bile reflux
Introduction
Introduction Bile reflux gastritis, also known as spastic reflux gastritis, refers to a series of manifestations of upper abdominal pain, vomiting bile, bloating, weight loss caused by bile reflux into the stomach, common in gastrectomy, gastrointestinal After anastomosis, the total incidence rate is about 5%, and the incidence of Billroth II gastrectomy is 2 to 3 times that of Billroth I. In view of the fact that its symptoms, pathological changes and treatment response are different from other post-gastric resection syndromes, Roberts et al. classify the disease from complications after gastrectomy and list it as an independent disease.
Cause
Cause
The occurrence of this syndrome must first have the basic conditions of pyloric function loss or pyloric insufficiency. For example, after gastric resection or gastrointestinal anastomosis, bile can directly flow back into the stomach; some patients have no history of surgery, duodenum content The substance can flow back into the stomach through the closed pylorus, causing reflux gastritis. After cholecystectomy, the function of storing bile is lost, and bile continues to flow into the duodenum. If it is returned to the stomach by closing the incomplete pylorus, it can also cause reflux gastritis.
Direct contact of the bile directly with the gastric mucosa does not cause damage, but it can stimulate the secretion of gastric acid. The combination of bile salts and gastric acid can enhance the activity of acidic hydrolase, destroy the lysosomal membrane, dissolve lipoprotein and destroy the barrier of gastric mucosa. The effect, H+ reverse diffusion increases, enters the mucosa and submucosa, can stimulate mast cells and release histamine, which in turn stimulates the secretion of gastric acid and pepsin, eventually leading to inflammation, erosion and bleeding of the gastric mucosa. After the bile is mixed with the pancreatic juice, the lecithin in the bile and the phosphatase A in the pancreatic juice act to be converted into lysolecithin, such as back into the stomach, which may also cause damage to the gastric mucosal barrier.
Gastrin can stimulate the proliferation of gastric mucosal cells to strengthen its barrier and prevent the reverse dispersion of H+, but the gastrin secretion is reduced by about 50-75% after Billroth II gastrectomy, which may be an important cause of this syndrome. one.
It is common for bile to return to the stomach after resection, but not every person has symptoms. The cause of the disease may also be related to the following factors:
1 gastric emptying disorder: the reflux fluid stays in the stomach for a long time, the pH rises, and the aerobic bacteria and anaerobic bacteria in the residual stomach are more likely to grow. These bacteria can cause the bile salts to liberate and cause inflammation of the gastric mucosa, thereby causing symptoms.
2 changes in bile acid composition Gadacz found that patients with normal bile acid composition did not develop symptoms, and those with markedly elevated deoxycholic acid often had symptoms.
3 There are bacteria in the gastric juice: Gram-negative bacilli or Pseudomonas in the gastric juice of patients with symptoms, the use of doxycycline can alleviate the symptoms; and the asymptomatic people have no bacteria in the gastric juice.
4 sodium concentration in gastric juice: sodium concentration is more than 15mmol / L is prone to gastritis, while sodium concentration is less than 15mmol / L without gastritis.
Examine
an examination
Related inspection
Ultrasound examination of gallbladder, oral gallbladder angiography, liver, gallbladder, spleen CT examination of percutaneous transhepatic biliary drainage (PTD)
Most patients complained of persistent burning pain in the upper abdomen, increased pain after meals, and could not be relieved after taking the drug, or vice versa. A small number of patients may present with retrosternal pain or a feeling of indigestion in the stomach. Biliary vomiting is a characteristic manifestation. Due to gastric emptying disorder, vomiting occurs mostly in the evening or in the middle of the night. The vomit may be accompanied by food and occasionally a small amount of blood. Because of the fear that the symptoms will worsen after eating, the patient will reduce the amount of food, and may have anemia, weight loss, malnutrition and diarrhea.
Those who have discovered the above-mentioned characteristic symptoms after gastric surgery should perform the following tests:
(1) Endoscopy
Bile reflux can be seen directly, gastric mucosa congestion, edema, or erosion. Biopsy suggests gastritis. Although bile reflux is a common condition after gastrectomy, such as atrophic gastritis by gastroscopy, bile reflux gastritis can be diagnosed.
(two) determination of gastric aspirate
After inserting the gastric tube, the fasting and postprandial gastric juice were aspirated, and the content of cholic acid, such as fasting basic gastric acid secretion (BAO), was measured.
(three) isotope determination
2mCi99mTc- butylimine diacetate was intravenously administered, and the liver and biliary tract were observed for 1 hour every 5 minutes. One hour of the patient drank 100 ml of water containing 0.3 mCi of 99 mTc to accurately determine the position of the stomach. Subsequently, the liver, gallbladder and stomach area were examined every 15 minutes within 2 hours to determine the gastrointestinal reflux index. The normal value was 8.6 ± 6.0; those with reflux gastritis increased to 86.3 ± 7.1. A solution of 99mTc can also be injected into the duodenum or upper jejunum, and the amount of isotope in the stomach can be traced to understand the extent of gastrointestinal reflux.
Diagnosis
Differential diagnosis
Differential diagnosis of bile reflux:
1, bile excretion is blocked: once the extrahepatic biliary system tumor or stone, the biliary tract is blocked, bile can not be excreted smoothly, and obstructive jaundice occurs. When the biliary system is blocked, the excretion of bile is blocked, and the jaundice caused by the return of bilirubin to the blood is called obstructive jaundice. The obstruction site may be in the liver or outside the liver, with complete obstruction and incomplete obstruction. Common causes include capillary bile duct hepatitis, cholelithiasis, liver cancer, cholangiocarcinoma, pancreatic cancer, and biliary ascariasis.
2, bile stasis: imaging diagnosis, most of the early stage of gallstones can be expressed as bile stasis and then formed bile mud, stones. The white blood cell count was significantly increased, the urinary tricholic abnormalities, elevated blood bilirubin, and abnormal liver function (such as ALT, AST, r-GT, ALP, etc.) increased to varying degrees. B-ultrasound, CT examination showed gallbladder enlargement, bile duct expansion and calculus, ERCP, PTC examination can more clearly show the lesions inside and outside the bile duct.
3, bile retention: common in the stomach: gastric juice yellow turbid, mixed with bile juice, mucous membrane smooth, no obvious congestion and edema, no ulcers, tumors. Gastric antrum: good peristalsis, mucosal plaque-like congestion and yellow bile, no obvious erosion, ulcers and masses. According to the gastroscope, the whole digestive tract is checked. Bloating, suffocating. The stomach feels full of swelling all day long. It feels bad after getting up in the morning and getting up in the morning. It is fasting on an empty stomach and after a meal. Sometimes you can get up in the morning and get up and feel comfortable after the gas is discharged.
