedure tolerance may be better with conventional manometry than with HRM, which should be considered in patient selection 3