Duodenogastric reflux and gastric histology after cholecystectomy with or without sphincteroplasty

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.

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.

Gastric pathology in cholecystectomy patients: role of Helicobacter pylori and bile reflux

The data regarding the role of Helicobacter pylori infection in patients with bile reflux are conflicting. Bile reflux is often observed after cholecystectomy. This study focuses on the role of H. pylori in gastric pathology of patients who had undergone cholecystectomy. Eighty-seven consecutive patients were included in the study. An upper gastrointestinal endoscopy was performed, and biopsy specimens were taken in the antrum, incisura angularis, and in the gastric body. The presence of bile reflux in gastric fluid at endoscopic examination was recorded. The overall H. pylori infection rate was 62%, with no difference between patients with (59.7%) and without (64%) endoscopic bile reflux (p = 0.67). The intestinal metaplasia rate in gastric mucosa was significantly higher in patients with both H. pylori and bile reflux than in patients without infection and bile reflux (36.4% vs. 5.6%, p = 0.02). Moreover, the mean number of years after cholecystectomy in patients with intestinal metaplasia was significantly higher than in those without metaplasia (21.1 +/- 7 vs. 11.5 +/- 8 years, p < 0.0001), whereas mean age did not differ significantly between groups (60.3 +/- 12 vs. 55.8 +/- 11 years, p = 0.14). Furthermore, we found four cases of gastric cancer, three with H. pylori infection. The mean number of years after cholecystectomy was significantly higher in patients with gastric cancer than in other patients (21.8 +/- 4 vs. 12.2 +/- 8 years, p = 0.009). This study found that H. pylori infection is frequent in cholecystectomized patients, also in the presence of endoscopic bile reflux. Bile reflux seems to act synergistically with H. pylori infection on gastric pathology.

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.

The postcholecystectomy syndrome. A role for duodenogastric reflux

We have assessed the relationship between dyspepsia and gallstones and evaluated the effects of cholecystectomy on symptoms, endoscopic findings, and degree of duodenogastric reflux. Thirty patients with gallstones were enrolled in our study. Their symptoms, gastroscopic findings, and bile salt concentrations in fasting gastric juice were evaluated before and after surgery. Before cholecystectomy, biliary colic was present in 26 patients and dyspepsia in 20 patients; 16 patients also had biliary colic. After surgery, biliary colic disappeared in all patients. Dyspeptic symptoms improved in 12 patients (40%), 13 (43%) remained the same, and five patients (17%) developed dyspepsia or showed increase in their symptoms, the postcholecystectomy syndrome (PCS). Endoscopic gastritis developed in 50% after surgery compared with 30% before. Benign gastric ulcers developed in three patients, whereas none had been present before. Concentration of bile salts in fasting gastric juice increased from 0.56 +/- 0.4 mM to 1.47 +/- 0.75 mM after cholecystectomy (p < 0.0001). There was a positive correlation between the severity of symptoms in the postcholecystectomy syndrome and the change in the concentration of bile salts in fasting gastric juice (p = 0.0012). These observations suggest that duodenogastric reflux may play a significant role in the pathogenesis of symptoms in the postcholecystectomy syndrome.

Gallbladder motility, gallstones, and the surgeon

Cholecystectomy is one of the commonest surgical procedures in the Western world, with more than half a million procedures performed annually in the United States alone. In recent years, studies of gallstone pathogenesis and gallbladder disease have increasingly focused on abnormal gallbladder motility in the pathogenesis of some, if not all, gallbladder conditions. The control of gallbladder motility is complex and depends on an intricate interplay of neural and hormonal factors. An understanding of the control of gallbladder motility is crucial to the understanding of the mechanisms of gallstone formation and may help to explain the failure to cure symptoms after cholecystectomy in up to one third of patients. The purpose of this article is to outline mechanisms controlling gallbladder motility, examine recent developments in our understanding of this complex process, and relate changes in motility to common disease conditions of the gallbladder. The role of altered motility in the pathogenesis of gallstones is discussed and the effects of commonly performed surgical procedures such as truncal vagotomy and cholecystectomy on upper gut physiology are reviewed.

Helicobacter pylori infection increases following cholecystectomy

Cholecystectomy is frequently linked with duodenogastric reflux and gastritis but its effect on Helicobacter Pylori (H pylori) infection has not been examined. In a prospective study, twenty two patients with documented cholelithiasis underwent upper gastrointestinal endoscopy and biopsy and 24hr dual channel pH monitoring prior to cholecystectomy and again at 3-6 months post-operatively. The antral biopsies were histologically assessed for H pylori and gastritis and awarded an alkaline reflux score. The number of patients with H pylori infection increased from 7 (32%) preoperatively to 15 (68%) post-cholecystectomy (p < 0.05). Cholecystectomy was also associated with an increase in the incidence of gastritis from 7 to 15 (p < 0.05). The increase in H pylori infection rate occurred in association with an increase in the percentage time gastric pH > 4 in the supine position, from 9.6 (2.2) to 22.2 (4.8) percent, (p < 0.01). The median chemical gastritis score, however, did not change significantly following surgery [8(3-11) vs 7(3-11)]. Seven patients remained symptomatic following cholecystectomy all of whom were H pylori positive and had gastritis. H pylori can survive in the alkaline environment which follows cholecystectomy and may contribute to the post-cholecystectomy syndrome.

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.

Cholecystectomy and oesophageal pathology: is there a link?

Symptoms persist in a significant proportion of patients following cholecystectomy, some of which may have an oesophageal aetiology. The oesophagus has not previously been studied in this patient group. In this study all patients who had undergone cholecystectomy over a four year period were invited for review and symptoms were documented. Oesophageal function was examined and compared with normal controls. Patients were subdivided into symptomatic and asymptomatic subgroups and their findings compared. Symptoms were present in 53 percent of the postcholecystectomy group. The mean (sem) DeMeester acid score was higher in the post-cholecystectomy group -20.6 (3.6) than in controls -6.7 (0.9) (p = 0.01). The incidence of oesophagitis and gastritis were also increased in this group. There was a trend towards increased reflux and oesophagitis in the symptomatic compared with the asymptomatic subgroup. Other findings confined to the post-cholecystectomy group included nutcracker oesophagus in 4 and irritable bowel syndrome in 3. It is suggested that cholecystectomy may be associated with changes in oesophageal function which, in turn, may be associated with persistent symptoms.

Cholecystectomy and oesophageal reflux: a prospective evaluation

The effect of cholecystectomy on oesophageal function was examined prospectively. Of 37 patients studied, 17 (46 per cent) were still symptomatic 3-4 months after surgery. Thirteen patients (35 per cent) had abnormal oesophageal pH profiles before cholecystectomy, increasing to 27 (73 per cent) afterwards (P < 0.002). The mean (s.e.m.) DeMeester acid reflux score increased from 15.2(2.1) to 34.2(5.2) (P < 0.001) after operation. Lower oesophageal sphincter function, as measured by the sphincter function index, was significantly reduced in the patients with abnormal pH profiles after operation (P < 0.01). Mean(s.e.m.) supine gastric alkaline shift (proportion of time at pH > 4) increased from 9.2(2.0) to 17.7(3.7) per cent (P < 0.02) and the incidence of gastritis from eight patients (22 per cent) to 23 (62 per cent) (P < 0.001). These data suggest that cholecystectomy results in gastro-oesophageal reflux that appears to be related to compromised sphincter competence.