Duodenogastric reflux: a cause of gastric mucosal hyperaemia and symptoms after operations for peptic ulceration.

Abstract

SUMMARY This study has investigated the possible association between duodenogastric reflux, gastritis, and symptoms in 35 patients with or without dyspepsia one to 15 years after gastric surgery. Five patients were excluded because of biliary disease, hiatus hernia, or recurrent ulceration. The remaining 30 were assessed by a symptomatic score, measurement of bilirubin and sodium concentrations in samples of fasting gastric juice, endoscopy, gastric biopsy, and the presence of radiological reflux. In 15 patients with a symptom score of less than the median, gastric bilirubin levels were less than 1 mg/100 ml in 80%; severe endoscopic changes were seen in only one patient and reflux was not observed. In contrast, in patients with a symptom score in excess of the median fluoroscopic and biochemical reflux was seen in 69 and 80% respectively and severe mucosal hyperaemia in half. There was a significant correlation between symptoms, gastric hyperaemia, and duodenal reflux (P < 0-02).After gastric operations there are a number of patients with continued dyspepsia in whom there is no evidence of recurrent peptic ulceration. Although a proportion of these individuals have biliary disease or gastrooesophageal reflux there are a substantial number who do not. In many of the latter, there is endoscopic evidence of gastric mucosal hyperaemia associated with the presence of bile in the stomach and it has been suggested that gastritis associated with duodenal reflux is a cause of their symptoms (DuPlessis, 1962).Because the results of further gastric surgery in patients who do not have a recurrent ulcer are particularly disappointing (Halpern, Hirschowitz, and Moody, 1973) it is important to establish the cause of continued dyspepsia. It could be argued that one of the reasons for the poor results of re-operating on these patients is that symptoms are related to duodenal reflux. However, it is also possible that regurgitation of bile-stained juice and gastric mucosal hyperaemia are coincidental findings, unrelated to the presence of symptoms. In order to investigate this problem, an attempt has been made to examine the relationship between duodenogastric "This work was presented in part at the spring meeting of the British Society of Gastroenterology, Nottingham, 1974. Reprint requests to: Mr J. Alexander-Williams.Received for publication 26 September 1974. reflux, gastritis, and dyspepsia in 35 subjects seen one to 15 years after ulcer surgery. Patients and MethodsThe clinical material for this study was provided from two sources. There were 17 patients who were referred because of recurrent dyspepsia after previous gastric surgery and 18 who had replied to a postal questionnaire. The latter were selected because of their willingness to attend hospital for investigation and because analysis of their replies showed that they had no complaints. A preliminary barium meal and cholecystogram was performed on all patients. Following this, three individuals were excluded because of gallstones or hiatus hernia whilst two more w...

Reflux Gastritis Syndrome

“…However, this viewpoint has not been supported by others [35,43], Measuring the natural markers in the gas tric aspirate, as a biochemical index of enterogastric reflux, has often been used to sup port the diagnosis of reflux gastritis syn drome. Bilirubin concentrations of greater than 1 mg/dl was observed in 80% of symp tomatic patients, as was reported by Keigh ley et al [ 14], In another study [16], 17 o f the 22 symptomatic patients had fasting total bile acids reflux in excess of 120 mol/h. Technetium-labelled HIDA scintigraphy, as a technique to quantitate enterogastric re flux, is now widely available [52].…”

“…Duodenogastric reflux has been suggested in the patho genesis of gastric ulcer [7] and gastritis [8]. It may also be seen in smokers without gastric ulcer [9], in patients with chronic heartburn and gastroesophageal reflux [10], in gallstone disease [11], and after cholecystectomy [ 12,13], Excessive enterogastric reflux in the re flux gastritis syndrome has been largely dem onstrated through indirect methods measur ing the concentration of natural markers such as bilirubin [14], bile acids [15][16][17][18], sodium [19], and trypsin [20] in the gastric aspirates. The gastric concentrations of bile acids have been shown to be significantly higher in a number of symptomatic patients.…”

“…Several studies have focused on the rela tionship between the intragastric concentra tion of natural markers, such as bilirubin [14] and bile acids [16], and the severity of symptoms. A recent study [43], however, in dicates that the amount of bile acid refluxed, the rate of gastric emptying, and the gross and microscopic appearance of the gastric mucosa cannot discriminate the symptom atic patients.…”

24-Hour Intragastric pH Measurement in the Quantification of Duodenogastric Reflux

“…This has given rise to a period of greater scientific rigor when diagnosing PARG, with duodeno gastric reflux (DGR) being quantified in these subjects before they are operated on [ 12,[24][25][26]. When quantify ing DGR in both asymptomatic and symptomatic pa tients, most authors [27,28] find a higher quantity of DGR in the latter.…”

Duodenogastrischer Reflux nach Vagotomie und Pyloroplastik

“…Untersuchungen, die auf einen duodenogastrischen Reflux nach Pyloroplastik hinweisen, sind sp~irlich und in ihren Ergebnissen uneinheitlich [4,12,13]. W~ihrend Capper [4] und Kilby [13] …”