The significance of gastric bile reflux seen at endoscopy

Systematic review: duodenogastroesophageal (biliary) reflux prevalence, symptoms, oesophageal lesions and treatment

BACKGROUND

The prevalence of duodenogastroesophageal reflux (DGER) and its effect on symptoms and oesophageal lesions in gastroesophageal reflux disease (GERD) is unclear.

AIMS

To conduct a systematic review to determine the prevalence of DGER among patients with GERD, the effect of DGER on symptoms and oesophageal lesions, and the treatment of DGER.

METHODS

We searched Pubmed and MEDLINE for full text, English language articles until October 2020 that evaluated DGER prevalence among patients with GERD, the effect of DGER on symptoms and oesophageal lesions, and the treatment of DGER.

RESULTS

We identified 3891 reports and included 35 which analysed DGER prevalence in GERD, 15 which evaluated its effect in non-erosive reflux disease (NERD), 17 on erosive oesophagitis, 23 in Barrett's, and 13 which evaluated the treatment of DGER. The prevalence of DGER, when evaluated by Bilitec, among all GERD patients ranged from 10% to 97%, in NERD 10%-63%, in erosive oesophagitis 22%-80% and in Barrett's 50%-100%. There were no differences in the presence or degree of DGER among patients who were asymptomatic or symptomatic on proton pump inhibitors (PPI). The most commonly evaluated treatments for DGER were PPIs and DGER reduced post-PPI therapy in all studies.

CONCLUSIONS

The prevalence of DGER increased with more advanced oesophageal lesions and did not explain persisting symptoms among patients taking PPI therapy. PPIs appear to be effective in the treatment of DGER. DGER remains an important consideration in patients with GERD and future therapies deserve more study.

Duodenogastro-esophageal reflux in children with refractory gastro-esophageal reflux disease

OBJECTIVE

To determine the role of duodenogastro-esophageal reflux (DGER) in the pathogenesis of refractory gastro-esophageal reflux disease (GERD) in children.

STUDY DESIGN

Twenty-two patients (12 boys, mean age, 13.2 years) with GERD symptoms that persisted on omeprazole (1 mg/kg) underwent upper gastrointestinal endoscopy and barium x-ray, 24-hour pH and DGER (Bilitec) monitoring, and a 13C octanoic acid gastric emptying breath test.

RESULTS

Patients presented mainly with epigastric pain, regurgitation, and nausea. Endoscopy revealed persistent esophagitis in 15 patients (68%). Pathologic acid and DGER exposure were present in 12 (55%) and 15 (68%) children, respectively, with combined pathologic reflux in 10 (45%). Acid exposure did not differ according to the presence of esophagitis, but patients with grade II esophagitis had significantly higher DGER exposure than those without esophagitis (9.1 +/- 5.3% vs 26.7 +/- 10.9% of the time, P < .05). Gastric emptying rate was not associated to acid or DGER exposure or persisting esophagitis. Symptoms improved after adding a prokinetic drug to the proton pump inhibitor therapy or referral for surgery (n = 5).

CONCLUSIONS

DGER may play a role in the pathophysiology of proton pump inhibitor-refractory GERD and esophagitis in children.

Review article: the role of bile and pepsin in the pathophysiology and treatment of gastro-oesophageal reflux disease

Gastro-oesophageal reflux disease is a multifaceted and multifactorial disorder which results from the reflux of gastric contents into the oesophagus. Animal studies suggest that synergism between acid and pepsin and conjugated bile acids have the greatest damaging potential for oesophageal mucosa, although unconjugated bile acids may be caustic at more neutral pH. Human studies are compatible with a synergistic action between acid and duodenogastric reflux in inducing lesions. During prolonged monitoring studies, typical gastro-oesophageal reflux symptoms are more related to acid reflux events than to non-acid reflux events. However, symptoms that persist during acid suppressive therapy are often related to non-acid reflux events. The therapeutic options for the non-acid component of the refluxate, including acid suppression, prokinetics, baclofen, surgery and mucosal protective agents like alginates, are discussed.

Review article: role of pepsin and bile in gastro-oesophageal reflux disease

Gastro-oesophageal reflux disease is defined as the presence of symptoms or lesions that can be attributed to the reflux of gastric contents into the oesophagus. Aspiration and prolonged monitoring studies in humans have shown that reflux of gastric contents is comprised of both acid and non-acid components, in healthy as well as diseased people. Methods to monitor the non-acid component of the refluxate are described in detail. Experimental models suggest that synergism between acid and pepsin and conjugated bile acids have the greatest damaging potential for oesophageal mucosa, although unconjugated bile acids may be caustic at a more neutral pH. Human studies are compatible with a synergistic action between acid and duodenogastric reflux in inducing lesions. During prolonged monitoring studies, typical gastro-oesophageal reflux disease symptoms are more related to acid reflux events than to non-acid reflux events. However, symptoms that persist during acid-suppressive therapy are often related to non-acid reflux events. The therapeutic options for the non-acid component of the refluxate, including acid suppression, prokinetics, baclofen and surgery, are discussed.

The role of acid and duodenal gastroesophageal reflux in symptomatic GERD

OBJECTIVE

Mixed reflux of acid and duodenal contents frequently occurs in patients with gastroesophageal reflux disease (GERD). The aim of this study was to establish the contribution of acid and duodenal gastroesophageal reflux (DGER) to symptoms in patients with presumed GERD.

METHODS

A total of 72 patients (37 women), mean age 45 yr (+/-2 yr), underwent 24-h ambulatory pH and Bilitec monitoring. Patients pressed a marker button when experiencing typical symptoms. For each symptom episode, minimal pH and maximal bilirubin optical density in a 2- or 4-min interval were calculated. For each patient, the symptom index (SI) and symptom-association probability for acid and for bile reflux were determined.

RESULTS

A total of 544 symptom episodes were identified. Using a 2-min interval, 28% were associated with acid reflux, 9% with DGER, and 12% with mixed reflux. No significant difference was found when a 4-min interval was used. A positive SI for acid reflux was present in 21% of the patients and for DGER in 14%. All patients with a positive SI for DGER had also a positive SI for acid reflux. A positive symptom-association probability for acid reflux was present in 22% of the patients, for DGER in 7% of the patients, and for mixed reflux in 10% of the patients.

CONCLUSIONS

Symptom episodes in patients with presumed GERD are more related to acid reflux than to DGER. DGER does not play a major role in producing typical esophageal symptoms.

Review article: the role of non-acid reflux in gastro-oesophageal reflux disease

The role of acid in the pathogenesis of gastro-oesophageal reflux disease (GERD) has been extensively studied and is well accepted. The role, if any, of non-acid reflux, in particular duodenogastro-oesophageal reflux, is much debated. The availability of new technology to detect non-acid reflux has heightened interest in this question. This article reviews the following: How do we define non-acid reflux? Does duodenogastro-oesophageal reflux (alone or in combination) cause oesophageal injury, symptoms or both? What is its role in complicated GERD? What methods are available to assess non-acid reflux? Does non-acid reflux need treatment and if so what modalities are available?

Bile reflux in columnar-lined esophagus

Barrett's esophagus represents a metaplastic process in which the normal squamous epithelium of the lower esophagus is replaced by metaplastic columnar epithelium. Although the role of acid and pepsin in the development of Barrett's esophagus is well accepted, the importance of duodenogastroesophageal reflux in this disorder is not clear.

Role of acid and duodenogastric reflux in esophageal mucosal injury: a review of animal and human studies

The role of acid and duodenogastric reflux (DGR) in the development of esophageal mucosal injury has been extensively investigated using both animal and human models. In this report, clinical and experimental data are reviewed. The mechanisms by which gastric and duodenal contents produce esophageal mucosal injury are also discussed. Acid and pepsin are unquestionably important in causing mucosal damage at low pH values in both animal and human models. Animal models suggest synergistic damaging potential for conjugated bile acids and HCI as well as that of unconjugated bile acids and trypsin in more neutral pH values. Human evidence for the involvement of bile and its constituents has been controversial; however, the advent of better technology to detect DGR is beginning to clarify the role of these constituents. The contribution of each methodology in clarifying the extent of involvement of DGR in esophageal mucosal injury is reviewed. Despite some conflicting results, preliminary human studies support the results from the animal data suggesting synergistic damaging effects for both bile and acid in esophageal mucosal injury. The implication of these studies in treating gastroesophageal reflux disease are discussed.

The clinical relevance of endoscopic and histologic inflammation of gastroduodenal mucosa in dyspepsia of unknown origin

Two hundred and ten patients were defined as having dyspepsia of unknown origin. At endoscopy 11% had body gastritis, 46% antral gastritis, and 19% bulbitis (two thirds combined with antral gastritis). Histologically, 22% had chronic corpus gastritis (79% superficial, 21% atrophic), which was combined with chronic antral gastritis in 84%, 33% had chronic antral gastritis (82% superficial, 18% atrophic); and 14% had duodenitis, which was combined with antral gastritis in 65%. Polymorphonuclear leukocytes were found in specimens from the body mucosa in 6%, from the antral mucosa in 13%, and from the duodenal cap in 4%. The endoscopic findings correlated significantly with the histologic findings in the duodenal bulb (kappa = 0.33) but not in the stomach. The frequency of endoscopic antral gastritis and the frequency of histologic chronic body and antral gastritis increased with age. Endoscopic bulbitis and histologic duodenitis and gastric metaplasia were commoner in men than in women. Peak acid output was higher in patients with than in those without endoscopic bulbitis and higher in smokers than in non-smokers when the significant sex differences in peak acid output were taken into account. Gastric metaplasia of the bulb was predominantly correlated to higher peak acid output and to some extent also to sex and smoking. Episodic pain was correlated to histologic duodenitis. Other dyspeptic symptoms and the intragastric bile acid concentration were not associated with any endoscopic or histologic findings. Of the 210 patients, 172 were reexamined after a double-blind 6-week treatment period with cimetidine, antacid, or placebo. The symptomatic outcome of these treatments was not associated with any significant change in endoscopic or histologic findings.