Bile salt reflux after cholecystectomy

The association between cholecystectomy and gastroesophageal reflux symptoms: a prospective controlled study

OBJECTIVE

A large controlled prospective observational study to compare pre- and postsurgery changes in reflux symptoms between cholecystectomy and hernia repair surgery patients.

SUMMARY BACKGROUND DATA

Six studies have suggested that gastroesophageal reflux worsens after cholecystectomy. However, all these studies had design limitations.

METHODS

We recruited 302 patients scheduled to undergo elective cholecystectomy (study group) or hernia repair (controls) at 2 hospitals. Both groups filled out the validated Reflux Symptom Score (RSS) and Gastrointestinal Symptom Rating Scale (GSRS) questionnaires 1 to 15 days prior to and 4 to 12 weeks after the operation. Changes in symptom scores between the pre and postsurgery assessments were measured, and compared between the 2 groups.

RESULTS

Baseline RSS and GSRS reflux subscores were higher in the study group than controls (1.44 vs. 1.02 and 1.91 vs. 1.43, respectively; P < 0.05). There were no significant differences in any of the symptom score changes between the 2 groups except for the GSRS pain subscore, which decreased more in the study group than the control group (-0.59 vs. -0.10; P < 0.001). With regard to reflux, the RSS decreased by -0.34 in the study group and -0.14 in controls (P = 0.27), while the GSRS reflux subscore decreased by -0.32 in the study group and -0.05 in controls (P = 0.12). GSRS diarrhea and constipation subscores decreased slightly after surgery, to the same extent in both groups.

CONCLUSIONS

This large prospective controlled study, the only one using validated reflux symptom questionnaires, shows that cholecystectomy does not lead to an increase in reflux symptoms. As expected, GSRS pain subscores were decreased in the cholecystectomy group but not the controls.

Effect of cholecystectomy on gastric and esophageal bile reflux in patients with upper gastrointestinal symptoms

Epidemiologic data have shown that cholecystectomy is associated with a moderately increased risk of esophageal adenocarcinoma. The study objective was to evaluate the role of refluxed bile. A total of 696 patients with upper gastrointestinal symptoms were included in the study, of whom 55 had a history of cholecystectomy (CHE). Bilirubin exposure was measured in percent time above absorbance 0.25 in the stomach and above 0.14 in the esophagus. Total gastric and esophageal bilirubin exposure was similar in both groups. Supine gastric bile reflux was slightly increased after cholecystectomy (30.6 +/- 30.2 vs. CHE: 37.1 +/- 29.5, P < 0.05). In patients with erosive esophagitis or Barrett's esophagus, there were differences in total gastric exposure (24.3 +/- 22.6 vs. CHE: 36.7 +/- 26.8, P < 0.05) but not in esophageal exposure. Cholecystectomy slightly augments bile reflux into the stomach without detectable differences in the esophagus. Therefore, increased esophageal bile reflux following cholecystectomy as a potential cause for the associated cancer risk could not be substantiated.

Bile reflux index after therapeutic biliary procedures

Background

Therapeutic biliary procedures disrupt the function of the sphincter of Oddi. Patients are potential "bile refluxers". The aim of this study was to assess how these procedures affect the histology-based bile reflux index (BRI), which can be used to reflect duodenogastric reflux (DGR).

Methods

Gastric antrum and corpus biopsies were collected from 131 subjects (56 men, 75 women; mean age, 55.9 ± 15.6 years). Group 1 (Biliary group-BG; n = 66) had undergone endoscopic sphincterotomy, endoscopic stenting, or choledochoduodenostomy for benign pathology; Group 2 (n = 20) had undergone cholecystectomy alone; and Group 3 (n = 6) Billroth II gastroenterostomy. Group 4 (no cholecystectomy; n = 39) had upper endoscopy with normal findings and served as controls. BRI > 14 indicated DGR (BRI [+]). To eliminate confounding effects of Helicobacter pylori (Hp) infection, comparisons were made according to Hp colonization.

Results

Fifty-nine subjects (45%) were Hp (+). The frequencies of BRI (+) status in antrum and corpus specimens from Hp (-) BG patients were 74.3% and 71.4%, respectively (85.7% for both antrum and corpus for choledochoduodenostomy). Corresponding results were 60% and 60% for Group 2, 100% (only corpus) for Group 3, and 57.1% and 38.1% for controls (BG, Group 2, and Group 3 vs controls – p > 0.05 antrum, p < 0.05 corpus). Fifty-four BG patients had previously undergone cholecystectomy. Excluding those, the rates of BRI (+) in Hp (-) BG patients were 75% antrum and 62.5% corpus (p > 0.05 for both vs. Group 2).

Conclusion

Patients who had undergone biliary procedures showed similar bile-related histological changes in both corpus and antrum biopsies, but the changes seen in controls were more prominent in the antrum than corpus. Therapeutic biliary procedures increase the rate of BRI (+) especially in the case of choledochoduodenostomy. Therapeutic biliary procedures without cholecystectomy also increase the rate of BRI (+) similar to that observed in patients with cholecystectomy.

Gastric emptying time, not enterogastric reflux, is related to symptoms after upper gastrointestinal/biliary surgery

BACKGROUND

It has been suggested that symptoms from bile reflux gastritis are related to the frequency and degree of enterogastric reflux (EGR).

METHODS

Patients with history of upper gastrointestinal surgery or cholecystectomy as well as control patients were studied. Presence of EGR, degree of EGR, and gastric bile emptying time were assessed and quantified via 99mTC scintillation imaging and then compared between symptomatic and asymptomatic patients.

RESULTS

Patients with vagotomy and pyloroplasty, Billroth I, Billroth II, and cholecystectomy demonstrated statistically higher degrees of EGR compared with controls. Although asymptomatic and symptomatic patients with a history of upper gastrointestinal or biliary surgery demonstrated no statistically significant differences between incidence of EGR and degree of EGR, there was a statistically significant difference in gastric emptying time.

CONCLUSIONS

Delayed gastric emptying time, not frequency or extent of EGR, was associated with the symptoms of bile reflux in patients who had previous upper gastrointestinal or biliary operations.

Association between cholecystectomy and adenocarcinoma of the esophagus

BACKGROUND & AIMS

Barrett's esophagus, which is linked to adenocarcinoma of the esophagus, is associated with reflux of bile. Duodenogastric reflux is increased after cholecystectomy. This study aims to evaluate if cholecystectomy is associated with an increased risk of adenocarcinoma of the esophagus.

METHODS

A population-based cohort study of cholecystectomized patients in Sweden between 1965 and 1997 cross-linked with the Swedish Cancer Register.

RESULTS

Cholecystectomized patients had an increased risk of adenocarcinoma of the esophagus (standardized incidence ratio [SIR], 1.3; 95% confidence interval [CI], 1.0-1.8). Esophageal squamous-cell carcinoma was not found to be associated with cholecystectomy (SIR, 0.9; 95% CI, 0.7-1.1). Patients with gallstone disease on whom surgery was not performed did not have an increased risk of adenocarcinoma or squamous-cell carcinoma of the esophagus.

CONCLUSIONS

Cholecystectomy is associated with a moderately increased risk of adenocarcinoma of the esophagus, possibly by the toxic effect of refluxed duodenal juice on the esophageal mucosa. Further studies are needed regarding the link between bile reflux and esophageal carcinogenesis.

Effect of cholecystectomy on gastroesophageal and duodenogastric reflux

OBJECTIVE

The majority of patients experience resolution of their symptoms after cholecystectomy, but a minority either find their symptoms unchanged or complain of new upper GI symptoms. It has been suggested that the effect of cholecystectomy on upper GI motility, sphincter function, or bile delivery may account for these postoperative symptoms. We aimed to determine whether cholecystectomy affects gastroesophageal reflux or duodenogastric reflux by using 24-h ambulatory pH and gastric bilirubin monitoring before and after surgery.

METHODS

Seventeen symptomatic patients with gallstones underwent 24-h ambulatory esophageal and gastric pH-metry and gastric bilirubin monitoring. Helicobacter pylori status was ascertained in all patients by 14C urea breath test and serology. Combined pH and bilirubin monitoring was repeated 3 months after cholecystectomy. Eleven healthy subjects served as a control group.

RESULTS

Three (17%) patients complained of persistent or new symptoms after surgery, whereas 14 (83%) patients were asymptomatic. Two patients (12%) underwent open cholecystectomy, and (88%) had the operation performed laparoscopically. No significant differences were detected in esophageal acid exposure (pH < 4), gastric alkaline shift (pH > 4), or gastric bilirubin exposure (absorbance > 0.14) after surgery. Three (17%) patients tested positive for Helicobacter pylori; the presence of infection did not appear to affect pre- or postoperative values.

CONCLUSIONS

Cholecystectomy does not result in increased bile reflux into the stomach or increased gastroesophageal acid reflux. Those patients who had increased postoperative duodenogastric reflux were entirely asymptomatic. The symptoms of postcholecystectomy syndrome are unlikely to be related to increased duodenogastric reflux after surgery.

Scintigraphic assessment of interdigestive duodenogastric reflux in humans: distinguishing between duodenal and biliary reflux material

BACKGROUND

Late duodenal phase III is characterized by retroperistalsis. The physiologic function of this phenomenon is unknown. Our aim was to study the relationship between duodenal motility and the transport of duodenal contents from the biliary tract and the duodenum by using a double-isotope technique.

METHODS

Manometric analysis of the direction of interdigestive duodenal pressure waves was performed in 12 volunteers. Duodenal marker was infused directly into the proximal duodenum, and bile marker was infused intravenously for 2 h. Radionuclide activity was examined for regions corresponding to the stomach, gallbladder, and duodenum.

RESULTS

In phase II, antegrade pressure waves dominated with propulsion of both markers to the jejunum. Retroperistalsis occurred in 90% of the activity fronts and was always (100%) followed by retropulsion of duodenal marker to the stomach. A clear-cut reflux of bile marker was seen in only 17% of the activity fronts. The incidence rate of duodenogastric reflux was highest in phase III (P=0.008) compared with phase II with an infrequent (P=0.002) admixture of bile. Bile marker contents increased abruptly in the gallbladder during phase III.

CONCLUSIONS

Late phase III acts as a retroperistaltic pump, retropelling duodenal contents to the stomach. In this physiologic duodenogastric reflux. bile is avoided by deviation to the gallbladder, probably by a phase lll-associated occlusion of the sphincter Oddi.

The effect of laparoscopic cholecystectomy on gastroduodenal reflux

BACKGROUND

The present study evaluates the effect of laparoscopic cholecystectomy on biliary reflux in patients with cholelithiasis.

METHODS

All patients over 18 years of age awaiting elective cholecystectomy for gallstone disease in one of two teaching hospitals were contacted by telephone, and those who gave informed consent were entered in the study. A total of 66 patients (43 females and 23 males) underwent milk 99mTc DIDA scans. Elective laparoscopic cholecystectomy was perfomed after a median of 28.5 days (range: 8-588 days) and patients were re-investigated with a milk 99mTc DIDA scan at a median time of 50 days (range: 18-370 days) postoperatively. Scans were carried out in the Nuclear Medicine Department of the Royal Adelaide Hospital.

RESULTS

All but two patients had a functioning gall-bladder on milk 99mTc N-2, 6-dimethylphenyl-carbamoylmethyl iminodiacetic acid scanning prior to cholecystectomy. One of these patients was found to have a gall-bladder carcinoma at cholecystectomy. Fifty-seven of the 66 patients had a successful laparoscopic cholecystectomy (nine open cholecystectomies). Nineteen patients experienced gastroduodenal reflux into the stomach prior to cholecystectomy and 23 patients experienced it postoperatively. There was no significant difference in gastroduodenal reflux in both the open and laparoscopic groups.

CONCLUSION

The present study demonstrated that laparoscopic cholecystectomy did not significantly alter gastroduodenal 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.

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.

Pathologic duodenogastric reflux associated with persistence of symptoms after cholecystectomy

BACKGROUND

The aim of this study was to determine whether increased duodenogastric reflux contributes to postcholecystectomy symptoms.

METHODS

Gastric pH monitoring, hepatobiliary scintigraphy, gastric emptying scans, and gastric acid analysis were performed in asymptomatic (n = 10) and in symptomatic (n = 27) patients after cholecystectomy. Normal subjects (n = 20), patients with dyspepsia related to gastric acid hypersecretion (n = 20), patients with reflux gastritis after gastric surgery (n = 10), and patients with confirmed primary pathologic duodenogastric reflux (n = 10) were studied as controls. Symptomatic patients also underwent upper gastrointestinal endoscopy.

RESULTS

Symptomatic patients had significantly increased interprandial gastric exposure to pH < 3 compared with asymptomatic subjects, which correlated well with a high incidence of hepatobiliary scans positive for abnormal duodenogastric reflux and chronic gastritis on endoscopy. Gastric alkaline exposure in symptomatic patients was similar to that seen in patients with primary pathologic duodenogastric reflux and patients with duodenogastric reflux related to gastric surgery. Gastric acid secretion and gastric emptying were not altered. Five patients tested before and after laparoscopic cholecystectomy showed that nocturnal gastric alkalization was enhanced after operation.

CONCLUSIONS

This study suggests that excessive duodenogastric reflux may be responsible for persistence of symptoms after cholecystectomy.

Altered antroduodenal motility after cholecystectomy

BACKGROUND

Persistent nonspecific symptoms such as epigastric pain, bloating, nausea, and bilious vomiting are common following cholecystectomy. The etiology of these symptoms is unknown, but abnormal antroduodenal motility associated with duodenogastric reflux (DGR) is a possible cause.

PATIENTS AND METHODS

Sixteen postcholecystectomy patients and 19 healthy volunteers ("normals") were studied. Ten of the patients were asymptomatic and 6 were symptomatic. The study consisted of a 4-hour 99mTc-DISIDA (diisopropyl imidodiacetic acid) infusion and gastric aspiration, 24-hour intragastric pH monitoring, and 24-hour ambulatory antroduodenal manometry.

RESULTS

The postcholecystectomy patients showed increased DGR of the infused 99mTc-DISIDA. The data are given as coulter counts x 10(6)/min. The increase was more marked in symptomatic postcholecystectomy patients (2.54 +/- 0.15) compared to asymptomatic patients (1.21 +/- 0.46) or normals (0.26 +/- 0.15). Postcholecystectomy patients had increased percentage of time with intragastric pH > 3. In the supine period in particular, the pH was > 3 in symptomatic patients 25.4% +/- 7.7% of the time versus 8.1% +/- 4.3% for asymptomatic patients (P < 0.01). The antral phase III frequency after cholecystectomy was 2.5 +/- 0.09 cycles/min compared to 3.2 +/- 0.08 cycles/min in normals (P < 0.0001). Furthermore, propagation of the phase III front in the duodenum was significantly slowed to 0.14 +/- 0.02 cm/s after cholecystectomy compared to 0.27 +/- 0.02 cm/s in normals (P < 0.001). The duration of phase III in the proximal duodenum after cholecystectomy was also decreased to 4.3 +/- 0.27 min compared to 5.9 +/- 0.35 min in normals (P < 0.005).

CONCLUSIONS

Fasting antroduodenal motility is altered after cholecystectomy. The abnormality is associated with increased DGR, which is more marked in symptomatic patients.

Effect of biliary tract procedures on duodenogastric reflux and the gastric mucosa

The effect of alterations in the biliary tract on the gastric milieu was evaluated in gallstone disease and after cholecystectomy or biliary fenestration and compared with a control group. Endoscopic bile reflux was often found in gallstone patients (67%) and almost always after cholecystectomy (89%). Gastric bile acid concentrations were greater in the gallstone patients than in the control patients, were higher still after cholecystectomy, and were highest after biliary fenestration. The pH of the gastric fluid was more alkaline in the cholecystectomized groups. Lysolecithin concentrations were generally low and did not differ between the groups, nor was there any difference in scintigraphic reflux between the groups. Endoscopic erythematous gastritis correlated with the grade of bile reflux and was a common finding after biliary tract procedures. There were no consistent histologic findings associated with duodenogastric reflux. Helicobacter pylori colonization rates were similar in the various patient groups and were not affected by the reflux grade.

Duodenogastric reflux and gastric histology after cholecystectomy with or without sphincteroplasty

Sixteen patients who had undergone cholecystectomy plus sphincteroplasty, 14 cholecystectomized patients and ten control patients were studied to evaluate whether differences existed in duodenogastric reflux and whether these were related to morphological damage of the gastric mucosa. Duodenogastric bile reflux during fasting was evaluated by measuring the concentration of total bile acids (by an enzymatic method) and single bile acids in the gastric juice by high performance liquid chromatography. The damage was evaluated histologically by systematic endoscopic biopsy of the antrum and body of the stomach. There was a statistically significant difference in fasting bile reflux between the three groups (Kruskal-Wallis test, P less than 0.001), and the group that underwent cholecystectomy plus sphincteroplasty had a significantly higher median value than the cholecystectomized group (P less than 0.05) and the control group (P less than 0.01). The distribution of chronic antral atrophic and superficial gastritis was different in the three groups (chi 2 test, P less than 0.005). Chronic atrophic gastritis was associated with cholecystectomy plus sphincteroplasty (P less than 0.01), while chronic superficial gastritis was more frequent in cholecystectomized patients. These results suggest that there may be more duodenogastric reflux after cholecystectomy plus sphincteroplasty than after cholecystectomy alone, and that there may be a correlation between the amount of duodenogastric reflux and the severity of mucosal damage.

Duodenogastric reflux of bile acids, gastrin and parietal cells, and gastric acid secretion before and 6 months after cholecystectomy

In order to evaluate the effect of cholecystectomy on the gastric mucosa, the duodenogastric reflux of total and single bile acids, the number of parietal and gastrin cells, and the volume of gastric acid secretion were examined in 15 patients with gallstones and functioning gallbladders before and 6 months after cholecystectomy. The duodenogastric reflux of the total bile acids increased from a mean preoperative value of 1.9 mumol/hour to a mean postoperative value of 21 mumol/hour (p = 0.008). The duodenogastric reflux of all single bile acids increased after cholecystectomy, with a higher increase in glycoconjugated compared with tauroconjugated bile acids. The parietal cells decreased from a mean preoperative value of 82.8 to a mean postoperative value of 68.7 (p = 0.05), whereas there was only a mild increase in the number of gastrin cells; the output of gastric acid remained unchanged. The variation of the gastrin cells before and after cholecystectomy was negatively correlated only with the variation of taurocholic acid (r = -0.50, p = 0.05), while the variation of the parietal cells was mildly correlated with all single bile acids (r = 0.35-0.50, 0.05 less than p less than 0.02). These findings show an increased duodenogastric reflux of bile acids 6 months after cholecystectomy with a mild morphologic alteration of the gastric mucosa.

Is there an abnormal fasting duodenogastric reflux in nonulcer dyspepsia?

A quantitatively and/or qualitatively abnormal duodenogastric reflux (DGR) could be involved in the pathogenesis of nonulcer dyspepsia (NUD). The aims of this prospective study were to look for (1) a pathological DGR profile during fasting and (2) an eventual correlation between DGR profile and clinical symptoms. Twenty-six NUD patients were investigated. Seven other operated patients with a surgical procedure facilitating DGR episodes and 27 healthy volunteers served as control groups. A clinical score was determined for each patient from a standardized questionnaire. Gastric aspiration was performed for 6 hr in fasting subjects. The aspirates were pooled into 17 samples. In each sample the concentration and the output of total bile acids was determined. If the concentration was larger than 30 mumol/liter in pooled samples, the concentrations of free bile acids and the distribution of the conjugated bile acids was determined. The percentage of aliquots with a total bile acid concentration larger than 50 mumol/liter (without upper limit), and the percentage with a concentration larger than 2500 mumol/liter was also obtained. No significant difference was demonstrated between the healthy volunteers and NUD patients, whatever the parameter considered. However, there was a significant increase in each of the quantitative parameters for the group of operated patients in comparison with the NUD patient group. No significant correlation was found between the clinical score and the DGR profile in NUD patients. Apparently, DGR episodes do not play a primary role in the pathogenesis of NUD.

The alkaline shift in gastric pH after cholecystectomy

Previous studies using cholescintigraphy and measurement of bile salts in gastric juice have demonstrated that duodenogastric reflux is increased after cholecystectomy, a factor that may contribute to postoperative complaints in some patients. We studied 24-hour continuous gastric pH in healthy subjects, patients with cholelithiasis, and patients who had undergone cholecystectomy. Cholecystectomy decreased the percentage of time that gastric pH is below 2 and increased the time it is above 4 and 6. Furthermore, there was a greater increase in the more alkaline pH values in patients who were symptomatic than in those who were asymptomatic. The results demonstrated that cholecystectomy is associated with an alkaline shift in the 24-hour gastric pH profile that is most marked in symptomatic patients. This suggests that gastric alkaline episodes may be related to some postcholecystectomy symptoms.

Healthy controls have as much bile reflux as gastric ulcer patients

Data on duodenogastric reflux of bile in gastric ulcer are conflicting. We therefore measured intragastric bile acid concentration and its composition from individual bile acids, duodenogastric bile acid reflux rate, gastric emptying rate, and secretion rates of volume and acid in 30 patients with gastric ulcer and in 66 healthy controls, both in the fasting state and after feeding a liquid meal. Patients had higher gastric bile acid concentrations (p less than 0.05) than controls in the fasting state, but the overlap between the groups was considerable. In fasting patients with corpus ulcer, gastric secretion rates were significantly decreased when compared with controls. There was no difference between patients and controls with respect to gastric emptying rate, bile acid reflux rate, intragastric amount of bile acids, and bile acid composition in the fasting state. Postprandially, all parameters tested were similar in patients and controls. Controls showed high reflux rates with similar frequency as did ulcer patients. We conclude that increased gastric bile acid concentrations in the fasting stomach of patients with gastric ulcer are the result of gastric hyposecretion and not of increased reflux. They probably are pathogenetically irrelevant.