Gastritis is a general term used for the description of symptoms associated with several very different physical conditions and require different treatments based on their ideology . Gastritis, gastroesophageal reflux, and bile reflux gastritis

Gastritis may be caused by excess acid or bile in the stomach. Some patients may have gastroesophageal reflux due to a hiatal hernia, which needs to be treated surgically with Nissen fundoplication, regardless of the size of the hernia, contrary to what gastroenterologists recommend by prescribing antacids for an extended period. I have seen patients who have had one cm hiatal hernia and have been very symptomatic, and others who have had larger hiatal hernias and have been asymptomatic. Size should not be a determinant of whether the patient has had or will have a hernia repair or not.

 

 

Billiary Diversion is the definitive surgical procedure for Bile Reflux Gastritis.

Bile reflux gastritis is not a the result of the cholecystectomy but may be seen in a subset of patient with other confounding conditions. Bile is produced in the liver and stored in the gallbladder. In response to high fat and protein in the stomach, the gallbladder contracts to ” squeeze” the bile stored in the gallbladder into the small bowel to help absorb the fat and protein.

 

With the gallbladder removed, the bile produced by the liver cannot be stored and goes directly to the small bowel via the biliary tree.

It is possible and likely that some of the bile will find its way back to the stomach. In some patients, due to compounding circumstances, the bile may collect and cause gastritis. We need to dissect this a little for it to make sense.

• Not every patient after cholecystectomy will have bile in their stomach.
• Not every patient with bile in the stomach has gastritis.

To appreciate this, let’s remember that for bile to get from the small bowel to the stomach, it needs to:

• Go upstream, against the peristalsis of the small bowel, and do not be washed down by the flow of the gastric
• juices coming out of the stomach.
• Go through the pyloric valve.
• If it reaches the stomach, the acid in the stomach does not neutralize it, causing gastritis.

As I’m sure we all appreciate, other contributing factors besides cholecystectomy may cause bile reflux and bile reflux gastritis. This is why it’s also emphasized that bile in the stomach alone does not confirm biliary reflux gastritis. It is also why we always state that bile reflux gastritis is a disease of exclusion, where other conditions such as gastroparesis, acid reflux, and hiatal hernia (regardless of size, as some patients are unfortunately told that since the hernia is small it does not need to be fixed, which is incorrect) must be considered. Further information on Bile Reflux.  

Billary Diversion is the only definitive surgical procedure for Bile Reflux Gastritis.

Gastroesophageal (GE) reflux is the condition when the stomach contents are able to “reflux” back through an incompetent lower esophageal sphincter (LES) into the esophagus.

Gastroesophageal reflux Disease (GERD) is a clinical condition caused by long-standing reflux that results in microscopic and visible changes to the inner lining of the esophagus and esophageal mucosa.

GERD is nondescript as to the cause of the condition. It only states that the stomach contents have been irritating the lining of the esophagus on a chronic basis. This can be caused by an anatomical abnormality of the GE junction (hiatal hernia) or may be related to dysfunction of the LES. Other possible causes of 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 refluxed content.

In Acid Reflux, the relative acid overproduction of acidic secretion and the exposure of the esophageal mucosa need to be addressed. This is accomplished by acid suppression medications, anti-histamine (H2 blockers), and Proton pump inhibitors (PPIs).  The physiology and the mechanism involving this condition are well understood. As a surgeon, however, I do 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 a related upper endoscopy. Patients who do not improve or where deterioration of the esophageal mucosa and the presence of precancerous cells are referred for surgical intervention.

Bile Reflux, contrary to acid reflux, may have tiny, if anything, to do with the LES. The symptoms experienced by the patient may be as after related to the excessive bile in the stomach, which is seen frequently

after cholecystectomy, or in those patients with a dysfunctional gallbladder (low EF on HIDA scan).

The treatment of Bile reflux is Duodenal Switch without the associated sleeve gastrectomy component in addition to repair of hiatal hernia if present. Ann Surg. 2007 Feb; 245(2): 247–253.

Bile reflux gastritis has been recognized as a significant cause of dyspepsia in a subset of patients. This patient group set does not respond to the standard treatment (not expected to) and some get improvement with the treatment of H.Pylori infection if one is diagnosed at the time of upper endoscopy and biopsy.

Inflammation and Foveolar hyperplasia are some of the findings that can be seen endoscopically. This and other findings have all been documented in the literature. An article published in 2005, reported over 40% incidence of Foveolar hyperplasia in patient with bile relax.

It is been noted that bile causes the thickening of the mucosa lining of the GI track. This is called Foveolar hyperplasia when the mucosa of the stomach is noted to be thicker with more numerous and deeper folds.

The treatment for this is reduction and prevention of bile reflux to the stomach, in some cases this can only achieved by surgical diversion of the bile from the stomach. Additional information on Bile Reflux and the surgical treatment can be found here.

In 1881, Dr. Theodore Billroth performed the first successful gastrectomy for pyloric tumor. He removed the distal part of the stomach and tumor of the pyloric region and reconnected the distal end of the transected stomach directly to the segment of the duodenum. This was later renamed as Billroth I procedure. In Billroth I the anastomosis allows the food pathway to stay in the same directional flow with the exception of pyloric valve having been removed. There is, however, increased incidence of bile reflux with the pyloric value removal.

There are incidences where the resected segment is so large that the proximal stomach and the distal duodenal can not be mobilized and brought close to each other to be able to create the Billroth-I anastomosis. Larger resection, where the Billroth I could not be completed Dr. Billroth in 1885 created a procedure call the Billroth II. The Billroth II was performed when the tumor was very large and the continuity of the GI track was created by a loop gastrojejunostomy. This procedure was named Billroth II.

In the Billroth II the bile flow from the small bowel flows toward the stomach, and this results in a much higher incidence of Bile reflux and its associated complication.

The lesson learned from Billroth I and Billroth II was that bile reflux can be a significant problem when creating the continuity of the proximal GI track with exclusion of the pyloric valve. In Bilroth II, there is the additional burden of the bile flowing toward the stomach unlike the Billroth I.

The SADI or SIPS, Loop procedures that are incorrectly promoted as “duodenal switch” employ a loop anastomosis, which results in a biliary flow toward the post pyloric duodenum significantly increasing the chance and the possible incidence of Bile reflux.

All these unknowns about the SIPS, SADI Loop are yet to be investigated.