Duodenogastroesophageal reflux and methods to monitor nonacidic reflux

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Abstract

The role of duodenogastroesophageal reflux (DGER), once erroneously termed “bile reflux,” in causing esophageal mucosal damage has been an area of interest in both animal and human studies. However, because of the lack of appropriate techniques to accurately measure DGER, extrapolation of findings from animal studies to humans has been difficult to make. The recent advent of the Bilitec system (Metronics Instruments, Minneapolis, MN), an ambulatory bilirubin monitoring device, is increasing our knowledge of the specific role of DGER in esophageal diseases. Studies suggest that DGER without acid reflux may result in symptoms, but unless acid reflux is present simultaneously, it does not cause esophagitis. Therefore, therapies should aim at reducing both DGER and acid reflux. Studies show that this may be accomplished by antireflux surgery or the use of proton pump inhibitors, which by reducing gastric volume, decrease the damaging potential of both acid and DGER.

Section snippets

Animal studies

The role of duodenal contents, specifically bile acids and the pancreatic enzyme trypsin, in the development of esophageal mucosal injury is controversial and the subject of many in vitro animal studies.1 Early studies2 suggested a role for bile and its constituents, namely bile acids, in esophageal mucosal damage. Using a dog model with biliary diversion and a jejunal conduit anastomosing directly to the esophagus, Moffat and Berkas3 showed that canine bile was capable of producing various

Methods for measuring duodenogastroesophageal reflux

Prior methodologies employed for measuring DGER, including endoscopy, aspiration studies (both gastric and esophageal), scintigraphy, and ambulatory pH monitoring, have technical difficulties and do not accurately measure DGER. Currently, the most commonly used means of assessing DGER is ambulatory esophageal bilirubin monitoring. Table 1 lists currently available tests and summarizes their strengths and shortcomings.

The observation of bile in the esophagus or stomach is a poor indicator of

Role of duodenal contents in human studies

Despite its limitations, Bilitec is an important advancement in the assessment of DGER in the clinical arena. Several studies using this new device have provided important insight into the role of DGER in causing esophageal mucosal injury in humans. These studies show a significant but graded increase in both acid and DGER from controls to patients with esophagitis, with the highest values in patients with Barrett’s esophagus (Figure 3). Furthermore, it appears that DGER occurs more commonly

Medical and surgical treatment of duodenogastroesophageal reflux

Recent studies37, 38, 39 in patients with severe GERD found that aggressive acid suppression with omeprazole (20 mg twice daily) dramatically decreased both acid and DGER (Figure 4). For example, esophageal acid and DGER were both significantly reduced (P <0.02) after 28 days of treatment with pantoprazole (40 mg once daily) compared with pretreatment values in 7 patients with endoscopic evidence of GERD.38 Similarly, esophageal and gastric bile reflux was evaluated in 23 patients with

Conclusions

Both animal and human studies strongly suggest that acid is the key factor in causing esophageal injury and Barrett’s esophagus in patients with GERD. Studies using advanced techniques to identify DGER spectrophotometrically and independent of pH (Bilitec), however, suggest that duodenal contents often are present in the esophageal refluxate. The degree of esophageal exposure to acid and DGER shows a graded and similar increase from controls to patients with esophagitis, with the highest value

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