Chest pain is one of the most common symptoms responsible for emergency department and primary care office visits in the United States. Chest pain can be noncardiac and may be attributed to multiple causes. Esophageal disorders including reflux, motility and functional conditions, affect a large proportion of patients with NCCP and lead to significant morbidity. The use of HRM has changed the diagnostic approach to esophageal motility disorders. It is the most specific and sensitive test for diagnosing motor disorders and a promising procedure in detecting dysmotility disorders in patients with NCCP. Despite the increased sensitivity of HRM, the main indications for esophageal manometry exclude NCCP. This study assessed the percentage of undiagnosed esophageal motility disorders in patients with NCCP referred for high resolution manometry. Differences in HRM findings in patients with NCCP versus patients meeting AGA recommendations for the clinical use of esophageal manometry were also compared. A retrospective descriptive design was utilized. Two hundred-nineteen patient charts were reviewed. One hundred sixty-eight (77%) patients underwent HRM and met AGA recommendations for esophageal manometry; 51 (23%) patients underwent the procedure after receiving a NCCP diagnosis. Findings showed that 116 (69%) patients in the AGA group had abnormal findings while 52 (31%) did not. In the NCCP group 34 (67%) had abnormal findings compared to 17 (33%) who did not. To compare normal and abnormal HRM findings in patients with NCCP versus those meeting AGA criteria, Chi-Square analysis was performed between the groups. The results were not statistically significant (p = 0.10). iv There were no significant differences in the results of HRM in both groups indicating the findings on HRM are the same despite the indication for the procedure. The findings support the use of HRM as a diagnostic tool in patients with chest pain after cardiac workup and endoscopic evaluation. This indicates a possible need to update the AGA indications for esophageal manometry and increase the awareness among healthcare providers regarding the use of HRM in patients with chest pain. Implication for future research is also discussed.

Introdução: A fisiopatologia da Doença do Refluxo Gastroesofágico (DRGE) é multifatorial, sendo a motilidade esofágica um dos fatores implicados na sua gênese. Todavia, ainda não há consenso sobre a existência de associação entre dismotilidade e Hérnia Hiatal (HH) em pacientes com DRGE. Esse estudo tem como objetivo estabelecer a prevalência de Dismotilidade Esofágica (DE) em pacientes com HH e avaliar se a herniação é fator relacionado à DE. Métodos: Foram estudados 356 pacientes com diagnóstico clínico de DRGE submetidos à Endoscopia Digestiva Alta e Manometria Esofágica. Hérnia Hiatal foi definida endoscopicamente por uma distância igual ou maior que 2 cm entre o pinçamento diafragmático e a junção escamo-colunar e Dismotilidade Esofágica quando a ME identificou amplitude das ondas peristálticas no esôfago distal < 30 mmHg e/ou menos de 80% de contrações efetivas. Foi feita a divisão dos pacientes para a análise estatística em 2 grupos, com e sem HH. Resultados: Pacientes com DRGE portadores de HH tiveram prevalência de DE igual a 14,8% e os sem HH, prevalência de 7,7% (p = 0,041). O grupo de pacientes com HH apresentou também maior frequência de esofagite erosiva (47,5% contra 24,2%, p <0,001), menor valor de pressão no EEI (10,4 versus 13,10; p < 0,001) e maior frequência de indivíduos com valores de pH-metria anormais (p < 0,001). A razão bruta de prevalências de DE, segundo a presença de HH, foi 1,92 (IC: 1,04 - 3,53; p = 0,037), porém essa associação não persistiu quando controlada por idade, esofagite, pH-metria alterada e EEI alterado (RP ajustada: 1,69; IC: 0,68 – 4,15; p = 0,257). Conclusão: Apesar da prevalência de DE no grupo HH ter sido maior do que no grupo sem HH, a associação entre HH e DE em indivíduos com DRGE desaparece ao se controlar por co-variáveis relevantes, levando a crer que neste tipo de paciente, HH não é fator de risco independente destas variáveis. / Introduction: The pathophysiology of gastroesophageal reflux disease is multifactorial, where esophageal motility is one of the factors implicated in its genesis. However, there is still no consensus on the existence of an association between esophageal dysmotility and hiatal hernia in patients with gastroesophageal reflux disease. The objective of this study was to establish the prevalence of esophageal dysmotility in patients with hiatal herina and to determine if herniation is a factor related to esophageal dysmotility. Methods: The study included 356 patients with a clinical diagnosis of gastroesophageal reflux disease submitted to upper digestive endoscopy and esophageal functional dagnostics. Hiatal Hernia was defined endoscopically by a distance equal to or greater than 2 cm between the diaphragmatic constriction and the squamo-columnar junction and esophageal dysmoyility when the esophageal manometry identified the amplitude of the peristaltic waves in the distal esophagus are < 30 mmHg and/or less than 80% of effective contractions. For statistical analysis, the patients were divided into 2 grups: with and without HH. Results: Gastroesophageal reflux disease patients with hiatal hernia had a prevalence of esophageal dysmotility equal to 14.8% and those without hiatal hernia, a prevalence of 7.7% (p = 0.041). The group of patients with hiatal hernia also showed a greater frequency of erosive esophagitis (47.5% versus 24.2%, p <0.001), lower low esophageal sphincter pressure (10.4 versus 13.10; p < 0.001) and greater frequency of individuals with abnormal pH-metry values (p < 0.001). The crude prevalence ratios for esophageal dysmotility, according to the presence of hiatal hernia, was 1.92 (CI: 1.04 - 3.53; p = 0.037), but this association did not persist when controlled for age, esophagitis, altered pH-metry and altered low esophageal sphincter (adjusted PR: 1.69; CI: 0.68 – 4.15; p = 0.257). Conclusion: Despite the prevalence of esophageal dysmotility in the hiatal hernia group being higher than that in the group without hiatal hernia, the association between hiatal hernia and esophageal dysmotility in individuals with gastroesophageal reflux disease disappeared on controlling for relevant co-variables, leading us to believe that in this type of patient, hiatal hernia is not a risk factor independent of these variables.

Introdução: A fisiopatologia da Doença do Refluxo Gastroesofágico (DRGE) é multifatorial, sendo a motilidade esofágica um dos fatores implicados na sua gênese. Todavia, ainda não há consenso sobre a existência de associação entre dismotilidade e Hérnia Hiatal (HH) em pacientes com DRGE. Esse estudo tem como objetivo estabelecer a prevalência de Dismotilidade Esofágica (DE) em pacientes com HH e avaliar se a herniação é fator relacionado à DE. Métodos: Foram estudados 356 pacientes com diagnóstico clínico de DRGE submetidos à Endoscopia Digestiva Alta e Manometria Esofágica. Hérnia Hiatal foi definida endoscopicamente por uma distância igual ou maior que 2 cm entre o pinçamento diafragmático e a junção escamo-colunar e Dismotilidade Esofágica quando a ME identificou amplitude das ondas peristálticas no esôfago distal < 30 mmHg e/ou menos de 80% de contrações efetivas. Foi feita a divisão dos pacientes para a análise estatística em 2 grupos, com e sem HH. Resultados: Pacientes com DRGE portadores de HH tiveram prevalência de DE igual a 14,8% e os sem HH, prevalência de 7,7% (p = 0,041). O grupo de pacientes com HH apresentou também maior frequência de esofagite erosiva (47,5% contra 24,2%, p <0,001), menor valor de pressão no EEI (10,4 versus 13,10; p < 0,001) e maior frequência de indivíduos com valores de pH-metria anormais (p < 0,001). A razão bruta de prevalências de DE, segundo a presença de HH, foi 1,92 (IC: 1,04 - 3,53; p = 0,037), porém essa associação não persistiu quando controlada por idade, esofagite, pH-metria alterada e EEI alterado (RP ajustada: 1,69; IC: 0,68 – 4,15; p = 0,257). Conclusão: Apesar da prevalência de DE no grupo HH ter sido maior do que no grupo sem HH, a associação entre HH e DE em indivíduos com DRGE desaparece ao se controlar por co-variáveis relevantes, levando a crer que neste tipo de paciente, HH não é fator de risco independente destas variáveis. / Introduction: The pathophysiology of gastroesophageal reflux disease is multifactorial, where esophageal motility is one of the factors implicated in its genesis. However, there is still no consensus on the existence of an association between esophageal dysmotility and hiatal hernia in patients with gastroesophageal reflux disease. The objective of this study was to establish the prevalence of esophageal dysmotility in patients with hiatal herina and to determine if herniation is a factor related to esophageal dysmotility. Methods: The study included 356 patients with a clinical diagnosis of gastroesophageal reflux disease submitted to upper digestive endoscopy and esophageal functional dagnostics. Hiatal Hernia was defined endoscopically by a distance equal to or greater than 2 cm between the diaphragmatic constriction and the squamo-columnar junction and esophageal dysmoyility when the esophageal manometry identified the amplitude of the peristaltic waves in the distal esophagus are < 30 mmHg and/or less than 80% of effective contractions. For statistical analysis, the patients were divided into 2 grups: with and without HH. Results: Gastroesophageal reflux disease patients with hiatal hernia had a prevalence of esophageal dysmotility equal to 14.8% and those without hiatal hernia, a prevalence of 7.7% (p = 0.041). The group of patients with hiatal hernia also showed a greater frequency of erosive esophagitis (47.5% versus 24.2%, p <0.001), lower low esophageal sphincter pressure (10.4 versus 13.10; p < 0.001) and greater frequency of individuals with abnormal pH-metry values (p < 0.001). The crude prevalence ratios for esophageal dysmotility, according to the presence of hiatal hernia, was 1.92 (CI: 1.04 - 3.53; p = 0.037), but this association did not persist when controlled for age, esophagitis, altered pH-metry and altered low esophageal sphincter (adjusted PR: 1.69; CI: 0.68 – 4.15; p = 0.257). Conclusion: Despite the prevalence of esophageal dysmotility in the hiatal hernia group being higher than that in the group without hiatal hernia, the association between hiatal hernia and esophageal dysmotility in individuals with gastroesophageal reflux disease disappeared on controlling for relevant co-variables, leading us to believe that in this type of patient, hiatal hernia is not a risk factor independent of these variables.

Introdução: A fisiopatologia da Doença do Refluxo Gastroesofágico (DRGE) é multifatorial, sendo a motilidade esofágica um dos fatores implicados na sua gênese. Todavia, ainda não há consenso sobre a existência de associação entre dismotilidade e Hérnia Hiatal (HH) em pacientes com DRGE. Esse estudo tem como objetivo estabelecer a prevalência de Dismotilidade Esofágica (DE) em pacientes com HH e avaliar se a herniação é fator relacionado à DE. Métodos: Foram estudados 356 pacientes com diagnóstico clínico de DRGE submetidos à Endoscopia Digestiva Alta e Manometria Esofágica. Hérnia Hiatal foi definida endoscopicamente por uma distância igual ou maior que 2 cm entre o pinçamento diafragmático e a junção escamo-colunar e Dismotilidade Esofágica quando a ME identificou amplitude das ondas peristálticas no esôfago distal < 30 mmHg e/ou menos de 80% de contrações efetivas. Foi feita a divisão dos pacientes para a análise estatística em 2 grupos, com e sem HH. Resultados: Pacientes com DRGE portadores de HH tiveram prevalência de DE igual a 14,8% e os sem HH, prevalência de 7,7% (p = 0,041). O grupo de pacientes com HH apresentou também maior frequência de esofagite erosiva (47,5% contra 24,2%, p <0,001), menor valor de pressão no EEI (10,4 versus 13,10; p < 0,001) e maior frequência de indivíduos com valores de pH-metria anormais (p < 0,001). A razão bruta de prevalências de DE, segundo a presença de HH, foi 1,92 (IC: 1,04 - 3,53; p = 0,037), porém essa associação não persistiu quando controlada por idade, esofagite, pH-metria alterada e EEI alterado (RP ajustada: 1,69; IC: 0,68 – 4,15; p = 0,257). Conclusão: Apesar da prevalência de DE no grupo HH ter sido maior do que no grupo sem HH, a associação entre HH e DE em indivíduos com DRGE desaparece ao se controlar por co-variáveis relevantes, levando a crer que neste tipo de paciente, HH não é fator de risco independente destas variáveis. / Introduction: The pathophysiology of gastroesophageal reflux disease is multifactorial, where esophageal motility is one of the factors implicated in its genesis. However, there is still no consensus on the existence of an association between esophageal dysmotility and hiatal hernia in patients with gastroesophageal reflux disease. The objective of this study was to establish the prevalence of esophageal dysmotility in patients with hiatal herina and to determine if herniation is a factor related to esophageal dysmotility. Methods: The study included 356 patients with a clinical diagnosis of gastroesophageal reflux disease submitted to upper digestive endoscopy and esophageal functional dagnostics. Hiatal Hernia was defined endoscopically by a distance equal to or greater than 2 cm between the diaphragmatic constriction and the squamo-columnar junction and esophageal dysmoyility when the esophageal manometry identified the amplitude of the peristaltic waves in the distal esophagus are < 30 mmHg and/or less than 80% of effective contractions. For statistical analysis, the patients were divided into 2 grups: with and without HH. Results: Gastroesophageal reflux disease patients with hiatal hernia had a prevalence of esophageal dysmotility equal to 14.8% and those without hiatal hernia, a prevalence of 7.7% (p = 0.041). The group of patients with hiatal hernia also showed a greater frequency of erosive esophagitis (47.5% versus 24.2%, p <0.001), lower low esophageal sphincter pressure (10.4 versus 13.10; p < 0.001) and greater frequency of individuals with abnormal pH-metry values (p < 0.001). The crude prevalence ratios for esophageal dysmotility, according to the presence of hiatal hernia, was 1.92 (CI: 1.04 - 3.53; p = 0.037), but this association did not persist when controlled for age, esophagitis, altered pH-metry and altered low esophageal sphincter (adjusted PR: 1.69; CI: 0.68 – 4.15; p = 0.257). Conclusion: Despite the prevalence of esophageal dysmotility in the hiatal hernia group being higher than that in the group without hiatal hernia, the association between hiatal hernia and esophageal dysmotility in individuals with gastroesophageal reflux disease disappeared on controlling for relevant co-variables, leading us to believe that in this type of patient, hiatal hernia is not a risk factor independent of these variables.