Disorders of gallbladder function related to duodenogastric reflux in technetium-99m DISIDA hepatobiliary scintigraphy

A flow visualization model of duodenogastric reflux after esophagectomy with gastric interposition

Background

Our goal was to verify surgical factors that affect duodenogastric reflux (DGR) after esophagectomy through the use of a flow visualization model that would mimic an intrathoracic gastric tube.

Methods

Transparent gastric tube models for different routes (retrosternal space [RS] and posterior mediastinum [PM]) were fabricated. Various distal pressures were applied to the experimental model filled with water, and the flow was recorded with a high-speed camera. The volume and maximum height of the refluxate through the pylori of two different sizes (7.5 mm, 15 mm) in two different postures (upright, semi-Fowler) was measured by analyzing the video clips.

Results

For the large pylorus setting, when the pressures of 20, 30, and 40 mmHg were applied in the upright position, the volumes of the refluxate in the RS/PM tubes were 87.7 ± 1.1/96.4 ± 1.7 mL, 150.8 ± 1.1/158.0 ± 3.2 mL, and 156.8 ± 3.3/198.0 ± 4.7 mL (p < 0.05), and the maximum heights were 101.6 ± 4.8/113.4 ± 2.9 mm, 151.4 ± 2.2/165.4 ± 1.5 mm, and 166.1 ± 1.7/193.7 ± 6.6 mm (p < 0.05). The data for the small pylorus setting or in the semi-Fowler position showed similar tendencies. For any given route, posture or pressure setting, DGR in the large pylorus model was definitively higher than that for small one.

Conclusions

This fluid mechanics study demonstrates posterior mediastinal gastric interposition or pyloric drainage procedure, or both, is associated with high reflux of duodenal contents.

Gallstones increase the prevalence of Barrett's esophagus

PURPOSE

Bile and acid exposures are thought to be major risk factors for Barrett's esophagus in Western countries. The association of gallstones with Barrett's esophagus has not been fully evaluated. The present study was designed as a case-control study for determining the possible factors associated with endoscopically suspected esophageal metaplasia (ESEM), defined as an endoscopic finding suggestive of Barrett's esophagus, in Japanese patients.

METHODS

A total of 528 patients with ESEM were allocated to the case group, while 528 age- and gender-matched patients without ESEM were allocated to the control group. Findings on esophagogastroduodenoscopy and clinical background factors were compared using a multivariate logistic regression model.

RESULTS

The presence of gallstones and hiatus hernia and the severity of gastric mucosal atrophy were independently associated with the presence of ESEM [odds ratio (OR) 1.67, 95% confidence interval (CI) 1.03-2.69; OR 2.75, 95% CI 1.75-4.33; OR 1.25, 95% CI 1.01-5.6, respectively]. Compared with subjects with neither gastric corpus atrophy nor gallstones, although subjects with gallstones alone were not associated with the presence of ESEM (OR 1.59, 95% CI 0.87-2.92), having both gastric corpus atrophy and gallstones was strongly associated with the presence of ESEM (OR 2.94, 95% CI 1.40-6.17).

CONCLUSIONS

The presence of gallstones was independently associated with the presence of ESEM in the Japanese outpatient population, suggesting a causal association of distal esophageal bile exposure with the development of ESEM. Further studies are needed to confirm our findings in cases with histologically confirmed Barrett's esophagus.

Le reflux biliaire duodéno-gastrique et gastro-œsophagien

This study reviews current data regarding duodenogastric and gastroesophageal bile reflux-pathophysiology, clinical presentation, methods of diagnosis (namely, 24-hour intraluminal bile monitoring) and therapeutic management. Duodenogastric reflux (DGR) consists of retrograde passage of alkaline duodenal contents into the stomach; it may occur due to antroduodenal motility disorder (primary DGR) or may arise following surgical alteration of gastoduodenal anatomy or because of biliary pathology (secondary DGR). Pathologic DGR may generate symptoms of epigastric pain, nausea, and bilious vomiting. In patients with concomitant gastroesophageal reflux, the backwash of duodenal content into the lower esophagus can cause mixed (alkaline and acid) reflux esophagitis, and lead, in turn, to esophageal mucosal damage such as Barrett's metaplasia and adenocarcinoma. The treatment of DGR is difficult, non-specific, and relatively ineffective in controlling symptoms. Proton pump inhibitors decrease the upstream effects of DGR on the esophagus by decreasing the volume of secretions; promotility agents diminish gastric exposure to duodenal secretions by improving gastric emptying. In patients with severe reflux resistant to medical therapy, a duodenal diversion operation such as the duodenal switch procedure may be indicated.

Bile exposure of the denervated stomach as an esophageal substitute

BACKGROUND

Both the supine position and the existence of a gastric drainage procedure are suspected to promote reflux of duodenal juice into the denervated intrathoracic stomach. Erythromycin has been shown to weaken pyloric resistance to gastric outflow and to enhance antral motility, gastric emptying, and gallbladder contractility.

METHODS

The presence of bile in the gastric transplant of 79 patients was monitored over a 24-hour period with use of the Bilitec 2000 optoelectronic device 3 to 195 months after subtotal esophagectomy. Ten patients were reinvestigated after a 3-year period. Five groups were studied: group I: n = 12, no gastric drainage, never given erythromycin, group 2: n = 40, gastric drainage, never given erythromycin, group 3: n = 7, no gastric drainage, given erythromycin, group 4: n = 13, gastric drainage, given erythromycin, and group 5: n = 7, no longer given erythromycin (with or without gastric drainage). The percentage of time gastric bile absorbance was more than 0.25 was calculated for the total, supine, and upright periods of recording in reference to data from 25 healthy volunteers.

RESULTS

The Bilitec test was pathologic in 9 of the 12 patients of group 1 whereas it was normal in three. Gastric exposure to bile was longer in group I patients than in controls for the total (p = 0.012) and supine (0.036) periods, but the difference did not reach statistical significance for the upright period (p = 0.080). Bile exposure in group 4 did not significantly differ from controls (total: p = 0.701; supine: p = 0.124; upright: p = 0.712). Bile exposure for the total period did not significantly differ whether patients were taking erythromycin or the drug had been discontinued at the time of the study (p = 0.234); and it tended to decrease with time in patients investigated twice (p = 0.046).

CONCLUSIONS

Gastric exposure to bile after truncal vagotomy and transposition of the stomach up to the neck is pathologic in three quarters of patients. It is more marked in the supine than in the upright position and tends to decrease with time. The addition of a gastric drainage procedure in combination with erythromycin therapy tends to normalize gastric exposure to bile. The effects of erythromycin may persist after discontinuation of the drug.

Morphine-augmented cholescintigraphy enhances duodenogastric reflux

Morphine intervention in cholescintigraphy decreases imaging time to diagnose acute cholecystitis. Not infrequently we observe duodenogastric reflux during scintigraphy with and without morphine intervention. To evaluate occurrence of duodenogastric reflux related to morphine, we reviewed 55 patients who underwent cholescintigraphy with (32) and without (23) morphine intervention. Morphine was injected when there was bowel activity with non-visualization of the gallbladder at 60 min. Duodenogastric reflux was identified by the appearance of activity in the area just below or immediately adjacent to the tip of the left hepatic lobe laterally. Among 32 patients with morphine intervention, 19 had acute cholecystitis and 13 chronic cholecystitis. Eleven of 19 (58%) with acute cholecystitis had duodenogastric reflux and 6 of 13 (46%) had duodenogastric reflux in chronic cholecystitis. The total of duodenogastric reflux in the group with morphine injection was 53%. Two patients' duodenogastric reflux occurred before morphine injection and was more apparent after morphine was given. In the without morphine group, 3 had acute cholecystitis and 20 had chronic cholecystitis; 2 (one acute and one chronic cholecystitis) of these 23 (9%) had duodenogastric reflux. Our results indicate: (1) occurrence of DG reflux in morphine augmented cholescintigraphy is not significantly different in cholecystitis from that in chronic cholecystitis; (2) duodenogastric reflux in morphine augmentation occurs significantly more often than without morphine intervention (p < 0.001). We conclude that cholescintigraphy with morphine enhances duodenogastric reflux. The degree of duodenogastric reflux in the acute cholecystitis patients has been more severe than in the chronic cholecystitis patients.

Comparative evaluation of scintigraphy and upper gastrointestinal tract endoscopy for detection of duodenogastric reflux

Duodenogastric reflux, the reflux of duodenal bile into stomach, when suspected clinically requires an objective evaluation for proper management. In this study hepatobiliary scintigraphy in 91 patients of different clinical conditions was evaluated for presence of duodenogastric reflux. Upper gastrointestinal endoscopy was also performed in 44 of these patients. On scintigraphy duodenogastric reflux was present in 26 (29%) of 91 patients. Upper gastrointestinal endoscopy revealed presence of refluxed bile in the stomach in 12 (27%) of 44 patients. In the same groups of patients scintigraphy detected reflux in 18 (41%) of 44 patients. This shows that hepatobiliary scintigraphy is superior to upper gastrointestinal endoscopy in detection of duodenogastric reflux and also has the advantage of being non-invasive and physiological.