SYMPTOMS ASSOCIATED TOWEAKLY ACIDIC REFLUX AND ESOPHAGEAL MOTILITY ABNORMALITIES ARE COMMON FINDINGS IN PATIENTS WITH NCCP NON-RESPONDING TO PPI THERAPY

Abstract

Background and aim: Proton pump inhibitor (PPI) therapy has been demonstrated to be less effective on symptom relief in patients with non-cardiac chest-pain (NCCP) than in those with heartburn. Data on the potential causes of this reduced response rate are lacking. Aim: To assess the frequency of esophageal motility abnormalities and reflux disease in NCCP non-responders patients. Material and methods: Consecutive NCCP patients non-responders to PPI (<50%) underwent manometry and impedance-pH testing (MII-pH) while on or off-therapy. Manometric pattern was defined according to international criteria as Normal peristalsis (NP), Ineffective Esophageal Motility (IEM), Distal Esophageal Spasm (DES), Nutcracker Esophagus (NE).We also measured esophageal acid exposure time (AET; % pH<4), reflux episodes (acid/weakly acidic) and symptom-reflux association using both symptom association probability (SAP+ if = 95%) and symptom index (SI+ if = 50%). Results: Ninety-seven NCCP patients (55F/42M) were enrolled. At manometry testing, NP was found in 62 (64%) patients, 23 (24%) had DES, 9 (9%) had NE and 3 (3%) had IEM. As to MII-pH monitoring (44 on- and 53 patients off-PPI), we found 13 (13%) patients with an abnormal AET, although 4 (4%) of them were on-PPI. Out of the remaining 84 (87%) patients, 8 (8%) had a positive SAP/SI to acid reflux only, 31 (32%) to weakly acidic reflux only and 11 (11%) to both acid and weakly acidic reflux (4 patient were positive considering both refluxes as a whole). Thirty-four (35%) patients had no association between reflux and symptoms and out of them 23 (23%) had NP (i.e. functional chest-pain). Thus, at manometry testing 35 (36%) patients had esophageal motility abnormalities, while at MII-pH monitoring 13 (13%) had acid GERD, 8 (8%) had SI/SAP+ to acid (i.e. hypersensitive esophagus to acid), 31 (32%) had SI/SAP+ to weakly acidic (i.e. weakly acidic GERD) and 11 (11%) had SI/SAP+ to both reflux (i.e. mixed GERD). Conclusions: Symptoms related to weakly acidic reflux and esophageal motility abnormalities are very common in NCCP patients non-responding to PPI therapy and may be responsible for the persistence of symptoms in the majority of these patients