New Causes for the Old Problem of Bile Reflux Gastritis

Histopathological differences in pediatric duodenogastric reflux: a comparative study

The histopathological effects of duodenogastric reflux (DGR) in children remain poorly described. This study aimed to evaluate and compare the gastric histopathological findings of pediatric patients with endoscopically confirmed DGR gastritis and those without, to identify potential morphological changes associated with bile reflux in childhood. This retrospective study compared children with endoscopically confirmed DGR to age- and sex-matched controls without DGR. Gastric biopsy samples were re-evaluated by a single pathologist blinded to clinical data. Histopathological features, including inflammation severity, activity, fibrosis, vascular congestion, edema, foveolar hyperplasia, the presence of Helicobacter pylori, lymphoid aggregates, reactive gastropathy, intestinal metaplasia, and glandular atrophy were compared. Logistic regression was used to identify significant predictors of DGR. A total of 73 patients with DGR and 65 controls were included. Fibrosis (60.2% vs. 9.2%, p < 0.001), congestion (63.0% vs. 27.7%, p < 0.001), foveolar hyperplasia (32.9% vs. 6.2%, p < 0.001), and edema (24.7% vs. 6.2%, p = 0.003) were significantly more common in the DGR group. Logistic regression identified foveolar hyperplasia (OR 10.67), edema (OR 9.01), fibrosis (OR 6.98), and congestion (OR 5.85) as independent predictors of DGR.

CONCLUSION

Fibrosis, congestion, foveolar hyperplasia, and edema are significantly associated with DGR in pediatric patients and may serve as supportive histological markers for diagnosis.

WHAT IS KNOWN

• DGR in children lacks a standardized diagnostic method, with endoscopy and histopathology being commonly used. • Histopathological features such as foveolar hyperplasia and fibrosis are known in adults but less studied in children.

WHAT IS NEW

• This study identifies fibrosis, congestion, foveolar hyperplasia, and edema as significant histopathological markers in pediatric DGR. • It suggests that endoscopic findings, combined with histopathology, can aid in the diagnosis of DGR in children.

Duodenogastric reflux in health and disease: insights from a computational fluid dynamics model of the stomach

The stomach is responsible for physically and chemically processing the ingested meal before controlled emptying into the duodenum through the pyloric sphincter. An incompetent pylorus allows reflux from the duodenum back into the stomach, and if the amount of reflux is large enough, it could alter the low-pH environment of the stomach and erode the mucosal lining of the lumen. In some cases, the regurgitated contents can also reach the esophagus, leading to additional complications. In this work, "StomachSim", an in silico model of the fluid dynamics of the stomach, is used to study the mechanism of duodenogastric reflux. The effects of variations in food properties and motility disorders on reflux are investigated. The simulations show that the primary driver of reflux is the relaxation of the antrum after a stomach contraction terminates near the pylorus. The region of the stomach walls exposed to the regurgitated contents depends significantly on the density of the stomach contents. For stomach contents of higher viscosity, the increased pressure required to maintain gastric emptying reduces the amount of duodenogastric reflux. Concomitant stomach motility disorders that weaken the relaxation of the walls also affect the amount of reflux. The study illustrates the utility of in silico models in analyzing the factors at play in gastrointestinal diseases.NEW & NOTEWORTHY An in silico model of the stomach is presented to study the phenomenon of duodenogastric reflux. We use the model to investigate the role of pyloric incompetence, food properties, and gastroparesis on reflux. This first-ever in silico study of duodenogastric reflux provides new insights into the mechanisms and factors implicated in this reflux and the sequelae of conditions that result from the exposure of the stomach lumen to bile.

Sesquiterpene-enriched extract of Chinese agarwood (Aquilaria sinensis) alleviates bile reflux gastritis through suppression of gastric mucosal cell apoptosis via the Wnt/β-catenin signaling pathway

ETHNOPHARMACOLOGICAL RELEVANCE

Chinese agarwood (Aquilaria sinensis) has been a traditional treatment for digestive disorders in South and East Asia. While sesquiterpenes are recognized as the key active constituents of Chinese agarwood, the efficacy and mechanism of the sesquiterpene-enriched extract of Chinese agarwood (PEE) on bile reflux gastritis (BRG) remain unclear.

AIM OF THE STUDY

To explore the protective impact of PEE against BRG and unveil its underlying mechanism in suppressing apoptosis of gastric mucosal cells.

MATERIALS AND METHODS

A taurocholic acid (TCA)-induced BRG mouse model was used to assess PEE's protective effects on gastric mucosa histopathology. Transcriptomic analysis was conducted to identify the key signaling pathways affected by PEE. The impact of PEE on apoptosis modulation and Wnt/β-catenin signaling in GES-1 cells was examined. Additionally, the influence of PEE on the Wnt/β-catenin pathway in BRG mouse gastric mucosa was evaluated.

RESULTS

PEE substantially improved gastric tissue damage and inflammation in BRG mice. Transcriptomic analysis revealed that PEE modulates genes linked to apoptosis and the Wnt/β-catenin pathway. In TCA-induced GES-1 cells, PEE enhanced cell viability and mitigated apoptosis via the Wnt/β-catenin pathway, a process potentially mediated by IWP-2, an antagonist of this pathway. Similar regulatory effects were noted in the gastric mucosa of BRG mice.

CONCLUSION

Our research suggests that PEE exerts a protective effect on the gastric tissue through modulating the Wnt/β-catenin pathway to combat apoptosis, which highlights the potential of PEE as a natural remedy for BRG and warrants further investigation into its therapeutic benefits.

H. pylori-Associated Gastritis, Gastritis after H. pylori Eradication and H. pylori-Negative Gastritis: Algorithm of Diagnosis and Treatment (Literature Review and Resolution of the Expert Panel of the Russian Gastroenterological Association)

Aim: to provide the basic points of the Expert Panel of the Russian Gastroenterological Association with discussion of measures to improve diagnostics, treatment and management of chronic gastritis patients.

Key points. In the Russian Federation in 2021 more than 30 million patients diagnosed with “Gastritis and duodenitis” were recorded (K29 in accordance with International Classification of Diseases-10). H. pylori incidence rate in the Russian population has reduced and presently is about 40 %. In chronic gastritis pattern H. pylori-associated gastritis has still dominated though gastritis percent after successful H. pylori eradication, reactive gastropathy (including reflux gastritis) and autoimmune gastritis, has increased. Endoscopic and histologic examinations serve as key diagnostic techniques that provide a means for assessing the ethiology of gastritis, topography and degree of atrophic changes, gastritis staging as per OLGA/OLGIM system that properly correlates with the risk of stomach cancer and determines endoscopic examination strategy. H. pylori eradication therapy of gastritis serves as an etiotropic treatment and makes it possible to prevent progression of atrophy and stomach cancer. Conventional triple therapy combined with bismuth tripotassium dicitrate allows for achieving optimal cure rates of H. pylori eradication. Addition of rebamipide to regimens of H. pylori eradication improves their efficiency. Rebamipide arrests symptoms of dyspepsia in the case of chronic gastritis and functional dyspepsia. The administration of rebamipide for chronic gastritis makes it possible to influence the syndrome of increased epithelial permeability and inflammation, which makes it advisable to study it as a means of preventing stomach cancer and the progression of atrophy in various types of chronic gastritis.

Conclusion. Members of the Expert Panel has approved the algorithm of diagnosis and treatment of H. pylori-associated gastritis, gastritis after H. pylori eradication and H. pylori-negative gastritis at the diagnostic stage in the case of initial presentation and long-term follow-up when needed.

[Impact of primary duodenogastric reflux and Helicobacter pylori infection on gastritis and antibiotic resistance in children]

OBJECTIVES

To investigate the risk factors for Helicobacter pylori (HP) infection in children with primary duodenogastric reflux (DGR) and its impact on gastritis and antibioticresistance.

METHODS

A retrospective analysis was performed on the clinical data of 2 190 children who underwent upper gastrointestinal endoscopy in Wuxi Children's Hospital from January 2019 to February 2022, among whom 308 children were diagnosed with primary DGR. According to the presence or absence of HP infection, the children were classified to HP infection group (53 children) and non-HP infection group (255 children). The risk factors for HP infection and its impact on the incidence rate and severity of gastritis were analyzed. According to the presence or absence of primary DGR, 331 children with HP infection were classified to primary DGR group (29 children) and non-primary DGR group (302 children), and then the impact of primary DGR with HP infection on antibiotic resistance was analyzed.

RESULTS

The HP infection group had a significantly higher age than the non-HP infection group (P<0.05), and there was a significant difference in the age distribution between the two groups (P<0.05), while there were no significant differences in the incidence rate and severity of gastritis between the two groups (P>0.05). The multivariate logistic regression analysis showed that older age was a risk factor for HP infection in children with DGR (P<0.05). Drug sensitivity test showed that there were no significant differences in the single and combined resistance rates of metronidazole, clarithromycin, and levofloxacin between the primary DGR group and the non-primary DGR group (P>0.05).

CONCLUSIONS

Older age is closely associated with HP infection in children with DGR. Primary DGR with HP infection has no significant impact on gastritis and antibiotic resistance in children.

Evaluation of Gastric pH and Gastrin Concentrations in Horses Subjected to General Inhalation Anesthesia in Dorsal Recumbency

The prevalence of gastric disorders in high-performance horses, especially gastric ulceration, ranges from 50 to 90%. These pathological conditions have negative impacts on athletic performance and health. This study was designed to evaluate changes in gastric pH during a 24 h period and to compare gastrin concentrations at different time points in horses undergoing general inhalation anesthesia and dorsal recumbency. Twenty-two mixed-breed mares weighing 400 ± 50 kg and aged 8 ± 2 years were used. Of these, eight were fasted for 8 h and submitted to 90 min of general inhalation anesthesia in dorsal recumbency. Gastric juice samples were collected prior to anesthesia (T0), and then at 15 min intervals during anesthesia (T15-T90). After recovery from anesthesia (45 ± 1 min), samples were collected every hour for 24 h (T1 to T24) for gastric juice pH measurement. During this period, mares had free access to Bermuda grass hay and water and were fed a commercial concentrate twice (T4 and T16). In a second group (control), four non-anesthetized mares were submitted to 8 h of fasting followed by nasogastric intubation. Gastric juice samples were then collected at T0, T15, T30, T45, T60, T75, and T90. During this period, mares did not receive food or water. After 45 min, mares had free access to Bermuda grass hay and water, and gastric juice samples were collected every hour for four hours (T1 to T4). In a third group comprising ten non-fasted, non-anesthetized mares with free access to Bermuda grass hay and water, gastric juice samples were collected 30 min after concentrate intake (T0). In anesthetized mares, blood gastrin levels were measured prior to anesthesia (8 h fasting; baseline), during recovery from anesthesia, and 4 months after the anesthetic procedure, 90 min after the morning meal. Mean values of gastric juice pH remained acidic during general anesthesia. Mean pH values were within the physiological range (4.52 ± 1.69) and did not differ significantly between time points (T15-T90; p  >  0.05). After recovery from anesthesia, mean gastric pH values increased and remained in the alkaline range throughout the 24 h period of evaluation. Significant differences were observed between T0 (4.88 ± 2.38), T5 (7.08 ± 0.89), T8 (7.43 ± 0.22), T9 (7.28 ± 0.36), T11 (7.26 ± 0.71), T13 (6.74 ± 0.90), and T17 (6.94 ± 1.04) (p  <  0.05). The mean gastric juice pH ranged from weakly acidic to neutral or weakly alkaline in all groups, regardless of food and water intake (i.e., in the fasted, non-fasted, and fed states). Mean gastric pH measured in the control group did not differ from values measured during the 24 h post-anesthesia period or in the non-fasted group. Gastrin concentrations increased significantly during the post-anesthetic period compared to baseline (20.15 ± 7.65 pg/mL and 15.15 ± 3.82 pg/mL respectively; p  <  0.05). General inhalation anesthesia and dorsal recumbency did not affect gastric juice pH, which remained acidic and within the physiological range. Gastric juice pH was weakly alkaline after recovery from anesthesia and in the fasted and fed states. Serum gastrin levels increased in response to general inhalation anesthesia in dorsal recumbency and were not influenced by fasting. Preventive pharmacological measures are not required in horses submitted to general anesthesia and dorsal recumbency.

The Efficacy of Chaihu-Guizhi-Ganjiang Decoction on Chronic Non-Atrophic Gastritis with Gallbladder Heat and Spleen Cold Syndrome and Its Metabolomic Analysis: An Observational Controlled Before-After Clinical Trial

Purpose

The aim of this study was to verify the effectiveness and explore the mechanism of Chaihu-Guizhi-Ganjiang decoction (CGGD) in the treatment of chronic non-atrophic gastritis (CNAG) with gallbladder heat and spleen cold syndrome (GHSC) by metabolomics based on UHPLC-Q-TOF/MS.

Patients and Methods

An observational controlled before-after study was conducted to verify the effectiveness of CGGD in the treatment of CNAG with GHSC from January to June 2023, enrolling 27 patients, who took CGGD for 28 days. 30 healthy volunteers were enrolled as the controls. The efficacy was evaluated by comparing the traditional Chinese medicine (TCM) syndrome and CNAG scores, and clinical parameters before and after treatment. The plasma levels of hormones related to gastrointestinal function were collected by ELISA. The mechanisms of CGGD in the treatment of CNAG with GHSC were explored using a metabolomic approach based on UHPLC-Q-TOF/MS.

Results

Patients treated with CGGD experienced a statistically significant improvement in TCM syndrome and CNAG scores (p < 0.01). CGGD treatment evoked the concentration alteration of 15 biomarkers, which were enriched in the glycerophospholipid metabolism, and branched-chain amino acids biosynthesis pathways. Moreover, CGGD treatment attenuated the abnormalities of the gastrointestinal hormone levels and significantly increased the pepsinogen level.

Conclusion

It was the first time that this clinical trial presented detailed data on the clinical parameters that demonstrated the effectiveness of CGGD in the treatment of CNAG with GHSC patients. This study also provided supportive evidence that CNAG with GHSC patients were associated with disturbed branched-chain amino acid metabolism and glycerophospholipid levels, suggesting that CNAG treatment based on TCM syndrome scores was reasonable and also provided a potential pharmacological mechanism of action of CGGD.

Assessment of the risk factors of duodenogastric reflux in relation to different dietary habits in a Chinese population of the Zhangjiakou area

Objective

To explore the risk factors of duodenogastric reflux (DGR) in relation to different dietary habits.

Methods

A total of 106 patients with symptoms of DGR who underwent electronic gastroscopy from June 2019 to June 2020 were selected and divided into the DGR group (n = 33) and the non-DGR group (n = 73) according to the diagnosis of bile reflux. Questionnaires were used to collect the basic information and dietary habits of the patients, including age, gender, body mass index, place of residence, comorbidities, dietary composition, salt intake, smoking and drinking consumption. The total bile acid (TBA) and cholesterol (CHO) of the gastric juice were measured using a fully automated biochemical analyser, with an enzyme-linked immunosorbent assay used for the serum cholecystokinin, gastrin and gastrin levels. Univariate analysis and multivariate logistic regression analysis were used to predict the attendant DGR risk factors.

Results

There was no significant difference in age or gender between the DGR and the non-DGR groups (P > 0.05). The proportion of patients living in the Bashang region was significantly higher in the DGR group (78.79%) than in the non-DGR group (38.36%) (P < 0.05). The levels of TBA and CHO in the gastric juice and the cholecystokinin and gastrin levels in the serum of the DGR group were higher than those in the non-DGR group, while the serum motilin levels were significantly lower in the DGR group than in the non-DGR group (P < 0.05). The univariate analysis indicated that the proportion of patients with daily consumption of dairy products and fried foods, a high salt intake and smoking and drinking consumption were significantly higher in the DGR than in the non-DGR group (P < 0.05).

Conclusion

The daily consumption of dairy products and a preference for fried food are independent risk factors for the occurrence of DGR (odds ratio ≥ 1, P < 0.05).

Post-cholecystectomy bile reflux gastritis: Prevalence, risk factors, and clinical characteristics

OBJECTIVE

Bile reflux gastritis is caused by the backward flow of duodenal fluid into the stomach. A retrospective cohort study was performed to estimate the prevalence and risk factors of bile reflux gastritis postcholecystectomy, and to evaluate the endoscopic and histopathologic changes in gastric mucosa.

METHODS

Patients with refractory upper abdominal pain right below the ribs with symptoms of bloating, burping, nausea, vomiting, and bile regurgitation during the period from January 2018 to December 2020, submitted to Zagazig University Hospitals were enrolled in this study. The studied 64 patients were divided into two groups; the control group (CG): 30 subjects who had never undergone any biliary interventions, and the post-cholecystectomy group (PCG): 34 patients who had undergone cholecystectomy.

RESULTS

The prevalence of bile reflux gastritis was (16.7%) and (61.8%) in CG and PCG, respectively. Diabetes, obesity, elevated gastric bilirubin, and elevated stomach pH were all risk factors for bile reflux gastritis in both groups (r = .28,.48,.78,.57 respectively). Age, sex, epigastric pain, heartburn, vomiting, and the existence of bile reflux gastritis, on the other hand, had no correlation.

DISCUSSION

After a cholecystectomy, bile reflux gastritis is prevalent, especially among obese and diabetic patients.

Persistent Post-endoscopic Retrograde Cholangiopancreatography Hiccups: An Unusual Presentation of Bile Reflux

Bile reflux is a pathological retrograde flow of bile into the stomach that may lead to gastric overdistension and gastritis. It generally manifests as abdominal pain, nausea, vomiting, or heartburn. Hiccups have thus far not been described as part of its presentation. Here, we describe a case of excessive post-endoscopic retrograde cholangiopancreatography bile accumulation in the stomach that caused persistent hiccups requiring endoscopic suctioning.

Diagnostic Principles for Chronic Gastritis Associated with Duodenogastric Reflux

This article systematizes available data from the literature on biliary gastritis (BG) in order to increase the awareness of specialists about the latest possibilities for diagnosing the disease. BG occurs as a result of pathological duodenogastric reflux. In patients with a preserved duodenogastric junction, the dominant factor is represented by motor disorders of the upper digestive tract (primary biliary gastritis), while in patients recovering from surgical interventions it is represented by structural changes (secondary biliary gastritis). Progressive BG can lead to atrophy of the gastric mucosa, intestinal metaplasia, epithelial dysplasia, and eventually to gastric cancer. Diagnostic methods for BG are carried out to identify risk factors, exclude alarm symptoms and identify persistent motor disorders and pathological reflux (24 h pH-impedancemetry, hepatobiliary scintigraphy, 24 h monitoring of bilirubin content in the reflux using a Bilitec 2000 photometer), as well as to diagnose gastritis itself (esophagogastroduodenoscopy, morphological gastrobiopsy examination). The diagnosis of BG should be based on a multidisciplinary approach that combines a thorough analysis of a patient's complaints, an anamnesis of the disease, and the results of endoscopic and histological research methods.

Diagnostic Principles for Chronic Gastritis Associated with Duodenogastric Reflux

This article systematizes available data from the literature on biliary gastritis (BG) in order to increase the awareness of specialists about the latest possibilities for diagnosing the disease. BG occurs as a result of pathological duodenogastric reflux. In patients with a preserved duodenogastric junction, the dominant factor is represented by motor disorders of the upper digestive tract (primary biliary gastritis), while in patients recovering from surgical interventions it is represented by structural changes (secondary biliary gastritis). Progressive BG can lead to atrophy of the gastric mucosa, intestinal metaplasia, epithelial dysplasia, and eventually to gastric cancer. Diagnostic methods for BG are carried out to identify risk factors, exclude alarm symptoms and identify persistent motor disorders and pathological reflux (24 h pH-impedancemetry, hepatobiliary scintigraphy, 24 h monitoring of bilirubin content in the reflux using a Bilitec 2000 photometer), as well as to diagnose gastritis itself (esophagogastroduodenoscopy, morphological gastrobiopsy examination). The diagnosis of BG should be based on a multidisciplinary approach that combines a thorough analysis of a patient’s complaints, an anamnesis of the disease, and the results of endoscopic and histological research methods.

Negative correlations between bile reflux gastritis and Helicobacter pylori infection

OBJECTIVE

There are a few articles to study the relationship between bile reflux gastritis (BRG) and H. pylori infection, and the results are debatable. This study set out to determine the relationship between BRG and Helicobacter pylori (H. pylori) infection.

METHODS

In this retrospective study, patients from January, 1st 2013 to January, 1st, 2021 were divided into two groups based on whether they had BRG. The control group was got by 1:1 propensity-score matching (PSM) based on age and sex. Then, the relationship between BRG and H. pylori in patients was analyzed via Chi-squared test and Phi (φ) detection.

RESULTS

26449 patients were included in this study, and there were 1918 patients in each group after age and sex matching. patients with HP were responsible for 35% (9345/26449) and patients with BRG were 7% (1918/26449). Further relationship exploration, there is a negative, but weak, the relationship between BRG and HP infection (X² = 45.62, p < .001, Phi (φ)= -0.109).

CONCLUSION

Patients with bile reflux may have less likely to get HP infection. HP eradication is an important thing for the prevention of gastric cancer and this study serves as a foundation and may provide directions for future research.

Management of upper gastrointestinal symptoms in patients with autoimmune gastritis

PURPOSE OF REVIEW

Autoimmune gastritis is characterized by atrophy of acid secreting parietal cells resulting in achlorhydria. Upper gastrointestinal symptoms are common in autoimmune gastritis and frequently result in prescriptions for acid suppressant medications despite the inability of the stomach to secrete acid. Evidence-based recommendations for management of gastrointestinal symptoms in autoimmune gastritis are lacking.

RECENT FINDINGS

The most common symptoms in patients with autoimmune gastritis are dyspepsia, heartburn, and regurgitation. Gastroesophageal reflux should be confirmed by pH-impedance testing and is typically weakly acid or alkaline. Therapy for reflux focuses on mechanical prevention of reflux (i.e., elevation of the head of the bed and alginates) or when severe, antireflux surgery. The etiology of dyspepsia in autoimmune gastritis is unclear and largely unstudied. In the first half of the 20th century, oral administration of acid to "aid digestion" was widely used with reported success. However, randomized, placebo-controlled trials are lacking. Here, we provide suggestions for attempting gastric acidification therapy.

SUMMARY

Upper GI symptoms are common in autoimmune gastritis. Their pathogenesis and therapy remain incompletely understood. Acid suppressant medications are useless and should be discontinued. A trial of acid replacement therapy is recommended especially in the form of placebo-controlled trials.

Bile Reflux Gastritis: Insights into Pathogenesis, Relevant Factors, Carcinomatous Risk, Diagnosis, and Management

Bile reflux gastritis (BRG), a kind of gastrointestinal disorder in clinical practice, is characterized by regurgitation and inflammation. However, lack of guidelines leads to simple cognition and even ignorance of this disease for clinicians. Primarily, making the pathogenesis of BRG clear contributes to a correct and general understanding of this disease for physicians. Next, although recently there has been an increasing awareness among researchers in terms of the relevant factors for BRG, further studies involving large samples are still required to certify the relationship between them explicitly. Besides, researches have established that BRG is closely associated with the development of precancerous lesions and gastric cancer. Till now, there is still no golden standard for diagnosis of BRG. Nevertheless, advances in techniques, especially extensive applications of endoscopy and chemical analysis of reflux contents, have improved our ability to identify the occurrence of this disease as well as distinguishing physiological reflux from pathological reflux. Finally, it is fortunate for patients that more and more importance has been attached to the treatment of BRG. From lifestyle modification to drug therapy to surgery, all of them with the view of realizing symptomatic relief are employed for patients with BRG. In this review, we briefly evaluate this disorder based on the best available evidence, offering an overview of its complicated pathogenesis, diverse relevant factors, potential carcinomatous risk, modern diagnostic investigations, and effective therapeutic plans.

Bile reflux alters the profile of the gastric mucosa microbiota

BACKGROUND

Bile reflux can cause inflammation, gastric mucosa atrophy, and diseases such as stomach cancer. Alkaline bile flowing back into the stomach affects the intragastric environment and can alter the gastric bacterial community. We sought to identify the characteristics of the stomach mucosal microbiota in patients with bile reflux.

METHODS

Gastric mucosal samples were collected from 52 and 40 chronic gastritis patients with and without bile reflux, respectively. The bacterial profile was determined using 16S rRNA gene analysis.

RESULTS

In the absence of H. pylori infection, the richness (based on the Sobs and Chao1 indices; P <0.05) and diversity (based on Shannon indices; P <0.05) of gastric mucosa microbiota were higher in patients with bile reflux patients than in those without. There was a marked difference in the microbiota structure between patients with and without bile reflux (ANOSIM, R=0.058, P=0.011). While the genera, Comamonas, Halomonas, Bradymonas, Pseudomonas, Marinobacter, Arthrobacter, and Shewanella were enriched in patients with bile reflux, the genera, Haemophilus, Porphyromonas, and Subdoligranulum, were enriched in those without bile reflux.

CONCLUSION

Our results demonstrate that bile reflux significantly alters the composition of the gastric microbiota.

2-(2-phenylethyl)chromone-enriched extract of the resinous heartwood of Chinese agarwood (Aquilaria sinensis) protects against taurocholic acid-induced gastric epithelial cells apoptosis through Perk/eIF2α/CHOP pathway

BACKGROUND

Injury of gastric epithelial cells is one of the most important pathological features of bile reflux gastritis. Chinese agarwood (the resinous heartwood of Aquilaria sinensis) has been used to treat stomach problems for thousands of years in China. However, the pathological mechanism of epithelial cells death induced by bile acids and the therapeutic target of Chinese agarwood for improving bile reflux gastritis have not yet been fully clarified.

PURPOSE

This study aimed to investigate the pro-apoptotic effect of taurocholic acid (TCA) by regulating the ER stress pathway. Moreover, the role of Chinese agarwood 2-(2-phenylethyl)chromone-enriched extract (CPE) to inhibit gastric epithelial cell death induced by TCA was also been demonstrated.

METHODS

We adopted human gastric epithelial GES-1 cells to explore the mechanism of TCA-induced cell death in vitro. Then the cell viability, apoptosis rate, and protein expressions were evaluated to explore the protective effects of CPE on GES-1 cells by TCA injury. The therapeutic effect of CPE on bile reflux gastritis was further confirmed by the bile reflux mice in vivo.

RESULTS

Our results demonstrated that TCA activated GES-1 cell apoptosis by increased cleavage of caspase-7 and PARP. Further experiments showed that TCA up-regulated endoplasmic reticulum (ER) stress, subsequently triggered the apoptosis of the epithelial cells. Our research explored that CPE is the main effective fraction in Chinese agarwood by preventing the TCA-induced gastric epithelial cell injury. CPE effectively suppressed GES-1 cell apoptosis activated by TCA through inhibiting Perk/eIF2α/CHOP pathway. The anti-apoptotic effect of CPE on gastric mucosa had also been confirmed in vivo. Moreover, the main effective components in CPE corresponding to the protection of epithelial cells were also been identified.

CONCLUSION

Our finding suggested that CPE recovered the TCA-induced epithelial cell apoptosis by mediating the activation of ER stress, which explored potential medicine to treat bile reflux gastritis.

Do obesity and diabetes increase the frequency and risk of bile reflux gastritis post-cholecystectomy?

<br><b>Introduction:</b> Biliary gastropathy is a disease characterized by upper abdominal pain, frequent heartburn, nausea, and vomiting of bile. It is caused by the backward flow of duodenal fluid into the stomach and esophagus.</br> <br><b>Aim:</b> A retrospective cohort study was performed to estimate the prevalence and risk factors of bile reflux gastritis secondary to cholecystectomy and to evaluate the endoscopic and histopathologic changes in gastric mucosa caused by bile reflux gastritis.</br> <br><b>Materials and methods:</b> The study involved 64 patients with epigastric pain and/or dyspeptic symptoms during the period from January 2018 to December 2020 who presented to Zagazig University Hospitals. The subjects were divided into two groups: the control group (CG), with 30 subjects who had never undergone any biliary interventions, and the post-cholecystectomy group (PCG), consisting of 34 patients who had undergone cholecystectomy.</br> <br><b>Results:</b> The prevalence of bile reflux gastritis was 16.7% in the CG and 61.8% in the PCG. In both groups, diabetes, obesity, increased gastric bilirubin, and increased gastric pH were risk factors for bile reflux gastritis (r = 0.28, 0.48, 0.78, and 0.57, respectively). However, there were no correlations between age, sex, epigastric pain, heartburn, vomiting, and the presence of bile reflux gastritis.</br> <br><b>Discussion:</b> Bile reflux gastritis is a common complication following cholecystectomy and is more common among obese and diabetic patients.</br>

Bile Reflux Gastropathy and Functional Dyspepsia

Background/Aims

The pathoetiology of functional dyspepsia remains unclear; one mechanism could be chemical gastropathy from chronic bile reflux. We aim to examine the association of bile reflux gastropathy with functional dyspepsia and identify predisposing factors.

Methods

In a retrospective study, patients with functional dyspepsia (Rome III) who completed symptom assessment, esophagogastroduodenoscopy, and biopsies were categorized into 3 groups; bile gastropathy (BG), non-bile gastropathy (NBG), and no gastropathy (NG). Demographics, symptoms, endoscopy, and motility data were compared between groups. Multivariate analysis identified clinical factors associated with BG.

Results

Of 262 patients (77.5% female), 90 had BG, 121 had NBG, and 51 had NG. Baseline demographics were similar, however, patients with BG reported significantly more severe abdominal pain than NBG or NG groups (P = 0.018). Gastric erythema was significantly more common in BG vs NBG groups (P < 0.001). Cholecystectomy was significantly associated (OR, 6.6; P = 0.003) with the presence of gastropathy in BG compared to NBG or NG group. Patients with cholecystectomy had significantly more severe abdominal pain (P < 0.05), gastric erythema (P < 0.03), and gastritis (P < 0.05), and were more likely to be prescribed narcotic medications (P < 0.004) than patients without cholecystectomy.

Conclusion

s Bile reflux gastropathy is associated with functional dyspepsia and causes more severe symptoms. Cholecystectomy predisposes to BG and abnormal pain, and could contribute to the pathogenesis of functional dyspepsia.

Helicobacter pylori infection over bile reflux: No influence on the severity of endoscopic or premalignant gastric lesion development

Helicobacter (H.) pylori infection and duodenogastric reflux (DGR) are both linked to endoscopic and premalignant gastric lesion development, but it is still unclear whether they are independent or have a causal relationship. This study investigated the histologic gastric changes in patients with primary DGR and H. pylori infection, as well as their endoscopic findings, symptoms, drug consumption, and social behavior in comparison with patients presenting only DGR. The study included 560 patients with primary DGR on endoscopy divided into two groups, according to the presence/absence of H. pylori infection on biopsy (utilizing usual stainings and immunohistochemical methods). There was no significant difference in terms of age and sex, nor in the frequency of diabetes or esophagitis between the studied groups. Epigastric pain was associated with H. pylori-positive biopsies in multivariate logistic regression analysis (P=0.005). Although without statistical significance, severe endoscopic lesions and premalignant gastric lesions were more frequent in the H. pylori group (45.1 vs. 28.4% and 37.4 vs. 32.3%, respectively). In patients with DGR, the final multivariate model revealed a positive association between smoking and immunohistochemically confirmed H. pylori infection (P=0.02, OR=1.88, 95% confidence intervals (CI)=1.10 to 3.21), but a negative effect of proton pump inhibitor consumption (P<0.001, OR=0.50, 95% CI=0.35 to 0.73). In conclusion, in patients with H. pylori infection and DGR, epigastric pain was the main reason for the endoscopic investigation. H. pylori infection over DGR did not influence the severity of endoscopic or premalignant gastric lesion development. Furthermore, smoking is directly related to immunohistochemically assessed active H. pylori infection in patients with bile reflux.

Bile reflux is an independent risk factor for precancerous gastric lesions and gastric cancer: An observational cross-sectional study

OBJECTIVE

To identify whether bile reflux on endoscopy and other related variables are risk factors for precancerous gastric lesions and gastric cancer (GC).

METHODS

A multicenter, cross-sectional and observational study was conducted in five centers in China from June to October 2019, 1162 patients were recruited and divided into the chronic gastritis (CG), the precancerous lesion (low-grade intraepithelial neoplasia and intestinal metaplasia), and GC groups (including high-grade intraepithelial neoplasia). All participants underwent detailed interviews, endoscopy and biopsy, and completed questionnaires. Odds ratio and 95% confidence interval were calculated with multivariate logistic regression models with or without adjustment for Helicobacter pylori infection.

RESULTS

We recruited 668 patients with CG, 411 with precancerous lesions and 83 with GC. By comparing the CG and precancerous lesion groups, independent risk factors for cancerous gastric lesions were the grade of bile reflux, patient's age, dietary habits and family history of GC. Similar results were obtained when comparing the CG and GC groups. In addition, bile reflux was confirmed as an independent risk factor for progression from precancerous lesions to cancer.

CONCLUSIONS

Bile reflux on endoscopy as well as age, dietary habits and a family history of GC were independent risk factors for the development of precancerous gastric lesions and GC.

A Narrative Review of update in per oral endoscopic myotomy (POEM) and endoscopic esophageal surgery

The field of endoscopic esophageal surgery is based on the concept of natural orifice transluminal endoscopic surgery (NOTES). Submucosal space surgery or third space surgery with the use of flexible endoscopy allows for decreased morbidity and hospital length of stay with equivalent outcomes for patients. In the case of achalasia, per oral endoscopic myotomy (POEM) allows for management of refractory cases in setting of previous Heller Myotomy or in patients whom laparoscopic or thoracoscopic surgery is contraindicated. Lastly, POEM more directly divides circular muscular layer of esophagus without destroying surrounding structures that exist to prevent reflux. The innovations in endoscopic surgery began in the animal lab with experiments in the porcine model to develop a way to access the peritoneal cavity through an entry point in the gastric mucosa. Over the last 10 years, the biggest treatment innovations in endoscopy have focused on management of achalasia with the use of POEM. POEM became possible as technology was developed that revolutionized the use of flexible technology and the methods of mucosal closure. In addition to benign esophageal disease, endoscopic methods improved in management of esophageal malignancy with endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD). The innovations of endoscopic surgery have been developed through the utilization of the submucosal space as a method to ensure adequate closure of the mucosal entry point into the peritoneal cavity. The goal of this review paper is to explore POEM and other techniques in endoscopic esophageal surgery for the management of esophageal diverticulum, submucosal tumors, gastroparesis, and gastrointestinal esophageal reflux disease.

Gastric Motility Disorders in Dogs and Cats

Gastric motility disorders present both diagnostic and therapeutic challenges and likely are under-recognized in small animal practice. This review includes a comparative overview of etiopathogenesis and clinical presentation of gastric motility disorders, suggests a practical approach to the diagnosis of these conditions, and provides an update on methods to evaluate gastric motor function. Furthermore, management of gastric dysmotility is discussed, including a review of the documented effect of gastric prokinetics.

Meta-Analysis Reveals the Prognostic Relevance of Nuclear and Membrane-Associated Bile Acid Receptors in Gastric Cancer

INTRODUCTION

Bile acids (BAs) arising from duodenogastric reflux are known to facilitate gastric cancer (GC) development. Although BAs traditionally contribute to carcinogenesis through direct cellular cytotoxicity, increasing evidence implicates nuclear and membrane BA receptors (BARs) as additional factors influencing cancer risk. Indeed, some BARs are already linked with GC, but conflicting evidence and lack of information regarding other endogenous BARs warrant further investigation. In this study, we meta-analyzed multiple data sets to identify clinically relevant relationships between BAR expression and prognosis, clinicopathology, and activity in GC.

METHODS

We collected transcriptomic data from the Gene Expression Omnibus and The Cancer Genome Atlas to analyze associations between BAR expression and GC prognosis, subtype, and clinicopathology. We also used Ingenuity Pathway Analysis to assess and predict functions, upstream regulators, and downstream mediators of membrane and nuclear BARs in GC.

RESULTS

BARs showed differential distribution in GC; membrane BARs (G protein-coupled BAR 1, sphingosine-1-phosphate receptor 2, and cholinergic receptor muscarinic 2) were enriched in diffuse-, genome-stable, and mesenchymal-type tumors, whereas nuclear BARs (pregnane-X-receptor, constitutive androstane receptor, and farnesoid-X-receptor) were enriched in chromosome instability and metabolic subtypes. High expression of all membrane but not nuclear BARs was associated with poor prognosis and unfavorable GC clinicopathologic features. Similarly, expression patterns of membrane but not nuclear BARs varied geographically, aligning with Helicobacter pylori infection and GC mortality rates. Finally, GC-related oncogenes, namely transforming growth factor β1, were associated with membrane BARs, whereas many metabolic-associated genes were associated with nuclear BARs.

DISCUSSION

Through transcriptomic meta-analysis, we identified distinct expression profiles between nuclear and membrane BARs that demonstrate prognostic relevance and warrant further investigation.

Laparoscopic Hiatal Hernia Repair and Roux-en-Y Conversion for Refractory Duodenogastroesophageal Reflux after Billroth I Distal Gastrectomy

Distal gastrectomy with Billroth I or II reconstruction may cause duodenogastroesophageal reflux (DGER), thereby resulting in digestive or respiratory symptoms. The mainstay of treatment is medication with proton pump inhibitors. However, these drugs may have limited effects in DGER. Laparoscopic fundoplication has been proven to be highly effective in treating gastroesophageal reflux disease (GERD), but it cannot be performed optimally for GERD that develops after gastrectomy. We report the case of a 72-year-old man with a history of distal gastrectomy and Billroth I anastomosis due to early gastric cancer. GERD due to bile reflux occurred after surgery and was refractory to medical therapy. The patient underwent Roux-en-Y conversion from Billroth I gastroduodenostomy and hiatal hernia repair with only cruroplasty. Fundoplication was not performed. His symptoms improved significantly after the surgery. Therefore, laparoscopic hiatal hernia repair and Roux-en-Y conversion can be an effective surgical procedure to treat medically refractory DGER after Billroth I gastrectomy.

2007-2019: a "Third"-Space Odyssey in the Endoscopic Management of Gastrointestinal Tract Diseases

PURPOSE OF REVIEW

The main scope of this review article is to introduce readers to the innovative field of third-space endoscopy and offer a closer look at its history, milestones, and procedure spectrum while discussing ongoing and future challenges arising from its increasing adoption worldwide.

RECENT FINDINGS

Over the past few years, third-space endoscopy has been utilized in various diagnostic and interventional procedures performed throughout the gastrointestinal tract: obliteration of Zenker's diverticulum, myotomy for achalasia, gastroparesis or Hirschsprung's disease, biopsy or removal of subepithelial tumors, stricture management, post-per-oral endoscopic myotomy endoscopic fundoplication, and mediastino-, thoraco-, and peritoneoscopy. Third-space endoscopic interventions have revolutionized the management of esophageal motility disorders, gastroparesis, and gastrointestinal tract subepithelial tumors. Despite the high efficacy and safety of such interventions, some common (e.g., the high level of necessary endoscopic skill) and unique for each procedure (e.g., post-procedure gastroesophageal reflux or poor outcomes in patient subgroups) challenges still remain. Through a dedicated endoscopic training, a rigorous pre-procedure patient evaluation and selection, and the application of modified or new techniques, challenges can be overcome thus establishing existing procedures and paving the way for additional breakthroughs in the field of third-space endoscopy.

Perspectives on the interlinked nature of systemic sclerosis and reflux disease

Systemic sclerosis (SSc) is a multisystem connective tissue disease, characterized by chronic inflammation and vascular changes that result in esophageal smooth muscle atrophy and fibrosis. Subsequent progressive loss of peristalsis in the distal esophagus and loss of lower esophageal sphincter function lead to problems with the protective barrier and exposure of sensitive tissues to the gastroduodenal contents, a disorder called reflux disease. Areas covered: Depending on the range, nature and symptoms of the disease, the term 'reflux disease' may refer to gastroesophageal reflux, laryngopharyngeal reflux, microaspiration into the airways and silent reflux. Despite the links between these visceral complications, this connection remains controversial. This is due to a lack of complete understanding, the asymptomatic nature of the disease and the limited diagnostic accuracy of tests, which can delay diagnosis. Such delays are problematic, given that the early detection of GERD in SSc patients, the timing of assessment, the treatment of the organs involved are critical aspects of patient prognosis and disease outcome. Expert commentary: This review summarizes the most recent knowledge about the pathophysiology, diagnosis and prospective treatment of GERD in SSc patients and highlights how innovative technologies applied through an integrative, interdisciplinary approach may soon lead to effective treatment strategies.