Duodenogastroesophageal reflux and esophageal mucosal injury in mechanically ventilated patients☆

Wilmer, Alexander; Tack, Jan; Frans, Eric; Dits, H.; Vanderschueren, Steven; Gevers, Anna-Maria; Bobbaers, Hesmann

doi:10.1016/s0016-5085(99)70492-0

Cited by 105 publications

(62 citation statements)

References 33 publications

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“…These findings provide strong evidence that changes in pH alter the toxicity of bile acids. Other supportive evidence comes from the development of esophagitis among ventilated patients in the intensive care unit on intravenous acid suppression therapy (ranitidine) (Wilmer et al, 1996). The same effect has also been reported for PPIs therapy.…”

Section: Role Of Ph In the Toxicity Of Refluxatementioning

confidence: 72%

Review Article; Duodeno-Gastro-Esophageal Reflux Combined and Isolated

Nasr¹

2013

American Medical Journal

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Barrett's esophagus is the chief risk factor for esophageal adenocarcinoma. Reflux of gastric acid has long been related to the development of esophagitis and Barrett's esophagus, but the role of duodenal contents is controversial. We review the literature on the role of duodenal contents in the development of esophagitis, Barrett's esophagus and adenocarcinoma in addition to the role of acid suppressant therapy in the development or prevention of these changes. A computer-based search of the literature using the terms "Bilirubin, Barrett, Bile Reflux, duodeno-gastric reflux and oesophagus/esophagus" was performed. The role of bile and other constituents of duodenal refluxate were examined. Techniques for identifying nonacid reflux were also reviewed, as were the role of pH, medication and surgery in modulating disease severity. Complicated Barrett's esophagus is associated with increased exposure to gastric and duodenal refluxate. Biological effect of bile acids depends on the conjugation status, the pH of the milieu and the pKa of bile acids. While Proton Pump Inhibitors reduce the levels of DGER, they also produce changes in gastric and lower esophageal pH that activate different bile acids at different pH levels resulting in unexpected injury. Conjugated bile acids are harmful in acidic environment while unconjugated bile acids are harmful at neutral pH environment. An overlap of toxicity among conjugated and unconjugated bile acids occurs between strongly acidic and neutral pH levels. Normalisation of gastric and duodenal refluxate should ideally be the goal of treatment.

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Section: Role Of Ph In the Toxicity Of Refluxatementioning

confidence: 72%

Review Article; Duodeno-Gastro-Esophageal Reflux Combined and Isolated

Nasr¹

2013

American Medical Journal

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“…Transient lower esophageal sphincter relaxation (TLESR) is believed to be the major mechanism of acid reflux in awake patients, with a defective basal LES pressure caused by hiatus hernia and straining associated with increased abdominal pressure being contributing factors [18,19] . In contrast, the absent or very low basal LES pressure induced by mechanical ventilation, opiates, endotoxemia-related sepsis and nasogastric tube are the major causes of reflux in critically ill patients [1,2,7,20] . The latter is considered to be a key factor for both the development and the degree of GER [21] .…”

Section: Discussionmentioning

confidence: 99%

“…The latter is considered to be a key factor for both the development and the degree of GER [21] . In several studies, 48%-60% of ICU patients were found to have erosive esophageal lesions induced by GER, 3 or 5 d after NGT placement [2,22] . Furthermore, the degree of GER correlates with the duration of NGT.…”

Section: Discussionmentioning

confidence: 99%

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Reasons of PEG failure to eliminate gastroesophageal reﬂuxin mechanically ventilated patients

Douzinas¹,

Andrianakis²,

Livaditi³

et al. 2009

WJG

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AIM:To investigate factors predicting failure of percutaneous endoscopic gastrostomy (PEG) to eliminate gastroesophageal reflux (GER). METHODS:Twenty-nine consecutive mechanically ventilated patients were investigated. Patients were evaluated for GER by pH-metry pre-PEG and on the 7th post-PEG day. Endoscopic and histologic evidence of reflux esophagitis was also carried out. A beneficial response to PEG was considered when pH-metry on the 7th post-PEG day showed that GER was below 4%. RESULTS:Seventeen patients responded (RESP group) and 12 did not respond (N-RESP) to PEG. The mean age, sex, weight and APACHE Ⅱ score were similar in both groups. GER (%) values were similar in both groups at baseline, but were significantly reduced in the RESP group compared with the N-RESP group on the 7th post-PEG day [2.5 (0.6-3.8) vs 8.1 (7.4-9.2, P < 0.001)]. Reflux esophagitis and the gastroesophageal flap valve (GEFV) grading differed significantly between the two groups (P = 0.031 and P = 0.020, respectively). Histology revealed no significant differences between the two groups. CONCLUSION:Endoscopic grading of GEFV and the presence of severe reflux esophagitis are predisposing factors for failure of PEG to reduce GER in mechanically ventilated patients.

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“…26 Gastric aspiration volumes increase during downstream intrajejunal enteral feeding. 27 Duodenogastric bile reflux has been shown to be a putative cause of esophagitis in these patients 28,29 and, indeed, it is of interest that intrajejunal diet infusion results in a significant increase in acid reflux in patients who have suffered a cerebral vascular accident with and without a history of gastroesophageal reflux disease. 30 To prevent build-up of intragastric fluid volumes and to minimize gastroesophageal reflux that might be stimulated by intrajejunal enteral feeding, nasojejunal feeding must incorporate a gastric aspiration capability.…”

Section: Nasojejunal Enteral Tube Feedingmentioning

confidence: 99%

The Evolving Role of Post–Ligament of Trietz Nasojejunal Feeding in Enteral Nutrition and the Need for Improved Feeding Tube Design and Placement Methods

Silk

2011

J Parenter Enteral Nutr

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Nutrition support is an important link in the chain of therapy for intensive care unit patients. The early institution of nutrition support significantly reduces the incidence of septic complications, reduces mortality, and shortens hospital stay. Unfortunately, impaired gastrointestinal function, particularly gastric atony, restricts the use of nasogastric enteral tube feeding, and the use of this route of administration in these patients can lead to regurgitation, aspiration, and the development of pneumonia. Postpyloric enteral feeding was heralded as a means of overcoming many of these problems. Overall, the results of controlled studies do not support a role of postpyloric duodenal feeding in reducing the incidence of aspiration pneumonia. As a consequence, post–ligament of Treitz nasojejunal enteral feeding is proposed as the technique of choice in these patients. Feeding tube design must incorporate a gastric aspiration port to overcome problems of gastroesophageal acid reflux, duodenogastric bile reflux, and increased gastric acid secretion, problems that occur during “downstream” jejunal feeding. Tube placement technique will need to be refined and patients will need to receive a predigested enteral diet. In postoperative surgical patients in the intensive care unit, there is also a need for a newly designed dual‐purpose nasogastric tube capable initially of providing a means of undertaking gastric aspiration and decompression and subsequently a means of initiating nasogastric enteral feeding.

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Duodenogastroesophageal reflux and esophageal mucosal injury in mechanically ventilated patients☆

Cited by 105 publications

References 33 publications

Review Article; Duodeno-Gastro-Esophageal Reflux Combined and Isolated

Review Article; Duodeno-Gastro-Esophageal Reflux Combined and Isolated

Reasons of PEG failure to eliminate gastroesophageal reﬂuxin mechanically ventilated patients

The Evolving Role of Post–Ligament of Trietz Nasojejunal Feeding in Enteral Nutrition and the Need for Improved Feeding Tube Design and Placement Methods

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