Post-cholecystectomy bile reflux gastritis: Prevalence, risk factors, and clinical characteristics

OBJECTIVE

Bile reflux gastritis is caused by the backward flow of duodenal fluid into the stomach. A retrospective cohort study was performed to estimate the prevalence and risk factors of bile reflux gastritis postcholecystectomy, and to evaluate the endoscopic and histopathologic changes in gastric mucosa.

METHODS

Patients with refractory upper abdominal pain right below the ribs with symptoms of bloating, burping, nausea, vomiting, and bile regurgitation during the period from January 2018 to December 2020, submitted to Zagazig University Hospitals were enrolled in this study. The studied 64 patients were divided into two groups; the control group (CG): 30 subjects who had never undergone any biliary interventions, and the post-cholecystectomy group (PCG): 34 patients who had undergone cholecystectomy.

RESULTS

The prevalence of bile reflux gastritis was (16.7%) and (61.8%) in CG and PCG, respectively. Diabetes, obesity, elevated gastric bilirubin, and elevated stomach pH were all risk factors for bile reflux gastritis in both groups (r = .28,.48,.78,.57 respectively). Age, sex, epigastric pain, heartburn, vomiting, and the existence of bile reflux gastritis, on the other hand, had no correlation.

DISCUSSION

After a cholecystectomy, bile reflux gastritis is prevalent, especially among obese and diabetic patients.

Etiology, pathogenesis, diagnosis and treatment of bile reflux gastritis

Bile reflux gastritis is a common disease of the digestive system, whose clinical characteristics are abdominal pain, abdominal distention and nausea and vomiting, affecting the quality of life of patients seriously. However, the etiology and pathogenesis of bile reflux gastritis are still unclear, which may be related to gastrointestinal surgery, gallbladder disease, Helicobacter pylori infection, psychological factors, etc. There are many diagnostic methods, but a consensus on diagnosis is still lacking. Most of the current treatments are symptomatic treatments, but the overall efficacy is poor. This article reviews the etiology, pathogenesis, diagnosis and treatment of bile reflux gastritis, with an aim to provide a reference for further research of this disease.

Bile reflux after cholecystectomy affects histology of gastric antral epithelial cells

AIM: To investigate the effect of bile reflux after cholecystectomy on the histology of gastric antral mucosal cells.

METHODS: Forty patients with gallstones diagnosed by type-B ultrasound and CT underwent endoscopy before and three months after the excision of the gallbladder to observe the degree of bile reflux in the pyloric opening and the extent of duodenal bile retention. Biopsy forceps were used to take antral gastric mucosal tissues for histological examination. The patients then underwent re-examinations annually for three years to observe the degree of bile reflux and histological changes of gastric mucosal cells.

RESULTS: The percentage of patients without bile reflux in the pyloric opening was reduced from 65% before cholecystectomy to 7.5% after cholecystectomy, and the corresponding percentages were 27.5% to 15% for patients with a small amount of bile reflux, 7.5% to 55% for those with a medium amount of bile reflux, and 0% to 22.5% for those with a large amount of bile reflux. The percentage of patients with a small amount of bile retention was reduced from 80% before cholecystectomy to 10% after cholecystectomy, and the corresponding percentages were 20% to 67.5% for patients with a medium amount of bile retention, and 0% to 22.5% for those with a large amount of bile retention. Gastric mucosal cells showed significant histological changes after cholecystectomy. The percentage of patients with intestinal metaplasia increased from preoperative 7.5% to postoperative 62.5%, and the percentage of patients with atypia-hyperplasia increased from preoperative 5% to 45%.

CONCLUSION: Bile reflux increases significantly after cholecystectomy, which can cause bile reflux gastritis and gradually lead to intestinal metaplasia and atypia-hyperplasia.

Ursodeoxycholic acid for treatment of bile reflux gastritis: A systematic review

AIM: To systematically evaluate the efficacy of ursodeoxycholic acid (UDCA) in the treatment of bile reflux gastritis.

METHODS: We searched PubMed, Cochrane Library, Chinese Academic Journal (CJFD), Chinese Biomedical Literature Database (CBM), Chinese Journal Full-Text Database (CNKI), Wanfang database, and VIP database (until December 2012) to collect randomized controlled trials (RCTs) that evaluated the efficacy of UDCA in the treatment of bile reflux gastritis. Other relevant journals were also searched manually. Literature screening, quality assessment and data extraction were conducted by two reviewers according to inclusion and exclusion criteria. Meta-analyses were conducted using RevMan 5.0.

RESULTS: A total of 17 RCTs involving 1365 patients were identified. According to the results of meta-analyses, trial groups was better than control groups in terms of overall efficacy (OR = 4.16, 95% CI: 2.68-6.46, P < 0.00001), rate of clinical symptom remission (OR = 4.99, 95% CI: 2.71-9.16, P < 0.00001) and cure rate (OR = 1.92, 95% CI: 1.24-2.99, P = 0.004). In terms of improvement of mucosal inflammation revealed by gastroscopy, the UDCA + PPI + prokinetic drug group was better than the control group (OR = 4.45, 95% CI: 2.04-9.69, P = 0.0002), but the groups of UDCA + prokinetic drug + mucosal protective drug (P = 0.13) and UDCA + prokinetic drug (OR = 2.34, 95% CI: 0.78-6.98, P = 0.13) showed no significant difference compared to the control group. Six RCTs reported adverse effects and the UDCA group did not report adverse events.

CONCLUSION: Our results show that UDCA is much more effective in the treatment of bile reflux gastritis than control drugs. However, there is a moderate risk of bias due to methodological quality problems in all 17 included RCTs. More strictly-designed, large-scale, high-quality, multi-centered RCTs are needed to confirm this result.