SYMPTOMS ASSOCIATED TO WEAKLY ACIDIC REFLUX AND ESOPHAGEAL MOTILITY ABNORMALITIES ARE MORE COMMON THAN FUNCTIONAL CHEST-PAIN IN PATIENTS WITH NON-CARDIAC CHEST PAIN REFRACTORY TO PPI THERAPY

INTRODUCTION: Previous studies showed that PPIs are less effective in relieving non-cardiac chest-pain (NCCP) than heartburn. Data on the potential causes of this finding are lacking. AIMS & METHODS: To assess the frequency of esophageal motility abnormalities and reflux disease in NCCP refractory patients. Consecutive NCCP refractory patients (response <50%) underwent conventional manometry and impedance-pH testing while on or off-PPI therapy. Manometric pattern was defined as follows: Normal peristalsis (NP; normal wave amplitude and progression), Ineffective Esophageal Motility (IEM; lower distal wave amplitude in 30% of wet swallows), Distal Esophageal Spasm (DES; simultaneous wave progression in >10% of wet swallows with normal/high distal amplitude), Nutcracker Esophagus (NE; normal wave progression and high distal wave amplitude). We also measured esophageal acid exposure time (AET), reflux episodes (acid/weakly acidic) and symptom-reflux association using both symptom association probability (SAP+ if 95%) and symptom index (SI+ if 50%). RESULTS: One-hundred and fifty NCCP patients (83F/67M; mean age 48; 6% ERD/94% NERD) were enrolled. At manometry testing, 96 (64%) patients had NP, 35 (23%) had DES, 16 (11%) had NE and 3 (2%) had IEM (i.e. 54 (36%) had motor abnormalities). At impedance-pH monitoring, 50 patients were studied on- and 100 off-PPI treatment. We found 26 (17%) patients with an abnormal AET, although 10 (8%) of them were on-PPI (i.e. acid GERD). Out of the remaining 124 (83%) patients, 16 (11%) had a positive SAP/SI to acid reflux (i.e. hypersensitive esophagus to acid), 41 (28%) to weakly acidic reflux (i.e. weakly acidic GERD) and 14 (9%) to both acid and weakly acidic reflux (i.e. mixed GERD). Fifty-three (35%) patients had no association between reflux and symptoms and out of them 34 (23%) had NP (i.e. functional chest-pain patients). CONCLUSION: Symptoms related to weakly acidic reflux and motility abnormalities are very common in NCCP refractory patients and may be responsible for the persistence of symptoms in the majority of them. A “functional” disorder may account for a quarter of these patients. Notably, an incomplete acid suppression may be responsible of poor response in a consistent group of patients.