Antroduodenal resistance to flow in the control of duodenogastric bile reflux during fasting

Our objectives in this study were (a) to determine the role of antroduodenal resistance in the control of fasting duodenogastric bile reflux in the dog and (b) to elucidate the contribution of the pylorus both to resistance and to reflux. Thus, we measured simultaneously throughout the interdigestive motor cycle (a) antroduodenal pressure activity by manometry, (b) antroduodenal resistance by a pneumatic resistometer, and (c) bile acid concentrations in duodenal and gastric juices. Experiments were performed in 15 conscious dogs (9 with pylorus intact and 6 with extramucosal pyloric myotomy). We found that antroduodenal resistance was lowest during phase I, increased gradually during phase II, and peaked during phase III (linear trend, p less than 0.001). Duodenogastric bile reflux was low during phase I, peaked during late phase II, and decreased again during phase III (quadratic trend, p less than 0.05). Therefore, variations in net resistance and reflux were differently related to the phases of the interdigestive motor complex. Pyloric myotomy significantly decreased antroduodenal resistance (linear trend different from control, p less than 0.001), but had no significant effect on duodenogastric bile reflux. We conclude (a) that changes in net antroduodenal resistance do not regulate duodenogastric bile reflux and (b) that the pylorus is an important determinant of antroduodenal resistance, but has no major role in the control of fasting duodenogastric bile reflux.     

Comparative evaluation of intragastric bile acids and hepatobiliary scintigraphy in the diagnosis of duodenogastric reflux

AIM:To assess the diagnostic value of a combination of intragastric bile acids and hepatobiliary scintigraphy in the detection of duodenogastric reflux(DGR).METHODS:The study contained 99 patients with DGR and 70 healthy volunteers who made up the control group.The diagnosis was based on the combination of several objective arguments:a long history of gastric symptoms(i.e.,nausea,epigastric pain,and/or bilious vomiting) poorly responsive to medical treatment,gastroesophageal reflux symptoms unresponsive to protonpump inhibitors,gastritis on upper gastrointestinal(GI) endoscopy and/or at histology,presence of a bilious gastric lake at > 1 upper GI endoscopy,pathologic 24-h intragastric bile monitoring with the Bilitec device.Gas-tric juice was aspirated in the GI endoscopy and total bile acid(TBA),total bilirubin(TBIL) and direct bilirubin(DBIL) were tested in the clinical laboratory.Continuous data of gastric juice were compared between each group using the independent-samples Mann-Whitney U-test and their relationship was analysed by Spearman’s rank correlation test and Fisher’s linear discriminant analysis.Histopathology of DGR patients and 23 patients with chronic atrophic gastritis was compared by clinical pathologists.Using the Independent-samples Mann-Whitney U-test,DGR index(DGRi) was calculated in 28 patients of DGR group and 19 persons of control group who were subjected to hepatobiliary scintigraphy.Receiver operating characteristic curve was made to determine the sensitivity and specificity of these two methods in the diagnosis of DGR.RESULTS:The group of patients with DGR showed a statistically higher prevalence of epigastric pain in comparison with control group.There was no significant difference between the histology of gastric mucosa with atrophic gastritis and duodenogastric reflux.The bile acid levels of DGR patients were significantly higher than the control values(Z:TBA:-8.916,DBIL:-3.914,TBIL:-6.197,all P < 0.001).Two of three in the DGR group have a significantly associated with e     

Dissociation of duodenogastric marker reflux and bile salt reflux

Duodenogastric reflux of a perfused marker and bile salt reflux, as well as emptying of fasting gastric contents and gastric secretion, were measured simultaneously in six healthy volunteers. Each of the subjects was studied three times in randomized order during intravenous administration of either saline or atropine (40 micrograms/kg/4 hr) or cerulein (360 ng/kg/4 hr). Fractional gastric emptying rate was inhibited from 4.57%/min +/- 0.50 SE to 0.70 +/- 0.15 by atropine (P less than 0.001) and to 1.80 +/- 0.29 by cerulein (P less than 0.005). Atropine increased reflux of duodenally perfused phenol red from 0.95 +/- 0.28 to 26.09 +/- 4.98% (P less than 0.005) without affecting bile salt reflux (0.44 +/- 0.07 vs 0.51 +/- 0.17 mumol/min). In contrast, cerulein did not significantly affect duodenogastric marker reflux (2.23 +/- 0.82%) but increased bile salt reflux to 0.94 +/- 0.16 mumol/min (P less than 0.05). It is concluded that reflux of duodenal contents and reflux of bile salts do not necessarily parallel each other. This may produce considerable confusion by apparently contradictory results in studies on duodenogastric reflux.     

Diagnostic value of gastric pHmetry in duodenogastric reflux

Several studies have been performed to examine the problem of diagnosing gastroduodenal reflux (GDR). No single method is widely accepted. The aim of this work was to evaluate the diagnostic value of gastric pHmetry in this regard. A gastric aspiration probe attached to a combined glass electrode was placed in the stomach of 24 patients, with its distal tip located between 9 and 12 cm below the cardia. One ml samples of gastric juice were taken from 8 of the patients every 30 min for 15 h and as well as, every time a spontaneous alkalinization (SA) (defined by a pH greater than or equal to 4 for at least 1 min) was observed. The pH of each sample was measured by colorimetry whereas the concentration of total biliary acids (CTBA) was evaluated by the fluorimetric method (Kit Sterognost 3 alpha Flu); pH value measured via the intragastric electrode during aspiration was also recorded (protocol A). Continuous gastric aspiration was carried out in the remaining 16 patients for the entire duration of the test (6 h) which was divided into periods of 20 min. Apart from the parameters evaluated during protocol A, the percentage of time during which the stomach had a pH greater than or equal to 4 was recorded, as well as the quantity of total biliary acids collected over the 20 min periods (protocol B). Correlation studies were carried out using the Kendall tau and Spearman tests. Percentages were compared using the chi 2 test.(ABSTRACT TRUNCATED AT 250 WORDS)     

Interdigestive motility pattern in subjects with duodenogastric bile reflux

The role of antroduodenal motility in the pathogenesis of duodenogastric biliary reflux is widely accepted, but few and conflicting data are available on the possible motor abnormalities related to this phenomenon in the fed and in the fasting state. In an attempt to define the motility pattern of the antroduodenal region associated with bile reflux in the fasting state, 20 subjects with proven duodenogastric reflux and without disorders of the upper gastrointestinal tract have been studied, and the results have been compared with those observed in 6 control subjects without evidence of reflux. The interdigestive motility complex (IDMC) has been evaluated (mean duration of IDMC and frequency and site of onset of migrating motor complexes). In subjects with duodenogastric reflux a significant increase (p less than 0.01) in the mean duration of IDMCs (179 +/- 22.19 min) was observed, in comparison with controls (108.5 +/- 37 min). A considerable reduction in the frequency of migrating motor complexes (MMC) was also observed, while no differences in the site of onset and the propagation of MMCs and in the percentage of time recorded occupied by the single phases of IDMC were found. This evidence suggests a strict relationship between duodenogastric reflux and the occurrence of phase III of IDMC and supports the hypothesis that the IDMC abnormalities are the cause and not the consequence of biliary reflux. The reduced incidence of MMC may also account for the high incidence of chronic gastritis due to prolonged contact in the fasting state between the gastric mucosa and the duodenal content.     

Relationship between antropyloric and intestinal motility and duodenogastric reflux in fasting dogs

Duodenogastric reflux was studied in fasting dogs with gastric and duodenal cannulae, by means of recovery from the gastric cannula of phenol red infused into the duodenum and bile acids recovered from the gastric cannula. Simultaneously, antropyloric and intestinal motility was studied in order to establish a relationship between motility and duodenogastric reflux. A different pattern of duodenogastric reflux was observed, depending on the method utilized. While a significantly higher reflux was observed during phase II in bile acid studies, an irregular pattern not related to the different phases of the interdigestive motor complex was observed in experiments with phenol red. Antral motility estimated by an antral motility index showed a statistically significant correlation with DGR estimated by both methods. Pyloric pressure and intestinal motility did not show a correlation with DGR. We concluded that the results obtained in studying duodenogastric reflux depend on the method used. The main factor related to increased duodenogastric reflux was the decreased antral motility.     

Gallstones, cholecystectomy, and duodenogastric reflux of bile acid

It has earlier been suggested that cholecystectomy, by eliminating the reservoir function of the gallbladder, will induce reflux of bile to the stomach. In the present study 23 patients were studied for duodenogastric reflux of bile acid before and 3 months after cholecystectomy. At the test the gastric contents were continuously aspirated via a nasogastric tube, collected at 15-min intervals for 2 h in the fasting patient, and analyzed for volume and bile acid concentration. The results were compared with those in 14 control subjects. Significant duodenogastric reflux of bile acid (greater than 100 mumol/h) was seen more frequently in gallstone patients than in controls. This is explained by a high prevalence of bile acid reflux in patients with a reduced or absent opacification of the gallbladder at cholecystography. Cholecystectomy increased the prevalence of bile acid reflux in the patients with well-opacified gallbladders at cholecystography. The duodenogastric reflux of bile acid in patients with a poor filling of the gallbladder at cholecystography was not further enhanced by cholecystectomy. It is concluded that gallstone patients have an increased tendency to duodenogastric reflux of bile acid. This tendency is further enhanced by removal of a functioning gallbladder. The findings may explain some of the symptoms in patients with gallstones. The reflux may also be responsible for symptoms in the so-called postcholecystectomy syndrome.     

The role of 24-hr gastric pH-monitoring in the interpretation of 24-hr gastric bile monitoring for duodenogastric reflux

BACKGROUND/AIMS: Duodenogastric reflux is a physiologic phenomenon. For a number of years, alkalinization of the acidic intragastric pH environment, as assessed by 24-hour gastric pH-monitoring, was thought to be caused by duodenogastric reflux. The recent introduction of the fotooptic Bilitec system for intraluminal bilirubin measurement has created the possibility to directly quantify a component of duodenal juice. METHODOLOGY: In this study, 24-hour gastric pH-monitoring and 24-hour bilirubin monitoring were performed in healthy subjects. The upper limits for physiologic bile reflux are the percentage of total time of bile reflux of 28.2% and an average absorbance during a reflux episode of 0.62 (95th percentile with threshold 0.25). RESULTS: Comparing bile with pH-monitoring (absorbance > 0.25 and/or pH > 4), an increase of bilirubin was found most frequently with constant pH (43%) or an increase of pH with constant bilirubin (37%). CONCLUSIONS: The hypothesis was drawn that the composition of duodenogastric refluxate can vary. Bile and pancreatic juice may separately contribute to duodenogastric reflux.     

Measurement of bile acids in fasting gastric aspirates: an objective test for bile reflux after gastric surgery.

We measured the concentration of bile acids in gastric aspirates from patients who had had operations for peptic ulcer. Some patients were asymptomatic and some had postoperative symptoms of the type that have been attributed to duodenogastric reflux. Samples were obtained via a nasogastric tube when the patients were fasting, after food, after pentagastrin, and overnight. We related the concentration and amount of bile acid and the volume aspirated to the presence or absence of symptoms and compared the results with radiological and endoscopic assessments of duodenogastric reflux. The most useful index to discriminate between symptomatic and asymptomatic patients was the amount of bile reflux in half an hour's aspiration from the fasting stomach; this we have termed 'fasting bile reflux' (FBR) and expressed as mumol bile acids refluxing/hour. A figure greater than 120 mumol/h was present in 17 of 22 symptomatic patients and in all who complained of bile regurgitation or bile vomiting. The FBR was less than 120 mumol/h in all of 20 asymptomatic patients, although some of them had reflux detected radiologically and endoscopically.     

Quantitative evaluation of bile diversion surgery utilizing 99mTc HIDA scintigraphy

This is a report of 21 patients presenting with epigastric pain, bilious vomiting, upper gastrointestinal bleeding, iron-deficiency anemia, and weight loss, who had undergone Billroth II gastrectomy from 3 to 35 yr earlier. Eighteen of 21 patients were found to have significant enterogastric reflux indices varying from 60% to 95% demonstrated by 99mTc HIDA scintigraphy. Thirteen patients had diversion antireflux surgery in the form of a Roux-en-Y procedure, and 1 patient had a Henley loop jejunal interposition. Postoperative 99mTc HIDA scintigraphic studies showed the enterogastric reflux indices to have decreased significantly to a range of 2%-26% (p less than 0.00001). There was marked improvement of symptoms, including correction of anemia and weight gain in those patients who had been anemic or who had sustained earlier weight loss. The enterogastric reflux indices of 10 asymptomatic control patients after Billroth II gastrectomy ranged from 4% to 45%. 99mTc HIDA scintigraphy is useful in evaluating patients before and after bile diversion surgery, and demonstrates the quantitative decrease in enterogastric reflux after such surgery.     

The influence of cholecystectomy on the duodenogastric reflux of bile

The effect of cholecystectomy on postprandial duodenogastric bile reflux was studied by biliary excretion scintigraphy in a group of 20 patients examined before and after gallbladder removal. Dyspeptic complaints were correlated with the presence of postprandial duodenogastric reflux in 37 patients admitted to the hospital for cholecystectomy. The removal of the gallbladder, whether functional or not, in patients presenting with gallstones, did not seem to influence the occurrence of postprandial duodenogastric bile reflux. Dyspeptic complaints were positively correlated with postprandial gastric reflux. This reflux was observed in 90% of dyspeptic patients, while only 7% of the patients without dyspepsia had reflux. The role of duodenogastric reflux in the production of dyspeptic complaints is open to discussion, but the removal of the gallbladder does not seem to interfere with the occurrence of bile reflux into the stomach after a milk meal.     

十二指肠胃反流与胃黏膜炎症关系探讨

目的　探讨非溃疡性消化不良患者十二指肠胃反流 (DGR)与胃黏膜炎症改变之间的关系。方法　对 5 6例有腹痛、腹胀等症状的非溃疡性消化不良患者行胃镜检查及组织活检 ,并用便携式胆红素监测仪行 2 4h胃内胆红素监测 ,以反流总时间百分率 (% )作为评价胆汁反流严重度的主要观察指标 ,分析其与胃黏膜病变之间的关系。结果　高反流组及低反流组 (各 2 8例 )的Hp阳性率为 4 6 %(13/2 8例 )和 5 0 % (14 /2 8例 ,P >0 .0 5 )。内镜下各种病变的检出率分别为 :胃窦黏膜充血 10 0 %比71% (P <0 .0 5 )、出血点 /斑 18%比 11% (P >0 .0 5 )、糜烂 39%比 2 1% (P >0 .0 5 )、血管透见 14 %比14 % (P >0 .0 5 )、黏液湖或黏膜胆汁染色 4 6 %比 18% (P <0 .0 5 )。Hp阳性与Hp阴性组慢性炎症的严重度积分 [(1.77± 0 .80 )比 (1.0 7± 0 .75 ) ,P <0 .0 5 ]及活动性积分 [(1.4 8± 0 .85 )比 (0 .86± 0 .6 4 ) ,P <0 .0 5 ]差异有显著性。在Hp阳性组 ,胆汁反流严重度与肠化严重度相关 (r =0 .5 4 8,P <0 .0 5 )。在Hp阴性组 ,胆汁反流严重度与慢性炎症 (r =0 .4 86 ,P <0 .0 5 )、萎缩 (r =0 .4 76 ,P <0 .0 5 )及肠化 (r =0 .6 2 3,P <0 .0 1)等组织病理学改变的严重度相关。结论　非溃疡性消化不良患者不论是否存     

Effect of cimetidine on gastric secretion and duodenogastric reflux.

In 19 subjects (four controls, one gastric ulcer and 14 duodenal ulcer) maximal gastric secretion was evoked with histamine 0.13 mumol/kg/h (0.04 mg/kg/h) for two to two and a half hours. A slow intravenous bolus dose of 200 mg cimetidine was given at the beginning of the last hour. Gastric secretion was measured before and after cimetidine administration and expressed both as mean acid output (mmol H+/h) and 'pyloric loss and duodenogastric reflux corrected' volume (Vg, ml/h). Mean reduction by acid output was 86%; mean reduction by corrected volume (Vg) was only 64%. The discrepancy, which is significant (p less than 0.01), is caused by a marked increase in duodenogastric reflux after cimetidine.     

Gastric histology and fasting bile reflux after partial gastrectomy

Forty-four randomized, partially gastrectomized subjects were studied to assess whether gastric histologic findings after partial gastrectomy were related to reflux. Gastric biopsy specimens (12) were taken at different distances from the anastomosis. Histologic findings were as follows: (a) hyperplastic changes of the foveolar epithelium and (b) loss of the chief and parietal gland cells with atrophy of gastric glands (chronic atrophic gastritis). Hyperplastic changes typical of the perianastomotic area gradually decreased with increasing distance from the anastomosis. Hyperplastic changes showed a greater prevalence in Billroth II than in Billroth I subjects (100% vs. 29.4%). No significant association was found between histologic findings and symptoms. Hourly bile acid quantity (fasting bile reflux) and concentration were determined in the gastric aspirates. Bile reflux was greater after Billroth II than after Billroth I (fasting bile reflux median values: 30.5 vs. 0.18 mumol/h, respectively). The same was true for bile acid concentration (mean bile acid concentration median values: 624.9 vs. 17.5 mumol/L, respectively). Moreover, Billroth I subjects with hyperplasia had a greater quantity and concentration of reflux than those without hyperplasia (fasting bile reflux and mean bile acid concentration median values: 2.6 vs. 0.8 mumol/h and 4.7 vs. 2.7 mumol/L, respectively). These findings show that bile reflux is correlated with hyperplastic changes of the foveolar epithelium, but prevalence and severity of atrophic gastritis were not related to reflux. Therefore, although we failed to show any relationship between chronic atrophic gastritis and reflux, foveolar hyperplasia was shown to be reflux related.     

Abnormalities of interdigestive motility complex and increased duodenogastric reflux in gastric ulcer patients

Just as cyclic changes in motility and secretions occur during fasting, recent evidence demonstrates that duodenogastric reflux during fasting is also cyclic and related to the motility and secretory variations. We investigated the characteristics of the migrating motility complex and duodenogastric reflux in 17 patients with gastric ulcer and compared these characteristics to those of 16 healthy subjects. We found three abnormalities of the complex in patients with gastric ulcer: (1) the antral motility was significantly decreased during the phase II of the complex (P<0.05) when compared to controls; (2) in about two thirds of them, the phase III of the complex was initiated at the duodenum or more distally; and (3) the mean bile salt concentration in the gastric aspirate was significantly higher (P<0.05) than that of the controls. We observed no relationship between the ulcer activity, the location of the crater, and the motility or reflux abnormalities.Drs. M. Miranda and C. Defilippi were International Fellows of the University of Southern California.