Gastroesophageal (GE) reflux is the condition when the stomach content are able to “reflux” back thru an incompetent lower esophageal sphincter (LES) into the esophagus.
Gastroesophageal reflux Disease (GERD) is the clinical condition which is the result of long standing reflux and results in microscopic and visible changes to the inner lining of the esophagus, esophageal mucosa.
GERD is a non descriptive as to the cause of the condition. It only states that the content of the stomach have been irritating the lining of the esophagus on chronic bases. This can be caused by an anatomical abnormality fo the GE junction (Hiatal Hernia), or may be related to disfunction the LES. Other possible causes of the GERD may be infection (H.Pylori) environmental (stress) and dietary (nicotine, alcohol, caffeine, spicy food) in origin.
So far we have not clarified the chemical nature of the the refluxed content.
In Acid Reflux, the relative acid overproduction of acidic secretion and the exposure of the esophageal mucosa is what needs to be addressed. This is accomplished by acid suppression medications, Anti Histamine (H2 blockers) Proton pump inhibitors (PPI) for example. The physiology, and the mechanism involving this condition is well understood. As a surgeon, we do however see patients who should have had surgical intervention. The initial mode of therapy for a patient with documented acid reflux, and or symptomatic hiatal hernia is placing them on medication. These patients are then recommended to have related upper endoscopy. Patients who do not improve or where deterioration of the esophageal mucosa, presence of precancerous cells, then the patients are referred for surgical intervention.
Bile Reflux, contrary to acid reflux may have very little if anything with the LES. The symptoms experienced by the patient may be as ofter related to the excessive bile in the stomach seen frequently
after cholecystectomy, or in those patients with dysfunctional gallbladder (low EF on HIDA scan).
Bile Reflux or Duodenogastroesophageal Reflux (DGER) can be difficult to differentiate from acid reflux. Bile reflux happens when bile and contents from the duodenum, the first part of the small intestine, backs up into the stomach and possibly the esophagus causing gastritis or esophagitis. It is important to note that Acid Reflux and Bile Reflux are two different conditions. You can not distinguish between Acid Reflux and Bile Reflux by symptoms alone. It is also possible to have a combination of Acid and Bile reflux. Bile reflux into the stomach may occur in some patients with no symptoms. The problem arises when patient who are diagnosed solely on the symptoms of “reflux” are inadequately worked up and are placed on PPI, proton pump inhibitor medication or similar, unsuccessfully.
What is bile?
Bile is a digestive fluid continually produced by the liver up to a liter a day. Bile is made of water, cholesterol, bicarbonate, bile acids and salts, electrolytes and copper. Bile travels through the hepatic duct and is stored in the gallbladder, if a person has a gallbladder. When the gallbladder is removed, the bile produced by the liver, continuously travels to the small bowel.
What does bile do?
Bile has a specific function in fat digestion. Bile acts as an emulsifying agent to breakdown fatty acids into small particles, micelles, so they can be absorbed. Bile is important in dietary fat and fat soluble vitamin absorption. Bile is also the means for the body to dispose of the byproduct of blood breakdown, bilirubin. Bile is also important in cholesterol regulation and removes some excess cholesterol into the stool.
Anatomy of Bile Pathway
Approximately 20-30 minutes after eating the gallbladder will secrete bile into the first part of the small intestines called the Duodenum through the Common Bile Duct. The Common Bile Duct will release bicarbonate and water into bile. Once in the Duodenum, the bile will mix with the food product entering from the stomach.
Symptoms of Bile Reflux:
- Chest Pain
- Food Regurgitation
- Upper Abdominal Pain
- Unexplained Weight Loss
Possible Causes of Bile Reflux:
- Gastric Bypass RNY or SADI/SIPS/Loop
- Peptic Ulcer
- Gastric Motility dysfunction (Diabetic gastroparesis)
- Pyloric Valve Dysfunction
- Gallbladder Surgery (Cholecystectomy)
- Biliary tree bypass surgery (Choledochoduodenostomy)
What is Bile Reflux or Duodenogastroesophageal reflux?
Bile Reflux or Duodenogastroesophageal Reflux is caused by the contents of the Duodenum entering the stomach and the esophagus causing symptoms and damage to the stomach and esophagus.
What is Gastroeseophageal Reflux?
What is Esophagitis?
Esophagitis is the inflammation (-itis) of the esophagus. An irritant that can be acid, bile, food and digestive enzymes coming back up the esophagus can cause irritation and swelling of the cells lining the esophagus. If left untreated, it can damage the lining of the esophagus to the point of erosion and scarring. There is a relationship between DGER occurrence and the severity of esophageal lesions.
What is Gastritis?
Gastritis is the inflammation of the lining of the stomach. This may cause erosion of the lining of the stomach. This could be caused by bacterial growth or bile reflux. Gastritis can be either a acute or chronic issue that left untreated can lead to more severe problems such as bleeding or cancer.
How to Diagnose Bile Reflux or Duodenogastroesophageal reflux?
Diagnosis takes careful consideration due to the high likelihood that DGER most often happens in conjunction with GERD and the symptoms of both are similar. Medical treatment with medication to treat GERD and assist with DGER. Other important diagnostic test may include:
- PH study
- Motility, Gastric emptying study
- Upper endoscopy and biopsy
- Esophogeal Bilirubin Monitoring Bilitec
- Proton Pump Inhibitor Test
- Avoid eating at least 3 hours prior to bedtime or reclining
- Weight loss if needed
- Avoid fatty foods, caffeine, peppermint, alcohol, garlic, onions, tomato products
- Cessation of smoking
- Medications: Acid and Pepsin suppression therapy
- Proton Pump Inhibitor *PPI use increases risk of Clostridium difficile colitis and bacterial gastroenteritis
- H2 Blocker
- Bile Acid Sequestrants
- Ursodeoxycholic acid
Surgery for Bile Reflux:
The Stand-Alone Duodenal Switch procedure without a Sleeve Gastrectomy or Gastric Bypass pouch was developed by Dr. Tom R. DeMeester in the 1980’s to treat bile-reflux gastritis, a condition in which the stomach and esophagus are irritated by bile that goes back through the pylorus to the stomach. The DeMeester procedure creates a shorter bilipancreatic channel than the Biliopancreatic Diversion with Duodenal Switch for weight loss. The Bile Reflux Duodenal Switch biliopancreatic channel is approximately 25-110 cm and alimentary channel 50 – 110 cm depending on symptoms, health history, weight, etc. These measurements are significantly different than the Biliopancreatic Diversion with Duodenal Switch for weight loss.
Duodenal Switch for Bile Reflux References:
Bile Reflux References:
1 Stein HJ, Kauer WKH, Feussner H, Siewert JR: Bile acids as components of the duodenogastric refluxate: detection, relationship to bilirubin, mechanism of injury and clinical relevance. Hepatogastroenterology. 1999, 46: 66-73.
Duodenalgastroesophageal Reflux medical and surgical https://www.ncbi.nlm.nih.gov/pubmed/18507090