Biliary reflux

Biliary reflux, bile reflux (gastritis), duodenogastroesophageal reflux (DGER) or duodenogastric reflux is a condition that occurs when bile and/or other contents like bicarbonate, and pancreatic enzymes flow upward (refluxes) from the duodenum into the stomach and esophagus.[1][2]

Biliary reflux can be confused with acid reflux, also known as gastroesophageal reflux disease (GERD). While bile reflux involves fluid from the small intestine flowing into the stomach and esophagus, acid reflux is backflow of stomach acid into the esophagus. These conditions are often related, and differentiating between the two can be difficult.

Bile is a digestive fluid made by the liver, stored in the gallbladder, and discharged into duodenum after food is ingested to aid in the digestion of fat. Normally, the pyloric sphincter prevents bile from entering the stomach. When the pyloric sphincter is damaged or fails to work correctly, bile can enter the stomach and then be transported into the esophagus as in gastric reflux. The presence of small amounts of bile in the stomach is relatively common and usually asymptomatic, but excessive refluxed bile causes irritation and inflammation.[3] Bile reflux has been associated with gastric cancer, chemical gastritis and the development of ulcers.[4]

Symptoms

Bile reflux can be asymptomatic when laying down or after eating, as bile reflux occurs physiologically.[4]

Causes

Bile reflux gastritis can result from excess bile in the duodenum, lack of a pylorus as a barrier to retrograde flow, and/or decreased anterograde peristalsis of the stomach and duodenum. This can occur following gastric or biliary surgery or as primary biliary reflux. The most common predisposing surgeries are those that either remove, disrupt or bypass the pylorus, resulting in unopposed reflux of duodenal contents. Primary biliary reflux occurs in the absence of gastric surgery. Risk factors include gallbladder dysfunction and gastric or duodenal dysmotility.[5]

Epidemiology

Obesity is an independent risk factor for development of bile reflux.[1] Bile reflux is very infrequent in healthy individuals.[6]

Diagnosis

At this time, whilst no gold standard exists, cholescintigraphy HIDA scan, is the least invasive investigation with good-patient tolerability, sensitivity, and reproducibility to be considered first-line for diagnosis of bile reflux.[1] An unpractical diagnosis method consists of identifying esophageal content when there is reflux, to test the presence of bile in the liquid that refluxed into the esophagus. Bile should not be in the esophagus; the presence of bile indicates the presence of bile reflux. Another method is the Bilitec monitoring system, it helps identify changes in the color of the refluxate in the esophagus. Because bile has a specific color range, this photo-colorimetric device enables a physician to determine whether there is bile in the refluxate and, if so, how much and for how long it was in the esophagus.[6] Bile reflux is usually associated with:

Management

Ursodeoxycholic acid is an adequate treatment of bile reflux gastritis. The dosage is usually of 1000 mg/day and for a 4 weeks treatment.[5]

Drugs that reduce the secretion of gastric acid (e.g., proton pump inhibitors) or that reduce gastric contents or volume can be used to treat acidic bile reflux. Because prokinetic drugs increase the motility of the stomach and accelerate gastric emptying, they can also reduce bile reflux. Other drugs that reduce the relaxations of the lower esophageal sphincter, such as baclofen, have also proven to reduce bile reflux, particularly in patients who are refractory to (medically unresponsive to) proton pump inhibitor therapy. It is important to note that proton pump inhibitors do not reduce the presence of bile acid.[6] Lifestyle modification, weight reduction, and the avoidance of eating immediately before sleep or being in the supine position immediately after meals.[6]

Medications used in managing biliary reflux include bile acid sequestrants, particularly cholestyramine, which disrupt the circulation of bile in the digestive tract and sequester bile that would otherwise cause symptoms when refluxed; and prokinetic agents, to move material from the stomach to the small bowel more rapidly and prevent reflux.

Surgery

Biliary reflux may also be treated surgically, if medications are ineffective or if precancerous tissue is present in the esophagus.[7] Surgical management of bile reflux aims to divert bile away from the stomach. The most commonly utilized procedures include interposed isoperistaltic jejunal (Henley) loop, Braun enteroenterostomy and a roux-en-Y procedure. A roux-en-y choledochojejunostomy can be used to divert bile directly from the biliary tree after cholecystectomy. These procedures are effective in relieving symptoms but can be complicated by stomal ulcerations, roux stasis syndrome, and bezoar formation. [5]

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References
  1. Eldredge TA, Myers JC, Kiroff GK, Shenfine J (2018). "Detecting Bile Reflux-the Enigma of Bariatric Surgery". Obes Surg. 28 (2): 559–566. PMID 29230622.CS1 maint: uses authors parameter (link)
  2. Cheifetz, Adam S.; Brown, Alphonso; Curry, Michael; Alan C. Moss (2011-03-10). Oxford American Handbook of Gastroenterology and Hepatology. Oxford University Press US. pp. 239–. ISBN 978-0-19-538318-8. Retrieved 2 August 2011.
  3. Distinguishing Between Bile Reflux and Acid Reflux can be Difficult
  4. Mabrut JY, Collard JM, Baulieux J. (2006). "[Duodenogastric and gastroesophageal bile reflux]". Journal de chirurgie. 143 (6): 355–65. PMID 17285081.CS1 maint: uses authors parameter (link)
  5. McCabe ME 4th, Dilly CK (2018). "New Causes for the Old Problem of Bile Reflux Gastritis". Clin Gastroenterol Hepatol. 16 (9): 1389–1392. PMID 29505908.CS1 maint: uses authors parameter (link)
  6. Sifrim D (2013). "Management of bile reflux". Gastroenterol Hepatol (N Y). 9 (3): 179–80. PMC 3745208. PMID 23961269.
  7. http://www.mayoclinic.org/diseases-conditions/bile-reflux/basics/definition/con-20025548
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