State of the Art Pediatrics: EndoFLIP Expands Pediatric Motility Diagnosis and Treatment Insights
Children with gastrointestinal motility disorders frequently experience years of symptoms before receiving a diagnosis. This is especially true with motility disorders of the esophagus, which often cause varied symptoms in the pediatric population such as vomiting, dysphagia, feeding difficulties, pain and weight loss. These symptoms are often progressive and debilitating.
Diagnostic workup for esophageal dysmotility was historically limited in pediatrics. Endoscopy is helpful to identify structural and mucosal abnormalities; however, it offers limited insight into the gastrointestinal tract function and motility. High-resolution manometry is the gold standard for evaluating esophageal motility, although it has several practical limitations in our young patient population. High-resolution esophageal manometry requires patient cooperation; hence, it is not always feasible in younger patients or those with developmental delays. It is also not readily available in every pediatric gastroenterology practice.
Fortunately, functional lumen imaging probe (FLIP) panometry, better known as EndoFLIP, offers a novel opportunity to assess motility and distensibility in a variety of pediatric gastrointestinal disorders during sedated endoscopy.1-3 Approved for children 5 years and older, it provides an opportunity to evaluate contractility, stiffness and sphincter function without some of the challenges of classic manometry.
EndoFLIP or FLIP panometry measures intraluminal dimension and pressure during controlled balloon distention. This is done with a catheter that measures impedance and pressure and has a compliant balloon that can be inflated at different volumes.3 The catheter is placed during a sedated endoscopy after visual inspection, where an endoscopist can gather helpful information about intraluminal diameter, distensibility or stiffness, and esophageal secondary peristalsis.
Most of the FLIP panometry experience has been in esophageal motility disorders. FLIP panometry has become a helpful tool in assessing esophageal dysmotility or impaired lower esophageal sphincter relaxation, such as in achalasia.3,4 It has also been helpful in evaluating fibrosis or subtle strictures in patients with eosinophilic esophagitis that might be missed during routine endoscopy. EndoFLIP can also be performed after myotomy for achalasia to measure treatment outcome, providing real-time data during the procedure on the effectiveness of the intervention. It complements the information obtained with high-resolution manometry, which is pressure, providing diameter and distensibility measurements.1,2 Recently, the published Dallas Consensus provided a standardized interpretation of FLIP panometry, improving consistency across centers and between adult and pediatric specialists.4
Recently, more applications for this technology have emerged. EndoFLIP has been used in some centers to assess pyloric distensibility in children with symptoms of gastric outlet obstruction or delayed gastric emptying.1 This may help target interventions for these patients, such as pyloric botulinum toxin injection, dilation or myotomy in the future. Similarly, some investigators have started exploring the role of EndoFLIP in anorectal disorders like fecal incontinence.1 In conjunction with manometry, this modality may provide a better understanding of anorectal dysfunction.
In summary, EndoFLIP is a great adjunct to standard motility tests. It provides real-time information during an endoscopy to help direct the best treatment and determine if further investigation with high-resolution manometry is needed. It also provides information on the efficacy of therapeutic interventions, such as after myotomy for achalasia. Pediatric studies have demonstrated that it is a safe procedure even in young children, with minimal risk, and only adds a few minutes to an endoscopy .1 EndoFLIP is a promising advancement in pediatric gastroenterology by providing objective data and an immediate assessment of the gastrointestinal tract stiffness and contractility. This information is a needed complement to conventional testing.
However, certain limitations should be acknowledged. As with many other modalities in pediatrics, we expect reference values will continue to evolve, and the wide range of ages in the pediatric population limits the standardization for different age groups. Additionally, the equipment is currently mostly available at specialized motility centers and requires dedicated expertise for accurate interpretation of results.
Future studies will likely focus on continuing to develop age-specific normative values, validating FLIP panometry across diverse populations, and defining diagnostic accuracy and prognostic value in its various applications. As our experience with FLIP panometry grows and access becomes more widespread, it has the potential to become an important tool in the evaluation and management of gastrointestinal motility disorders, providing unique physiologic insights that complement current modalities.
References:
- Mutalib M, et al. Use of endoluminal functional lumen imaging probe in investigating paediatric gastrointestinal motility disorders. World J Gastroenterol. 2023.
- Lerner DG, Mencin A, Novak I, et al. Advances in pediatric diagnostic endoscopy: a state-of-the-art review. JPGN Reports. 2022;3(3):224. doi:10.1097/PG9.0000000000000224
- Donnan EN, Pandolfino JE. EndoFLIP in the esophagus: assessing sphincter function, wall stiffness, and motility to guide treatment. Gastroenterol Clin North Am. 2020;49(3):427-435. doi:10.1016/j.gtc.2020.04.002
- Carlson DA, Pandolfino JE, Yadlapati R, et al. A standardized approach to performing and interpreting functional lumen imaging probe panometry for esophageal motility disorders: The Dallas Consensus. Gastroenterology. 2025;168(6):1114-1127.e5.