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Hiatal hernia (HH) plays a prominent role in the pathogenesis of GERD. A rapid pull through (RPT) technique during esophageal manometry discloses various pressure profiles of HH, based on the identification of two high pressure zones: the crural diaphragm (CD) and the lower esophageal sphincter (LES). Our aim was to correlate the different profiles of HH with frequency of reflux episodes in patients with GERD. Methods: We included 69 patients with GERD and small «3cm) and reducible HH diagnosed endoscopically. In all subjects esophageal manometry and 24 pH-metry were performed on two successive days. The RPT (1 ern/sec) was performed in end-inspiration apnoea using a three-lumen (radial opentips) catheter. The procedure was repeated ten times, obtaining 30 pressure traces in each patient. The CD and LES provoke either distinct pressure peaks: diaphragm peak (DP) and sphincter peak (SP) respectively or distinct small pressure deflections: diaphragm deflection (DD) and sphincter deflection (SD). The various combinations of peak and/or deflection identified four manometric HH profiles: A (DD-SP), B (DP-SD), C (DPSP) and D (DD-SD). The overlapping of CD and LES, that is consistent with HH reducibility, determines a fifth pressure profile (E) characterised by a single peak. Patients were divided in 5 groups according to the prevalence of one of the pressure profiles (A n=4; B n=2; C n=30; D n= 18; En= 15). Twenty four hours pH-metry in distal esophagus was also performed to calculate the number of reflux events during total, upright, recumbent and postprandial periods. Statistical analysis comparison was performed among the different patients groups using Mann-Whitney test. Groups A and B were excluded from analysis because of the small number of patients. Results: The frequency of reflux events during total and upright periods was significantly higher in the D group (240±37 and 180±33) than in the C group (120±19 and 95±18 respectively). No significant differences were found during recumbent and postprandial periods. In conclusion, patients with small hiatal hernia with a double-deflection pressure profile (absence of pressure peaks) have the highest frequency of reflux events reinforcing the concept that both CD and LES pressure peaks are necessary for the continence of esophagogastric junction. Finally, the manometric study of esophagogastric junction by RPT technique represents an useful approach to understand pathogenetic mechanisms of GERD