Gallbladder function and fasting enterogastric bile reflux

Bile reflux of the remnant stomach following Roux-en-Y gastric bypass: an etiology of chronic abdominal pain treated with remnant gastrectomy

BACKGROUND

Bile reflux gastritis of the remnant stomach following Roux-en-Y gastric bypass (RYGB) causing chronic abdominal pain has not been reported. We report a series of symptomatic patients with remnant gastritis treated effectively with remnant gastrectomy (RG).

OBJECTIVE

The objective was to report our experience with bile reflux remnant gastritis after RYGB and our outcomes following RG.

SETTING

Community teaching hospital.

METHODS

All patients undergoing RG were retrospectively reviewed for presenting symptoms, diagnostic workup, pathology, complications, and symptom resolution.

RESULTS

Nineteen patients underwent RG for bile reflux gastritis at a mean of 4.4 years (52.3 mo, range 8.5-124 mo) after RYGB. All patients were female and presented with pain, primarily epigastric (18/19; 95%), and described as burning (11/19; 58%), with 10 (53%) reporting nausea. Endoscopy was performed preoperatively on all patients with successful remnant inspection in 13 (68%), using push endoscopy (n = 10) or operative assist (n = 3), with 12 (of 13; 92%) biopsy-positive for reactive gastropathy. Seventeen (90%) completed a hepatobiliary scintigraphy scan with 100% positivity demonstrating bile reflux across the pylorus. Surgical approach was laparoscopic or robotic in 18 (95%) with a hospital length of stay of 2.7 days (range 0-12 d), with no major complications or readmissions. Pathology of the remnant confirmed reactive gastropathy in 90% (n = 17). Ninety percent of patients (n = 17) reported sustained symptom resolution, and 11% of patients (n = 2) remained symptomatic at last follow-up. We followed all patients for a mean of 6.6 years (1-194 mo).

CONCLUSION

Bile reflux gastritis of the remnant stomach is a new consideration for chronic abdominal pain months to years following RYGB. Hepatobiliary scintigraphy imaging and endoscopic biopsy are highly suggestive. RG is safe and effective treatment.

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.

Duodenogastric bile reflux after gastric bypass: a cholescintigraphic study

In this exploratory study, we examined the occurrence of duodenogastric bile reflux to the excluded stomach after Roux-en-Y gastric bypass, a standard surgical therapy for morbid obesity. We studied 22 unselected patients (median age 44, 20 females) 18 months postoperatively. BMI at surgery and cholescintigraphy was 45 and 29 kg/m2, respectively. Mebrofenin labeled with 200 MBq 99mT was injected intravenously and the fate of radioactivity followed for 90 min. Bile flow was enhanced with cholecystokinin. We found scintigraphic evidence of duodenogastric bile reflux in 36% of the patients. The tracer remained in the excluded stomach throughout the study period. In conclusion, our investigation indicates that in more than one third of the patients undergoing gastric bypass, the gastric mucosa in the excluded stomach is exposed to the potential deleterious effects of bile.

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.

Evidence for hypomotility in non-ulcer dyspepsia: a prospective multifactorial study

A prospective multifactorial study of symptoms and disturbance of gastrointestinal function has been undertaken in 50 patients with non-ulcer dyspepsia. Objective tests including solid meal gastric emptying studies, gastric acid secretion, E-HIDA scintiscan for enterogastric bile reflux, and hydrogen breath studies were carried out in all patients and validated against control data. Gastroscopy and biopsy were carried out in non-ulcer dyspepsia patients only. Non-ulcer dyspepsia patients were categorised on the basis of predominant symptoms as: dysmotility-like dyspepsia (n = 22); essential dyspepsia (n = 14), gastro-oesophageal reflux-like dyspepsia (n = 11); and ulcer-like dyspepsia (n = 3). In the total non-ulcer dyspepsia population, solid meal gastric emptying was delayed (T50 mean (SEM) = 102 (6) minutes (patients) v 64 (6) minutes (controls), (p less than 0.01) and high incidences of gastritis (n = 26) and Helicobacter pyloridis infection (n = 18) were found. An inverse correlation was observed between solid meal gastric emptying and fasting peak acid output (r = -0.4; p less than 0.01). Indeed gastric emptying was particularly prolonged in eight patients (T50 mean (SEM) = 139 (15) minutes) with hypochlorhydria. In the non-ulcer dyspepsia population oral to caecal transit time of a solid meal was delayed (mean SEM = 302 (14) minutes (patients) v 244 (12) minutes (controls) (p less than 0.01]. Seven patients had a dual peak of breath hydrogen suggestive of small bowel bacterial overgrowth. No association was observed between symptoms and any of the objective abnormalities. This multifactorial study has shown that hypomotility, including gastroparesis and delayed small bowel transit, is common in non-ulcer dyspepsia and may be related to other disorders of gastrointestinal function. No relation between symptoms and disorders of function, however, has been shown.