Diagnostic testing for esophageal motility disorders: Barium radiography, high-resolution manometry, and the functional lumen imaging probe (FLIP)

Esophageal motility disorders present with symptoms that can include dysphagia, regurgitation, and/or retrosternal pain. After an initial upper endoscopy, choice of esophageal physiologic evaluation modality includes barium radiography, high-resolution manometry (HRM), and/or the functional lumen imaging probe (FLIP), based on patient characteristics, symptoms, availability, and the clinical context. Barium radiography is particularly useful when oropharyngeal dysfunction is evaluated (using modified barium swallow), when anatomic abnormalities are suspected, when HRM is unavailable, and when esophageal emptying needs determination before or after achalasia therapy (using timed barium esophagram). HRM has been extensively evaluated in the diagnosis of esophageal motor disorders and in subtyping achalasia. FLIP is particularly useful in the initial diagnosis and subsequent follow-up of achalasia spectrum disorders, as well as arbitration of HRM-diagnosed esophagogastric junction outflow obstruction (EGJOO). In this chapter, we discuss the indications, patient selection, protocol, technical considerations, interpretation, and costs for each of these diagnostic modalities.