Introduction/Background
Achalasia is a primary oesophageal motility disorder characterised by impaired lower oesophageal sphincter (LES) relaxation and absent peristalsis. While high-resolution manometry (HRM) remains the diagnostic gold standard, the functional lumen imaging probe (EndoFLIP) has emerged as a valuable adjunct in the evaluation of LES distensibility, hence aiding diagnosis1. In addition, EndoFLIP can provide real-time, intraoperative feedback during peroral endoscopic myotomy (POEM) in assessing procedural adequacy1. We present a case of type I achalasia in which EndoFLIP was used both for diagnostic clarification and intra-procedural assessment of myotomy effectiveness during POEM.
Case Presentation
A 32-year-old male was referred to Gastroenterology from his primary care physician for progressive dysphagia to solids and liquids, regurgitation and significant loss of weight over the past year (Eckardt score 6 points). A computed tomography (CT) scan of the chest and abdomen were unremarkable. Oesophagogastroduodenoscopy (OGD) revealed a dilated oesophagus with retained food residue up until the proximal oesophagus and a puckered gastro-oesophageal junction. A high-resolution manometry (HRM) was unsuccessful due to difficulty traversing the catheter beyond the LES. An EndoFLIP was then performed which found a low esophagogastric junction (EGJ) distensibility index (DI) of 1.7 mm²/mmHg at 60 mL fill volume and an absent contractile response during volumetric distension, confirming severe EGJ outflow obstruction and supporting a diagnosis of type I achalasia. He subsequently underwent a POEM, during which an intra-procedure EndoFLIP was performed post-myotomy to assess adequacy prior to mucosal incision closure – this revealed a DI of 6.3 mm²/mmHg at 60 mL fill volume, indicating adequate disruption of the LES muscle fibres. The patient had significant improvement in symptoms and was discharged 2 days post-POEM.
Conclusion
This case report highlights the utility of EndoFLIP as a diagnostic tool in patients with underlying oesophageal motility disorders, especially in circumstances where HRM is challenging to perform. Furthermore, its use as an intra-procedure guide in providing objective, real-time physiological feedback in the setting of POEM has great potential in guiding and optimising therapeutic outcomes.