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.

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.

Therapeutic effect of DA-9601 on chronic reflux gastritis induced by sodium taurocholate in rats

AIM: To investigate the therapeutic effects of DA-9601 on sodium taurocholate (TCA)-induced chronic reflux gastritis in SD rats.METHODS: In this study, we have investigated the therapeutic effects of DA-9601 on chronic erosive and atrophic gastritis induced by 6 mo of TCA administration (5 mmol/L in drinking water) in SD rats. RESULTS: Four weeks of DA-9601 administration (0.065%, 0.216% in rat chow), following the withdrawal of TCA treatment, resulted in a significant decrease in total length of erosions in rats in a dose-dependent manner. Furthermore, the indicators of atrophic gastritis, such as reduced mucosal thickness and reduction in the number of parietal cells, were improved by the administration of DA-9601 in a dose-related manner. DA-9601 also attenuated inflammatory cell infiltration and the proliferation of collagenous fiber in the gastric mucosa. The improvement in the reduction of the gastric mucus was observed in the rats receiving a high dose of DA-9601 (0.216%). The therapeutic effect of DA-9601 on experimental chronic erosive gastritis was superior to that of rebamipide (1.08% in rat chow). Biochemical analyses showed increased mucosal prostaglandin E2 and reduced glutathione levels by DA-9601 treatment. CONCLUSION: We suggest that DA-9601 is apromising agent for the treatment of chronic erosive and atrophic gastritis with an etiological factor of bile reflux. Increasedmucosal prostaglandin E2 and reduced glutathione by DA-9601 treatment may be therapeutic mechanisms for chronic erosive and atrophic gastritis.

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.

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.

Inverse correlation between gastroesophageal reflux disease and atrophic gastritis assessed by endoscopy and serology

BACKGROUND Helicobacter pylori(H.pylori)infection is known to prevent the occurrence of gastroesophageal reflux disease(GERD)by inducing gastric mucosal atrophy.However,little is known about the relationship between atrophic gastritis(AG)and GERD.AIM To confirm the inverse correlation between AG and the occurrence and severity of GERD.METHODS Individuals receiving health checkups who underwent upper gastrointestinal endoscopy at Seoul National University Healthcare System Gangnam Center were included.The grade of reflux esophagitis was evaluated according to the Los Angeles classification.Endoscopic AG(EAG)was categorized into six grades.Serologic AG(SAG)was defined as pepsinogen I≤70 ng/m L and pepsinogen I/II ratio≤3.0.The association between the extent of EAG and SAG and the occurrence and severity of GERD was evaluated using multivariate logistic regression analysis.RESULTS In total,4684 individuals with GERD were compared with 21901 healthy controls.In multivariate logistic regression analysis,advanced age,male sex,body mass index>23 kg/m2,presence of metabolic syndrome,current smoking,and alcohol consumption were associated with an increased risk of GERD.Seropositivity for H.pylori immunoglobulin G antibodies was associated with a decreased risk of GERD.There was an inverse correlation between the extent of EAG and occurrence of GERD:Odds ratio(OR),1.01[95%confidence interval(CI):0.90-1.14]in C1,0.87(0.78-0.97)in C2,0.71(0.62-0.80)in C3,0.52(0.44-0.61)in O1,0.37(0.29-0.48)in O2,and 0.28(0.18-0.43)in O3.Additionally,the extent of EAG showed an inverse correlation with the severity of GERD.The presence of SAG was correlated with a reduced risk of GERD(OR=0.49,95%CI:0.28-0.87,P=0.014).CONCLUSION The extent of EAG and SAG exhibited strong inverse relationships with the occurrence and severity of GERD.AG followed by H.pylori infection may be independently protect against GERD.

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

Potential mechanism of corpus-predominant gastritis after PPI therapy in Helicobacter pylori-positive patients with GERD

The long-term use of proton pump inhibitors(PPIs)exacerbates corpus atrophic gastritis in patients with Helicobacter pylori(H.pylori)infection.To identify a potential mechanism for this change,we discuss interactions between pH,bile acids,and H.pylori.Duodenogastric reflux,which includes bile,occurs in healthy individuals,and bile reflux is increased in patients with gastroesophageal reflux disease(GERD).Diluted human plasma and bile acids have been found to be significant chemoattractants and chemorepellents,respectively,for the bacillus H.pylori.Although only taurine conjugates,with a pKa of 1.8-1.9,are soluble in an acidic environment,glycine conjugates,with a pKa of 4.3-5.2,as well as taurine-conjugated bile acids are soluble in the presence of PPI therapy.Thus,the soluble bile acid concentrations in the gastric contents of patients with GERD after continuous PPI therapy are considerably higher than that in those with intact acid production.In the distal stomach,the high concentration of soluble bile acids is likely to act as a bactericide or chemorepellent for H.pylori.In contrast,the mucous layer in the proximal stomach has an optimal bile concentration that forms chemotactic gradients with plasma components required to direct H.pylori to the epithelial surface.H.pylori may then colonize in the stomach body rather than in the pyloric antrum,which may explain the occurrence of corpus-predominant gastritis after PPI therapy in H.pylori-positive patients with GERD.

Phlegmonous gastritis after biloma drainage:A case report and review of the literature

BACKGROUND Phlegmonous gastritis(PG)is a rare bacterial infection of the gastric submucosa and is related to septicemia,direct gastric mucosal injury,or the direct influence of infection or inflammation in neighboring organs.Here,we present a patient who had spontaneous biloma caused by choledocholithiasis and then PG resulting from bile leakage after biloma drainage.CASE SUMMARY A 79-year-old man with a medical history of hypertension had persistent diffuse abdominal pain for 4 d.Physical examination showed stable vital signs,icteric sclera,diffuse abdominal tenderness,and muscle guarding.Laboratory tests showed hyperbilirubinemia and bandemia.Contrast computed tomography(CT)of the abdomen showed a dilated common bile duct and left subphrenic abscess.Left subphrenic abscess drainage revealed bilious fluid,and infected biloma was confirmed.Repeated abdominal CT for persistent epigastralgia after drainage showed gastric wall thickening.Esophagogastroduodenoscopy(EGD)showed an edematous,hyperemic gastric mucosa with poor distensibility.The gastric mucosal culture yielded Enterococcus faecalis.PG was diagnosed based on imaging,EGD findings,and gastric mucosal culture.The patient recovered successfully with antibiotic treatment.CONCLUSION PG should be considered in patients with intraabdominal infection,especially from infected organs adjacent to the stomach.

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.

Analysis of risk factors associated with primary bile reflux:A multicenter cross-sectional study

To the Editor:Bile reflux(BR),also known as duodenogastric reflux,refers to the reflux of duodenal contents such as bile,pancreatic juice,and duodenal juice into the stomach.BR that occurs without gastric surgery is called primary bile reflux(PBR).^([1])A retrospective study showed that the prevalence of PBR in patients with chronic gastritis was as high as 20.5%.^([2])BR can contribute to the development of upper gastrointestinal diseases,^([3–5])but the corresponding risk factors are currently unknown.We aimed to identify the related risk factors for PBR.

Comparative evaluation of intragastric bile acids and hepatobiliary scintigraphy in the diagnosis of duodenogastric reflux

AIM:To assess the diagnostic value of a combination of intragastric bile acids and hepatobiliary scintigraphy in the detection of duodenogastric reflux(DGR).METHODS:The study contained 99 patients with DGR and 70 healthy volunteers who made up the control group.The diagnosis was based on the combination of several objective arguments:a long history of gastric symptoms(i.e.,nausea,epigastric pain,and/or bilious vomiting) poorly responsive to medical treatment,gastroesophageal reflux symptoms unresponsive to protonpump inhibitors,gastritis on upper gastrointestinal(GI) endoscopy and/or at histology,presence of a bilious gastric lake at > 1 upper GI endoscopy,pathologic 24-h intragastric bile monitoring with the Bilitec device.Gas-tric juice was aspirated in the GI endoscopy and total bile acid(TBA),total bilirubin(TBIL) and direct bilirubin(DBIL) were tested in the clinical laboratory.Continuous data of gastric juice were compared between each group using the independent-samples Mann-Whitney U-test and their relationship was analysed by Spearman's rank correlation test and Fisher's linear discriminant analysis.Histopathology of DGR patients and 23 patients with chronic atrophic gastritis was compared by clinical pathologists.Using the Independent-samples Mann-Whitney U-test,DGR index(DGRi) was calculated in 28 patients of DGR group and 19 persons of control group who were subjected to hepatobiliary scintigraphy.Receiver operating characteristic curve was made to determine the sensitivity and specificity of these two methods in the diagnosis of DGR.RESULTS:The group of patients with DGR showed a statistically higher prevalence of epigastric pain in comparison with control group.There was no significant difference between the histology of gastric mucosa with atrophic gastritis and duodenogastric reflux.The bile acid levels of DGR patients were significantly higher than the control values(Z:TBA:-8.916,DBIL:-3.914,TBIL:-6.197,all P < 0.001).Two of three in the DGR group have a significantly associated with each other(r:TBA/DBIL:0.362,TBA/TBIL:0.470,DBIL/TBIL:0.737,all P < 0.001).The Fisher's discriminant function is followed:Con:Y = 0.002TBA + 0.048DBIL + 0.032TBIL 0.986;Reflux:Y = 0.012TBA + 0.076DBIL + 0.089TBIL-2.614.Eighty-four point zero five percent of original grouped cases were correctly classified by this method.With respect to the DGR group,DGRi were higher than those in the control group with statistically significant differences(Z =-5.224,P < 0.001).Twenty eight patients(59.6%) were deemed to be duodenogastric reflux positive by endoscopy,as compared to 37 patients(78.7%) by hepatobiliary scintigraphy.CONCLUSION:The integrated use of intragastric bile acid examination and scintigraphy can greatly improve the sensitivity and specificity of the diagnosis of DGR.

Analysis of the Effectiveness of Biling Weitong Granules Combined with Trimethoprim and Vonoprazan in The Treatment of Reflux Esophagitis

Objective:To analyze the effectiveness of Biling Weitong Granules(BLWTG)combined with trimethoprim and vonoprazan in treating reflux esophagitis.Methods:Sixty patients with reflux esophagitis admitted to our hospital from March 2020 to March 2023 were selected as study subjects and randomly divided into a control group and an experimental group,with 30 cases in each group.The control group received only the combination treatment of trimethoprim and vonoprazan,while the experimental group was treated with BLWTG based on the control group.The acid reflux and heartburn symptom scores,quality-of-life scores,clinical efficacy,Chinese medicine symptom incidences,and the occurrence of adverse reactions before and after treatment in the two groups were compared.Results:After treatment,the acid reflux and heartburn symptom scores of patients in the experimental group were lower than those of the treatment control group,and the quality-of-life scores were higher than those of the treatment control group(P<0.05).The total clinical efficacy of the experimental group was 96.66%,which was significantly higher than that of the control group(73.33%,P<0.05).After treatment,the incidence of Chinese medicine symptoms,such as nausea and vomiting,abdominal distension and abdominal pain,and loss of appetite of the patients in the experimental group were significantly lower than those of the control group(P<0.05).During the treatment period,there was no significant difference in the incidence of adverse reactions between the two groups,which indicated that the safety of the two treatments was comparable(P>0.05).Conclusion:BLWTG combined with trimethoprim and vonoprazan was safe and reliable in treating reflux esophagitis,effectively relieving the symptoms and improving its clinical efficacy.This treatment is worthy of popularization.

The Therapeutic Effect of Biling Weitong Granules Combined with Oryz-Aspergillus Enzyme and Pancreatin Tablet on Reflux Esophagitis with Functional Dyspepsia

Objective:To investigate the therapeutic effect of Biling Weitong Granules combined with oryz-aspergillus enzyme and pancreatin tablets on patients with reflux esophagitis with functional dyspepsia.Methods:Sixty patients diagnosed with reflux esophagitis with functional dyspepsia who were admitted to the Affiliated Hospital of Hebei University between June 2020 and June 2023 were selected and divided into two groups:the control group and the observation group,each consisting of 30 cases.The control group received oryz-aspergillus enzyme and pancreatin tablets only,while the observation group received Biling Weitong Granules in addition to the tablets.The clinical efficacy,Chinese medicine syndrome points,esophageal kinetic indexes,gastrointestinal hormone levels,and therapeutic safety of both groups were evaluated.Results:The total efficiency of the observation group reached 93.33%,significantly higher than the 73.33%of the control group(P<0.05).After treatment,patients in the observation group exhibited significantly lower scores for Chinese medicine symptoms such as early satiety,belching,abdominal distension,abdominal pain,and loss of appetite compared to the control group(P<0.05).Furthermore,the observation group showed significantly higher upper esophageal sphincter pressure,lower esophageal sphincter pressure,and distal esophageal contraction scores compared to the control group(P<0.05).Additionally,levels of gastric motility hormone,vasoactive intestinal peptide,and gastrin were significantly higher in the observation group compared to the control group(P<0.05).Throughout the treatment period,there was no significant difference in the incidence of adverse reactions between the two groups,indicating comparable safety of the two treatment modalities(P>0.05).Conclusion:The combination of Biling Weitong Granules with oryz-aspergillus enzyme and pancreatin tablets demonstrates significant efficacy in the treatment of reflux esophagitis with functional dyspepsia,with a better safety profile.This finding warrants further clinical promotion.

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）.

Carcinogenic potential of duodenal reflux juice from patients with long-standing postgastrectomy

AIM: To determine whether study on the carcinogenic potential of reflux juice from patients with remote gastrectomy could clarify the inherent relationship between duodenal reflux and gastric stump cancer. METHODS: A total of 37 reflux juice samples (13 Billroth I, 24 Billroth II) were employed in the present study. A two-stage transformation assay using BALB/c 3T3 cells was carried out to test the initiating or promoting activity of these samples. RESULTS: Two of 18 (11.1%) reflux samples exerted initiating activities, whereas 9/19 (47.4%) samples enhanced the MNNG-initiating cell transformation, suggesting the duodenal reflux juice might more frequently possess the tumor-promoter activity (P = 0.029). In addition, there was no difference in initiating activities of the samples irrespective of surgical procedures (P = 0.488), while Billroth II samples exhibited stronger tumor-promoter activity than Billroth I samples (P = 0.027). Furthermore, the promoter activities were well correlated with the histological changes of the stomas (r(s) = 0.625, P = 0.004), but neither their cytotoxicities nor initiating activities had this correlation (Probabilities were 0.523 and 0.085, respectively). CONCLUSION: The duodenal reflux juice from patients with remote postgastrectomy did have carcinogenic potential, and suggested that tumor-promoting activity should principally account for the high incidence of gastric cancer in gastrectomy patients. In contrast, it is difficult to explain the high stump-cancer incidence with the N-nitroso compounds theory-a popular theory for the intact stomach carcinogenesis, and it seemed to be justified to focus chemo-prevention of this cancer on the tumor-promoting potential of reflux juice.

Esomeprazole regimens for reflux symptoms in Chinesepatients with chronic gastrit

AIM To compare symptom control with esomeprazoleregimens for non-erosive reflux disease and chronicgastritis in patients with a negative endoscopy.METHODS： This randomized, open-label study wasdesigned in line with clinical practice in China. Patientswith typical reflux symptoms for ≥ 3 mo and a negativeendoscopy who had a Gastroesophageal Reflux DiseaseQuestionnaire score ≥ 8 were randomized to initialtreatment with esomeprazole 20 mg once daily eitherfor 8 wk or for 2 wk. Patients with symptom reliefcould enter another 24 wk of maintenance/on-demandtreatment, where further courses of esomeprazole 20mg once daily were given if symptoms recurred. Theprimary endpoint was the symptom control rate at week24 of the maintenance/on-demand treatment period.Secondary endpoints were symptom relief rate, successrate （defined as patients who had symptom reliefafter initial treatment and after 24 wk of maintenancetreatment）, time-to-first-relapse and satisfaction rate.RESULTS： Based on the data collected in the modifiedintention-to-treat population （MITT; patients in the ITTpopulation with symptom relief after initial esomeprazoletreatment, n = 262）, the symptom control rate showeda small but statistically significant difference in favorof the 8-wk regimen （94.9% vs 87.3%, P = 0.0473）.Among the secondary endpoints, based on the datacollected in the ITT population （n = 305）, the 8-wkgroup presented marginally better results in symptomrelief after initial esomeprazole treatment （88.3% vs83.4%, P = 0.2513） and success rate over the wholestudy （83.8% vs 72.8%, P = 0.0258）. The 8-wkregimen was found to provide a 46% reduction in riskof relapse vs the 2-wk regimen （HR = 0.543; 95%CI：0.388-0.761）. In addition, fewer unscheduled visits andhigher patient satisfaction supported the therapeuticbenefits of the 8-wk regimen over the 2-wk regimen.Safety was comparable between the two groups, withboth regimens being well tolerated.CONCLUSION： Chinese patients diagnosed withchronic gastritis achieved marginally better control ofreflux symptoms with an 8-wk vs a 2-wk esomeprazoleregimen, with a similar safety profile.

Bile salts inhibit growth and induce apoptosis of culture human normal esophageal mucosal epithelial cells

AIM： To investigate the effect of six bile salts： glycocholate （GC）, glycochenodeoxycholate （GCDC）, glycodeoxycholate （GDC）, taurocholate （TC）, taurochenodeoxycholate （TCDC）, taurodeoxycholate （TDC）, and their mixture on cultured human normal esophageal rnucosal epithelial cells. METHODS： Human normal esophageal mucosal epithelial cells were cultured with serum-free keratinocyte medium. 3-[4,5-Dimethylthiaolyl]-2,5- diphenyl-tetrazolium bromide assay was applied to the detection of cell proliferation. Apoptotic morphology was observed by phase-contrast video microscopy and terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling （TUNEL） assay. Sub-G1 DNA fragmentations and early apoptotic cells were assayed by flow cytometry （FCI） with propidium iodide （PI） staining and annexin V-FITC conjugated with PI staining. Apoptotic DNA ladders on agarose gel electrophoresis were observed. RESULTS： Except for GC, GCDC, GDC, TC, TCDC, TDC and their mixture could initiate growth inhibition of esophageal mucosal epithelial cells in a dose- and time-dependent manner. TUNEL and FCM assays demonstrated that the bile salts at 500 μmol/L and their mixture at 1 500 μmol/L induced apoptosis except for GC. The percentage of sub-G1 detected by FCM with PI staining was 83.5% in cells treated with 500 μmol/L TC for 2 h, and 19.8%, 20.4%, 25.6%, 13.5%, and 75.8% in cells treated with 500 μmol/L GCDC, TCDC, GDC, TDC, and 1 500 μmol/L mixture for 24 h, respectively, which were higher than that of the control （1.5%）. The percentage was 1.4% in cells with 500 μmol/L GC for 24 h. DNA ladders on agarose gel electrophoresis were seen in cells treated with 500 μmol/L TC for 2 h and i 500 μmnol/L mixture for 24 h. CONCLUSION： All GCDC, GDC, TC, TCDC, TDC and their mixture can inhibit growth and induce apoptosis of cultured human normal esophageal mucosal epithelial cells, but GC is well tolerated by the cells.

A case of gallbladder carcinoma associated with pancreatobiliary reflux in the absence of a pancreaticobiliary maljunction:A hint for early diagnosis of gallbladder carcinoma

A 62-year-old man with progressive thickening of the gallbladder wall visited our outpatient clinic. The biliary amylase level in the common bile duct was 19900 IU/L and that of the gallbladder was 127000 IU/L, although endoscopic retrograde cholangiopancreatography revealed no pancreaticobiliary maljunction. Histology demonstrated a moderately differentiated adenocarcinoma of the gallbladder. Pancreatobiliary reflux and associated gallbladder carcinoma were confirmed in the present case, in the absence of a pancreaticobiliary maljunction. Earlier detection of the pancreatobiliary reflux and progressive thickening of the gallbladder wall might have led to an earlier resection of the gallbladder and improved this patient＇s poor prognosis.

Gallbladder carcinoma associated with pancreatobiliary reflux

AIM: To detect the patients with and without pan-creaticobiliary maljunction who had pancreatobiliary reflux with extremely high biliary amylase levels.METHODS: Ninety-six patients, who had diffuse thickness (> 3 mm) of the gallbladder wall and were suspected of having a pancreaticobiliary maljunction on ultrasonography, were prospectively subjected to endoscopic retrograde cholangiopancreatography, and bile in the common bile duct was sampled. Among them, patients, who had extremely high biliary amylase levels (>10 000 IU/L), underwent cholecystectomy, and the clinicopathological findings of those patients with and without pancreaticobiliary maljunction were examined.RESULTS: Seventeen patients had biliary amylase levels in the common bile duct above 10 000 IU/L, including 11 with pancreaticobiliary maljunction and 6 without pancreaticobiliary maljunction. The occurrence of gallbladder carcinoma was 45.5% (5/11) in patients with pancreaticobiliary maljunction, and 50% (3/6) in those without pancreaticobiliary maljunction.CONCLUSION: Pancreatobiliary reflux with extremely high biliary amylase levels and associated gallbladder carcinoma could be identified in patients with and without pancreaticobiliary maljunction, and those patients might be detected by ultrasonography and bile sampling.