EndoFLIP® in real-world esophagology: a versatile tool for diagnosing and managing dysphagia across diverse clinical scenarios

BACKGROUND: High-resolution manometry (HRM) is the gold standard for evaluating esophageal motility but may be inconclusive, poorly tolerated, or unavailable. The Endoluminal Functional Lumen Imaging Probe (EndoFLIP) provides real-time assessment of esophageal distensibility and contractility and is emerging as a complementary diagnostic modality. AIM: To evaluate the impact of routine EndoFLIP use across diverse esophageal pathologies, particularly when HRM is inconclusive or unavailable and to contextualize findings within current evidence. METHODS: We retrospectively analyzed 106 adults with dysphagia who underwent endoscopy with EndoFLIP (16-cm catheter). Indications included inconclusive/unavailable HRM ( n = 27), suspected esophagogastric junction outflow obstruction (EGJOO, n = 14), eosinophilic esophagitis (EoE, n = 29), achalasia ( n = 13), and postsurgical dysphagia ( n = 23). Distensibility index, cross-sectional area, and maximal diameter were correlated with endoscopic, histologic, and clinical data. RESULTS: EndoFLIP clarified diagnoses in 92.6% of inconclusive HRM cases and prompted management changes in 81.1% overall. Only 2/14 EGJOO patients showed reduced esophagogastric junction distensibility, avoiding unnecessary interventions in the remainder. In EoE, 86.2% exhibited reduced distensibility, leading to dilation ( n = 6) or escalation to biologic therapy ( n = 3). In achalasia, EndoFLIP-guided referral for peroral endoscopic myotomy or Heller myotomy enabled posttreatment assessment. In postsurgical dysphagia, reduced distensibility was detected in 45% of cases, prompting intra-procedure intervention in 44%. CONCLUSION: EndoFLIP provides objective, real-time evaluation of esophageal mechanics, enhancing diagnostic accuracy and facilitating targeted therapy in complex or indeterminate cases. These findings, consistent with contemporary literature, support its integration into routine esophageal assessment.