Episode 5: EGJ Outflow Obstruction and FLIPEpisode keywords: EGJ outflow obstruction EGJOO, FLIP panometry, functional luminal imaging probe, EGJ distensibility index, Dallas Consensus FLIP classification, upright IRP, EGJOO differential diagnosis, opioids elevated IRP, timed barium esophagramEpisode SummaryEGJOO is the most over-diagnosed entity in motility. The Chicago Classification v3.0 was too permissive; CCv4.0 significantly tightened the criteria and introduced the concept that manometric EGJOO is always clinically inconclusive without confirmatory testing. This episode covers the full differential, the new criteria, and the FLIP — the tool that tells you what manometry cannot: whether the EGJ actually opens when you push something through it.Key TopicsEGJOO pattern: Elevated IRP + preserved peristalsis. Not achalasia (which requires absent peristalsis), but something is obstructing EGJ outflow.The differential:Early or evolving achalasiaEosinophilic esophagitis (fibrosis impairing EGJ distensibility)Malignancy at the EGJHiatal hernia artifact (especially paraesophageal hernias)Opioid useObesity (increased intra-abdominal fat)Spurious finding of no clinical importanceCCv4.0 EGJOO criteria (all required for manometric diagnosis):Median IRP above ULN in BOTH supine AND upright positionsSome preserved peristalsis≥20% of swallows show increased intrabolus pressureEGJOO is ALWAYS clinically inconclusive on manometry alone. A clinically relevant diagnosis additionally requires: symptoms of dysphagia and/or chest pain, PLUS confirmatory testing (timed barium esophagram showing delayed emptying, or FLIP showing reduced distensibility).Upright IRP pearl: Upright IRP >12 mmHg identifies radiographically confirmed EGJOO with 98% sensitivity. If upright IRP is ≤12 mmHg, true obstruction is unlikely.FLIP — functional luminal imaging probe: Impedance planimetry catheter with 16 paired electrodes and a pressure sensor. Measures cross-sectional area using impedance data. Produces a real-time 3D image of the esophagus during balloon distension.EGJ Distensibility Index (DI): Narrowest cross-sectional area ÷ intraluminal pressure at that segment. At 60 mL fill volume: Normal EGJ opening (NEO): DI ≥2.0 mm²/mmHg AND max diameter ≥16 mmReduced EGJ opening (REO): DI <2.0 mm²/mmHg AND max diameter <12 mmInconclusive: between NEO and REOFLIP panometry contractile responses: Normal = repetitive antegrade contractions (RACs; rule of 6s: ≥6 consecutive antegrade contractions, ≥6 cm axial length, 6±3 per minute). Abnormal: absent, spastic, disordered (pressure >40 mmHg), or diminished (pressure <40 mmHg).Dallas Consensus classification grid (EGJ opening × contractile response):NEO + Normal → Normal (major motility disorder highly unlikely)REO + Normal → Mechanical obstruction patternREO + Spastic → Spastic obstruction (Type III achalasia variant)REO + Absent → Non-spastic obstruction (Types I/II achalasia)NEO + Absent/Diminished → Hypocontractility patternNEO + Spastic → Possible spasm patternBoard PearlsBoard trap: Patient on chronic opioids with manometric EGJOO — do not diagnose achalasia. Rule out opioid-induced IRP elevation first.High-yield: Normal FLIP panometry (NEO + normal contractile response) makes a major motility disorder highly unlikely. Most experts still require HRM to diagnose achalasia, but normal FLIP is strongly reassuring.

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