Effects of bile reflux on gastric mucosal lesions in patients with dyspepsia or chronic gastritis

AIM: To investigate the influences of bile reflux on profiles of gastric mucosal lesions in patients with dyspepsia or chronic gastritis.METHODS: A total of 49 patients diagnosed with dyspepsia and chronic gastritis underwent 24-h ambulatory andsimultaneous monitoring of intragastric bilirubin absorbance and pH values, and then they were divided into bile refluxpositive group and bile reflux negative group. Severity of pathological changes in gastric mucosa including activeinflammation, chronic inflammation, intestinal metaplasia, atrophy and dysplasia as well as Helicobacter pylori (H pylori) infection at the corpus, incisura and antrum were determined respectively according to update Sydney system criteria. The profiles of gastric mucosal lesions in the two groups were compared, and correlations between time-percentage of gastric bilirubin absorbance ＞0.14 and severity of gastric mucosal lesions as well as time-percentage of gastric pH ＞4 were analyzed respectively. RESULTS: Thirty-eight patients (21 men and 17 women, mean age 44.2 years, range 25-61 years) were found existing with bile reflux (gastric bilirubin absorbance ＞0.14) and 11 patients (7 men and 4 women, mean age 46.2 years,range 29-54 years) were bile reflux negative. In dyspepsia patients with bile reflux, the mucosal lesions such as active inflammation, chronic inflammation, intestinal metaplasia, atrophy or H pylori infection in the whole stomach, especially in the corpus and incisura, were significantly more severe than those in dyspepsia patients without bile reflux. Moreover, the bile reflux time was well correlated with the severity of pathological changes of gastric mucosa as well as H pylori colonization in the near-end stomach, especially in the corpus region. No relevance was found between the time of bile reflux and pH ＞4 in gastric cavity. CONCLUSION: Bile reflux contributes a lot to mucosal lesions in the whole stomach, may facilitate H pylori colonization in the corpus region, and has no influence on acid-exposing status of gastric mucosa in patients with dyspepsia or chronic gastritis.

Prevalence of bile reflux in gastroesophageal reflux disease patients not responsive to proton pump inhibitors

AIM:To determine the prevalence and characteristics of bile reflux in gastroesophageal reflux disease(GERD) patients with persistent symptoms who are non-responsive to medical therapy.METHODS:Sixty-five patients(40 male,25 female;mean age,50 ± 7.8 years) who continued to report symptoms after 8 wk of high-dose proton pump inhibitor(PPI) therapy,as well as 18 patients with Barrett's esophagus,were studied.All patients filled out symptom questionnaires and underwent endoscopy,manometry and combined pH-metry and bilimetry.RESULTS:There were 4 groups of patients:22(26.5%) without esophagitis,24(28.9%) grade A-B esophagitis,19(22.8%) grade C-D and 18(21.6%) Barrett's esophagus.Heartburn was present in 71 patients(85.5%) and regurgitation in 55(66.2%),with 44(53%) reporting simultaneous heartburn and regurgitation.The prevalence of pathologic acid reflux in the groups without esophagitis and with grades A-B and C-D esophagitis was 45.4%,66.6% and 73.6%,respectively.The prevalence of pathologic bilirubin exposure in these 3 groups was 53.3%,75% and 78.9%,respectively.The overall prevalence of bile reflux in non-responsive patients was 68.7%.Pathologic acid and bile reflux was observed in 22.7% and 58.1% of non-esophagitic patients and esophagitic patients,respectively.CONCLUSION:The high percentage of patients poorly responsive to PPI therapy may result from poor control of duodenogastroesophageal reflux.Many patients without esophagitis have simultaneous acid and bile reflux,which increases with increasing esophagitis grade.

Systematic Review and Meta-analysis of Efficacy of Banxia Xiexin Decoction for Treatment of Bile Reflux Gastritis

[Objectives]The purpose was to study the clinical efficacy and safety of Banxia Xiexin decoction in treating bile reflux gastritis(BRG).[Methods]Randomized controlled trial was adopted to conduct scientific and standardized assessment on the risk of bias in the included articles.With overall effect and epigastric pain relief as indices,meta-analysis was performed,and sensitivity and safety analysis was conducted on the included literature.[Results]A total of 13 articles were included,involving a total of 1478 patients.The results of meta-analysis show that the efficacy of Banxia Xiexin decoction alone and Banxia Xiexin decoction-Western medicine combination is better than that of Western medicine alone.[Conclusions]Banxia Xiexin decoction is safe and effective in treating bile reflux gastritis.However,as the 13 articles included are all low in quality and there is a certain degree of publication bias,the objectivity of the results is affected to some extent.

Randomized controlled trial of uncut Roux-en-Y vs Billroth Ⅱ reconstruction after distal gastrectomy for gastric cancer: Which technique is better for avoiding biliary reflux and gastritis?

AIM To identify which technique is better for avoiding biliary reflux and gastritis between uncut Roux-en-Y and Billroth Ⅱ reconstruction. METHODS A total of 158 patients who underwent laparoscopyassisted distal gastrectomy for gastric cancer at the First Hospital of Jilin University(Changchun, China) between February 2015 and February 2016 were randomized into two groups: uncut Roux-en-Y(group U) and Billroth II group(group B). Postoperative complications and relevant clinical data were compared between the two groups. RESULTS According to the randomization table, each group included 79 patients. There was no significant difference in postoperative complications between groups U and B(7.6% vs 10.1%, P = 0.576). During the postoperative period, group U stomach p H values were lower than 7 and group B p H values were higher than 7. After 1 year of follow-up, group B presented a higher incidence of biliary reflux and alkaline gastritis. However, histopathology did not show a significant difference in gastritis diagnosis(P = 0.278), and the amount of residual food and gain of weight between the groups were also not significantly different. At 3 mo there was no evidence of partial recanalization of uncut staple line, but at 1 year the incidence was 13%. CONCLUSION Compared with Billroth II reconstruction, uncut Rouxen-Y reconstruction is secure and feasible, and can effectively reduce the incidence of alkaline reflux, residual gastritis, and heartburn. Despite the incidence of recanalization, uncut Roux-en-Y should be widely applied.

Effect of domperidone therapy on nocturnal dyspeptic symptoms of functional dyspepsia patients

AIM:To investigate the incidence of nocturnal dyspeptic symptoms in patients with functional dyspepsia(FD) and whether prokinetic drugs can alleviate them. METHODS:Eighty-five consecutive Chinese patients with FD were included in this study.One week after single-blinded placebo run-in treatment,baseline nocturnal intragastric pH,bile reflux and nocturnal dyspeptic symptoms of eligible patients,including epigastric pain or discomfort,abdominal distention and belching, were investigated with questionnaires.Patients exhibiting nocturnal dyspeptic symptoms were randomly and double-blindly assigned to domperidone group or placebo group.Nocturnal intragastric pH and percentage of duodenogastric bile reflux time were determined after treatment. RESULTS:Of the 85 FD patients,2 females withoutnocturnal symptoms,who responded to placebo run-in treatment,were excluded from the study,30(36.1%) exhibited nocturnal dyspeptic symptoms with increased duodenogastric bile reflux time(intragastric bilirubin absorbance>0.14)and mean gastric pH(confirming the existence of bile reflux)(P=0.021,0.023) at night were included in the study.Of these 30 patients,21(70%)had overt nocturnal duodenogastric bile reflux,which was significantly higher than that of those without nocturnal symptoms(P=0.026).The 30 patients were allocated to domperidone group or placebo group(n=15).The nocturnal duodenogastric bile reflux and gastric pH were significantly decreased after domperidone treatment(P=0.015,0.021).The severity score of nocturnal dyspeptic symptoms was also significantly decreased after domperidone treatment (P=0.010,0.015,0.026),which was positively correlated with the reduced nocturnal bile reflux or gastric pH(r=0.736,0.784,0.753 or r=0.679,0.715,0.697, P=0.039,0.036,0.037 or P=0.043,0.039,0.040). CONCLUSION:A subgroup of Chinese FD patients show overt nocturnal dyspeptic symptoms,which may be correlated with the excessive nocturnal duodenogastric bile reflux.Domperidone therapy can alleviate these symptoms.

Biliary reflux detection in anomalous union of the pancreaticobiliary duct patients

AIM： To demonstrate the imaging findings of biliopan creatic and pancreatico-biliary reflux in patients with anomalous union of the pancreatico biliary duct （AUPBD） on gadoxetic acidenhanced functional magnetic resonance cholangiography （fMRC）.

Does the addition of Braun anastomosis to Billroth Ⅱ reconstruction on laparoscopic-assisted distal gastrectomy benefit patients?

BACKGROUND Operation is the primary therapeutic option for patients with distal gastrectomy.Braun anastomosis is usually performed after Billroth Ⅱ reconstruction,which is wildly applied on distal gastrectomy because it is believed to benefit patients.However,studies are needed to confirm that.AIM To identify whether the addition of Braun anastomosis to Billroth Ⅱ reconstruction on laparoscopy-assisted distal gastrectomy benefits patients.METHODS A total of 143 patients with gastric cancer underwent laparoscopy-assisted distal gastrectomy at Centre 1 of PLA general hospital between January 2015 and December 2019.Clinical data of the patients were collected,and 93 of the 143 patients were followed up.These 93 patients were divided into two groups:Group 1(Billroth Ⅱ reconstruction,33 patients);and Group 2(Billroth Ⅱ reconstruction combined with Braun anastomosis,60 patients).Postoperative complication follow-up data and relevant clinical data were compared between the two groups.RESULTS There were no significant differences between Group 1 and Group 2 in postoperative complications(6.1%vs 6.7%,P=0.679),anal exhaust time or blood loss.The follow-up prevalence of reflux gastritis indicated no significant difference between Group 1 and Group 2(68.2%vs 51.7%,P=0.109).The followup European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core-30 scores revealed no evident difference between Group 1 and Group 2 as well.Group 1 had a shorter operating time than Group 2 on average(234.6 min vs 262.0 min,P=0.017).CONCLUSION Combined with Billroth Ⅱ reconstruction,Braun anastomosis has been applied due to its ability to reduce the prevalence of reflux gastritis.Whereas in this study,the prevalence of reflux gastritis showed no significant difference,leading to a conclusion that under the circumstance of Braun anastomosis costing more time and more money,simple Billroth Ⅱ reconstruction should be widely applied.

Acute pancreatitis as a rare complication of gastrointestinal endoscopy:A case report

BACKGROUND Acute pancreatitis is an uncommon complication of gastrointestinal endoscopy,especially if the patient has none of the common risk factors associated with pancreatitis;such as alcoholism,gallstones,hypertriglyceridemia,hypercalcemia or the use of certain drugs.CASE SUMMARY A 56-year-old female patient developed abdominal pain immediately after the completion of an upper gastrointestinal endoscopy.The pain was predominantly in the upper and middle abdomen and was persistent and severe.The patient was diagnosed with acute pancreatitis.Treatment included complete fasting,octreotide injection prepared in a prefilled syringe to inhibit pancreatic enzymes secretion,ulinastatin injection to inhibit pancreatic enzymes activity,esomeprazole for gastric acid suppression,fluid replacement and nutritional support.Over the next 3 d,the patient's symptoms improved.The patient remained hemodynamically stable throughout hospitalization and was discharged home in a clinically stable state.CONCLUSION Pancreatitis should be considered in the differential diagnosis of abdominal pain after upper and lower gastrointestinal endoscopy.

Bile reflux and bile acids in the progression of gastric intestinal metaplasia

Gastric intestinal metaplasia(GIM)is a precancerous lesion of gastric cancer(GC)and is considered an irreversible point of progression for GC.Helicobacter pylori infection can cause GIM,but its eradication still does not reverse the process.Bile reflux is also a pathogenic factor in GIM and can continuously irritate the gastric mucosa,and bile acids in refluxed fluid have been widely reported to be associated with GIM.This paper reviews in detail the relationship between bile reflux and GIM and the mechanisms by which bile acids induce GIM.

Diagnostic value of confocal laser endomicroscopy in primary bile reflux gastritis

Objective To evaluate the accuracy of confocal laser endomicroscopy(CLE)in primary bile reflux gastritis(BRG).Methods From November 10 to December 15,2015,55 patients undergoing CLE examination and preliminarily diagnosed as BRG with traditional white-light endoscopy were enrolled.CLE score standard was designed.Dixon pathologic score was considered as

Deciphering the chemical profile and pharmacological mechanism of Jinlingzi powder(金铃子散)against bile reflux gastritis using ultra-high performance liquid chromatography coupled with Q exactive focus mass spectrometry,network pharmacology,and molecular docking

OBJECTIVE:To elucidate the chemical profile and the pharmacological mechanism by which Jinlingzi powder(金铃子散,JLZP)treats bile reflux gastritis(BRG).METHODS:A BRG model was established in rats by oral administration of the model solution.JLZP was orally administered for 35 d.Residual gastric rate and tumor necrosis factor(TNF)-α,interleukin(IL)-6,and gastrin levels in the serum were measured,and stomach tissues were collected for histopathological analysis.We used ultra-high performance liquid chromatography coupled with Q Exactive Focus mass spectrometry to identify the chemical ingredients in JLZP.Then,protein-protein interaction and herb-compound-target networks were constructed to screen potential bioactive compounds and targets.Kyoto Encyclopedia of Genes and Genomes pathway analysis was then performed to elucidate the pathway involved in the JLZP-mediated treatment of BRG.After constructing the core compound-target-pathway interaction network,molecular docking was performed to study the binding free energy of core bioactive compounds and two candidate targets[RAC-alpha serine/threonine-protein kinase(AKT1)and phosphatidylinositol 4,5-bisphosphate 3-kinase catalytic subunit alpha isoform(PIK3CA)].RESULTS:JLZP extracts significantly promoted gastric emptying,regulating the release of cytokines(TNF-αand IL-6)and improving gastrin secretion and mucosal repair.Fifty-six compounds were tentatively characterized in JLZP.Moreover,the network pharmacology and molecular docking results showed that alkaloids and flavonoids might be the bioactive compounds in JLZP that treat BRG.JLZP might improve mucosal repair during BRG progression by modulating the phosphatidylinositol-4,5-bisphosphate 3-kinase-protein kinase B,hypoxia inducible factor-1,mitogen-activated protein kinase,forkhead box O,TNF,and IL-17 signaling pathways.CONCLUSIONS:We elucidated the chemical constituents and the pharmacological mechanism of JLZP in treating BRG and provided a basis for clinical application.

Clinical curative effect of electroacupuncture combined with Zhizhukuanzhong Capsules for treating gastroesophageal reflux disease

OBJECTIVE：To study the clinical curative effect,safety and mechanism of action of electroacupuncture combined with Zhizhukuanzhong capsules（ZZKZC） in treating gastroesophageal reflux disease（GERD）.METHODS：A total of 480 patients with confirmed GERD were randomly divided into four groups：the electroacupuncture group,the ZZKZC group,the combined therapy group,and the control group,with 120 cases in each group.Each case in the electroacupuncture group was treated with electroacupuncture on Zusanli（ST36）,Zhongwan（CV12）,Neiguan（PC6）,Taichong（LR3）and Gongsun（SP 4）once daily for 6 weeks.Each case in the ZZKZC group was treated with oral administration of 1.29 g ZZKZC three times daily.The combined therapy group had electroacupuncture and ZZKZC.The control group was given oral administration of 5 mg mosapride three times and 20 mg pantoprazole twice daily.The 24-hour intraesophageal total number of reflux episodes with pH 0.05）;however,these indices all significantly deteriorated in the ZZKZC and control groups（P〉0.05）.The short and long-term total efficacy rates in the combined therapy group showed significant superiority to those in the other groups（P〈0.05 or P〈0.01）.No serious adverse reactions were found in the four groups.CONCLUSION：Electroacupuncture and ZZKZC play an important role in inhibiting intraesophageal acid and bile reflux,decreasing the endoscopic grading score,and alleviating the symptoms of gastroesophageal reflux to improve the quality of life.However,the effect of combined treatment is more effective,with better security and long-term efficacy,and therefore,this combination treatment is appropriate for clinicaluse.

Clinical Study on the Treatment of Gastroesophageal Reflux by Acupuncture

Objective： To explore the clinical efficacy and safety of acupuncture in treating gastroesophageal reflux （GER）. Methods： Sixty patients with confirmed diagnosis of GER were randomly assigned to two groups. The 30 patients in the treatment group were treated with acupuncture at acupoints Zhongwan （CV 12）, bilateral Zusanli （ST36）, Sanyinjiao （SP6）, and Neiguan （PC6）, once a day, for 1 week as a therapeutic course, with interval of 2-3 days between courses; the 30 patients in the control group were administered orally with omeprazole 20 mg twice a day and 20 mg mosapride thrice a day. The treatment in both group lasted 6 weeks. Patients＇ symptoms and times of reflux attacking were recorded, the 24-h intraesophageal acid/bile reflux were monitored, and the endoscopic feature of esophageal mucous membrane was graded and scored at three time points, i.e., pro-treatment （T0）, immediately after ending the treatment course （T1） and 4 weeks after it （T2）. Besides, the adverse reactions were also observed. Results： Compared with those detected at TO, 24-h intraesophageal pH and bile reflux, endoscopic grading score and symptom score were all decreased significantly at T1 in both groups similarly （P〈0.01）, showing insignificant difference between groups （P〉0.05）. These indices were reversed at T2 to high level in the control group （P〈0.05）, but the reversion did not occur in the treatment group （P〉0.05）. No serious adverse reaction was found during the therapeutic period. Conclusion： Acupuncture can effectively inhibit the intraesophageal acid and bile reflux in GER patients to alleviate patients＇ symptoms with good safety and is well accepted by patients.