Role of Mixed Reflux and Hypomotility with Delayed Reflux Clearance in Patients with Non-cardiac Chest Pain

Mentore Ribolsi, Paola Balestrieri, Dario Biasutto, Sara Emerenziani, Michele Cicala

Gastroesophageal reflux disease (GERD) is the most common cause of non-cardiac chest pain (NCCP). Currently available data reveal a weak relationship between NCCP and dismotility. Moreover, it is unclear why some refluxes are perceived as heartburn and others as NCCP. We aimed to evaluate the role of the reflux pattern and of the esophageal motility in the pathogenesis and perception of NCCP in non-erosive reflux disease (NERD) patients. Forty-eight NERD patients with NCCP as main symptom (Group 1) and 50, presenting only typical symptoms (Group 2), underwent high-resolution manometry (HRM) and multichannel intraluminal impedance-pH monitoring. Weak peristalsis was found in 60% of patients with NCCP and in 24% of patients with typical symptoms (P < 0.05). In patients belonging to Group 1, the majority of reflux episodes associated with chest pain were acid and mixed. Both in Group 1 and Group 2 the proportion of mixed refluxes associated with NCCP was higher than the proportion of mixed refluxes associated with typical symptoms. In patients belonging to Group 1, the reflux clearing time at 5, 9, and 15 cm, measured in reflux episodes associated to NCCP was higher than in reflux episodes associated to typical symptoms (mean ± 95% CI: 27.2 ± 5.6, 23.3 ± 4.4, and 14.6 ± 2.3 seconds vs 18.3 ± 3.5, 13.3 ± 2.2, and 11.1 ± 1.8 seconds; P < 0.01). The presence of gas in the refluxate seems to be associated with NCCP perception. The impaired motility observed in NCCP patients may play a relevant role in delaying reflux clearing, hence increasing the time of contact between refluxate and esophageal mucosa.