Is there an abnormal fasting duodenogastric reflux in nonulcer dyspepsia?

Controversy surrounding 'mini' gastric bypass

Mini gastric bypass is a modification of Mason loop gastric bypass with a longer lesser curvature-based pouch. Though it has been around for more than 15 years, its uptake by the bariatric community has been relatively slow, and the procedure has been mired in controversy right from its early days. Lately, there seems to be a surge in the interest in this procedure, and there is now published experience with more than 5,000 procedures globally. This review examines the major controversial aspects of this procedure against the available scientific literature. Surgeons performing this procedure need to be aware of these controversies and counsel their patients appropriately.

Reconstructive procedure after distal gastrectomy for gastric cancer that best prevents duodenogastroesophageal reflux

Billroth I and II reconstructions are commonly performed after distal gastrectomy. Both may cause duodenogastric and duodenogastroesophageal reflux, conditions reported to have carcinogenetic potential. The aim of this study was to investigate which reconstructive procedure would most effectively prevent bile reflux into the gastric remnant and esophagus after distal gastrectomy. A group of 92 patients who underwent curative distal gastrectomy for gastric cancer were subjected and classified into three groups retrospectively by the reconstructive procedure undertaken: group A, Roux-en-Y (Roux-Y) reconstruction (n = 29); group B, Billroth I reconstruction (n = 41); group C, Billroth II reconstruction (n = 22). The bile reflux periods (percent time) for the gastric remnant and esophagus were measured with the Bilitec 2000 under standardized conditions. The percent time for the gastric remnant was significantly less in group A than in group B or C. In 61% of all patients, bile reflux into the esophagus was found to be more than 5.0% of the time; it was less in group A than in group B or C (p = 0.057). A questionnaire revealed a good correlation between the incidence of reflux symptoms and the percent time for the gastric remnant and esophagus. Roux-Y reconstruction is superior to either Billroth I or II reconstruction for preventing bile reflux into the gastric remnant and esophagus after distal gastrectomy.

Fiberoptic technique for 24-hour bile reflux monitoring. Standards and normal values for gastric monitoring

Physiologic bile reflux was assessed in 27 in vivo test with healthy volunteers to define a standardized protocol and normal values for 24-hour enterogastric bile reflux monitoring (protocol with supine, upright, and meal phases and a free diet avoiding alcohol, smoking, and coffee, evaluation with different thresholds of absorbance units: 0.14, 0.25). In vitro tests with bile-sodium solutions demonstrated a linear dependence of absorbance for bilirubin up to 600 mumol/liter (range of the fiberoptic device: 0.0-1.0). Fluids and food might interfere with absorbances below 0.25 (exception: coffee). In vivo bile often remains in the stomach for more than 1 hr; these events were defined as reflux episodes. The upper limits for physiologic bile reflux are a percentage of total time of bile reflux of 28.2% and an average absorbance during a reflux episode of 0.62 (95th percentile with threshold 0.25). Comparing bile with pH monitoring (absorbance > 0.25 and/or pH > 4), an increase of bilirubin was found most frequently with constant pH (45%) or an increase of pH with constant bilirubin (36%). The hypothesis was drawn that bile and duodenal or pancreatic secretions may separately contribute to duodenogastric reflux.

Duodenogastric bile reflux and gastrointestinal motility in pathogenesis of functional dyspepsia. Role of cholecystectomy

To establish the pathogenic role of duodenogastric reflux in dyspeptic symptoms we have compared the clinical features, gastrointestinal motility, and rates of duodenogastric bile reflux in 12 cholecistectomized dyspeptic patients, 12 dyspeptic patients with intact gallbladder, and 12 healthy controls. Specific symptoms were scored for severity and frequency. Gastrointestinal manometry was performed during 3 hr of fasting and 2 hr postprandially. Simultaneously, samples of duodenal and gastric contents were obtained sequentially for quantification of bile acids. Results show that symptom global severity (9.6 +/- 0.4 vs 8.8 +/- 0.7) and frequency (9.9 +/- 0.8 vs 9.0 +/- 0.5) were similar in both dyspeptic groups; only abdominal pain was milder in cholecystectomized patients (1.9 +/- 0.1 vs 2.6 +/- 0.2; P < 0.05). Fasting gastric bile acid concentrations were higher in cholecystectomized patients (P < 0.05) and antral postcibal motility lower (P < 0.05) than in the groups. No relation among gastric hypomotility, duodenogastric bile reflux, and symptom scores was detected. We concluded that patients with functional dyspepsia and a prior cholecystectomy have clinical features similar to those with gallbladders, but some physiological features are dissimilar: antral motility is decreased and duodenogastric bile reflux is increased. Thus, a uniform clinical expression of various pathophysiological disturbances constitutes the basis of functional dyspepsia.

Review article: functional dyspepsia--should treatment be targeted on disturbed physiology?

In patients who present with chronic unexplained upper abdominal pain or discomfort (functional dyspepsia), therapy should ideally be targeted on correcting the individual's disturbed pathophysiology. Here, putative mechanisms implicated in functional dyspepsia and potential approaches to therapy are critically reviewed in order to determine if targeting treatment is of value. Pharmacological therapies reviewed include those that aim to correct disordered gastric emptying (e.g. cisapride, dopaminergic receptor antagonists, macrolides), reduce visceral hypersensitivity (e.g. somatostatin analogues, cholecystokinin antagonists, opioid agonists, serotonin type 3 receptor antagonists), reduce gastric acid secretion (e.g. H2-blockers, acid pump inhibitors), cure Helicobacter pylori infection, enhance muscosal defence (e.g. sucralfate, bismuth) or modify central nervous system processes. It is concluded that the imperfectly understood pathophysiology of functional dyspepsia contributes to the paucity of established efficacious therapies.

Wide gastric antrum in patients with non-ulcer dyspepsia. Effect of cisapride

Fasting antral area was examined by ultrasonography in 40 healthy subjects and in 106 patients with non-ulcer dyspepsia (NUD) and erosive prepyloric changes (EPC) before and after treatment with cisapride or placebo. The patients were examined twice, first after a run-in period of 14 days of placebo and then after 14 days of cisapride, 10 mg three times daily, or placebo. The relaxed width of the antral area was measured in two sections: a vertical section in which the antrum, the superior mesenteric vein, and the aorta were visualized simultaneously, and a horizontal section that included the pylorus and the middle of the antrum up to 5 cm proximal to the pylorus. The mean antral area was wider (p less than 0.001), both in vertical and horizontal sections, in patients with NUD and EPC than in controls. The antral area in NUD patients was wider (p less than 0.05) in smokers than in non-smokers. The area tended to decrease during treatment with cisapride (p = 0.08). Bloating was the only symptom significantly associated with a wide antral area (p = 0.01). The results suggest a relationship between a wide fasting antral area and NUD with EPC.

Scintigraphic study of gallbladder emptying and duodenogastric reflux during non-ulcerous dyspepsia

Cholescintigraphy with technetium 99m hydroxy imino diacetic acid (99mTc-HIDA) was used to study gallbladder emptying (GE) and duodenogastric reflux (DGR) simultaneously during the postprandial period in humans. Two groups of subjects were examined prospectively; one was a group of healthy volunteers (n = 14) and the other a group of patients with non-ulcerous dyspepsia (NUD) (n = 22). Symptoms were quantified using a clinical score (CS). GE kinetics was quantified according to two indices. DGR episodes were detected by an image-subtraction method and quantified. The group of patients with NUD showed significant early acceleration of GE (P less than 0.01). One DGR episode equivalent to 1% of the injected dose was observed in 1 of the 14 control subjects, and greater than 1% in 3 of the 22 NUD patients. However, there was no correlation between the CS, GE kinetics and DGR episodes. The physiopathological mechanism and clinical significance of these digestive motility anomalies remain to be demonstrated.