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Category: Endoscopy

Gastroesophageal Reflux: Bile Vs. Acid

May 14, 2019 12:52 pm

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

Bile Reflux Gastritis
Foveolar Hyperplasia- Bile Reflux Gastritis

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

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

GI Bleed following Weight Loss Surgery

September 17, 2018 10:28 am

Gastrointestinal (GI) Bleed following weight loss surgery is rare but does require knowledge of the particular bariatric surgical procedure the patients has and how to proceed with diagnostics to fully evaluate the situation. Acute or chronic gastrointestinal bleeding can cause anemia in patients. However, Anemia may also be caused by nutritional deficiencies (iron, vitamin , minerals), Kidney disease, bone marrow disease and others. The work-up for anemia following weight loss surgery follows a routine protocol. If there is an evidence of bleeding from intestine (bloody emesis, bloody bowel movement, “tar” like black bowel movements) then the diagnostic work up would include an upper and lower endoscopy.

Endoscopic Procedures:

Upper endoscopy Esophagogastroduodenoscopy (EGD): evaluates the esophagus, stomach and a limited area of the duodenum past pyloric valve.

Normal Anatomy
Normal Anatomy

Lower endoscopy Colonoscopy or coloscopy: evaluates the rectus and the entire colon.

Between these two tests, there is still a considerable amount of the small bowel that is not accessible or visualized with endoscopic procedures. For the small bowel, examination Capsule endoscopy is an option in an intact GI tract. Patients who have had Gastric bypass RNY or the Duodenal Switch, the large segments of the small bowel can not be visualized or examined with capsule endoscopy.

RNY Gastric Bypass
RNY Gastric Bypass
Duodenal Switch Two Anastomosis
Duodenal Switch Two Anastomosis
SADI-S Single Anastomosis Duodeno-ileal - Sleeve
SADI-S Single Anastomosis Duodeno-ileal - Sleeve

Patients who have had Duodenal Switch, Gastric Bypass and SADI – S would need a tagged red cell scan or CT angiography if GI bleed is suspected in areas of the small intestine that are inaccessible by endoscopic procedures.