Bile in the stomach (duodenogastric reflux)
Duodenogastric reflux is the reflux of the contents of the duodenum into the stomach cavity. Normally, after a certain period of time after food enters the stomach, a portion of bile is released into the lumen of the duodenum, aimed at further, more thorough digestion of the food bolus. The presence of bile creates an alkaline environment in the cavity of the duodenum. At the border of the stomach and duodenum there is a pyloric sphincter, which prevents the movement of food in the opposite direction and separates the acidic environment of the stomach from the alkaline environment of the duodenum. If the function of the sphincter is impaired, for example, if it is not fully closed, the alkaline contents of the duodenum enter the stomach. Burning has an irritating effect on the gastric mucosa, which, when exposed to it regularly, causes a chronic inflammatory process called reflux gastritis.
results
In the comparison group, drainage periods varied from 2 to 28 days (on average 17.2±7.6 days). The amount of excreted bile per day ranged from 100 to 1500 ml (average 720.9±322.1 ml). Bile began to be returned to the gastrointestinal tract through a nasointestinal tube almost immediately after drainage, i.e. on days 1-3. Radical operations were performed when the serum bilirubin level was from 16 to 120 µmol/l, palliative - from 20.2 µmol/l to 258.4 µmol/l. In the main group, the unloading stage in patients lasted 13.1±2.3 days and the criteria for its end were the level of hyperbilirubinemia less than 50 µmol/l when planning radical surgery and less than 80 µmol/l with the proposed biliodigestive shunting, as well as the levels of AST and ALT in blood serum less than 60 IU/l.
Specific postoperative complications directly related to the presence of obstructive jaundice and surgery in a certain anatomical zone include acute liver and kidney failure, acute postoperative pancreatitis, purulent cholangitis, and biloma. Nonspecific general surgical complications that are possible with any abdominal operation include anastomotic leakage, peritonitis, intra-abdominal abscesses, sepsis, intra-abdominal bleeding, pneumonia, acute myocardial infarction, postoperative wound suppuration, eventration. The distribution of postoperative complications and mortality is presented in Table. 1.
Table 1. Postoperative complications and mortality in the study groups, taking into account the volume of operations
The data obtained indicate that the total number and frequency of specific postoperative complications are significantly lower in the main group during both radical and palliative operations ( p
<0.05).
General surgical postoperative complications during extensive radical operations occurred significantly more often in the comparison group ( p
<0.05), while when performing bypass biliodigestive anastomoses, no statistically significant difference in the frequency of complications was obtained (
p
>0.05).
The total number of complications in the comparison group (55-37.9%) also turned out to be significantly higher than in the main group (9-26.5%) ( p
<0.05).
In the comparison group, 2 deaths were recorded after radical surgery (SSR): in one case, acute pancreatitis of the pancreatic stump, secondary leakage of pancreaticojejunostomy (PEA), peritonitis, abdominal sepsis; in the second case, acute hepatic-renal failure, pneumonia with an outcome in MOF. Mortality after radical surgery in the comparison group was 6.9%. After palliative operations in the comparison group there were 6 (5.2%) deaths. Thus, the overall postoperative mortality in the comparison group was 5.5%.
In the main group, there were no deaths after radical operations; after the application of bypass anastomoses, 1 (2.9%) patient died from purulent cholangitis and abdominal sepsis. Thus, the overall mortality rate in the main group was also registered significantly lower than in the comparison group ( p
<0,05).
When analyzing the postoperative results of the comparison group, the average values of laboratory parameters before surgery and their relationship with treatment outcomes were calculated. When conducting regression analysis and calculating Spearman's rank correlation coefficient, a strong direct correlation was revealed between the level of hyperbilirubinemia (ρ=0.943; p
<0.05) and hyperenzymemia (ρ=0.932;
p
<0.05) before surgery, on the one hand, and the level of postoperative complications, on the other.
Moreover, in the case of fermentemia, the function had a linear ascending form, and in relation to hyperbilirubinemia, the dependence was nonlinear. After radical operations, a jump in the level of postoperative complications from 42.1 to 66.7% was noted with initial hyperbilirubinemia more than 50 μmol/l. After performing biliodigestive bypass anastomoses, the critical level of preoperative hyperbilirubinemia was 80 μmol/L, after which the complication rate increased from 11.1 to 37.5% ( p
<0.05) (see figure).
Dependence of the frequency of postoperative complications on the value of total serum bilirubin before surgery in the comparison group (n=145).
When performing mathematical processing of data from patients in the main group, the average concentration values of the studied parameters in blood serum and bile were calculated. Some bile indicators do not have generally accepted standards, so the average values of these indicators in samples with a normal value of blood bilirubin, i.e. in the absence of obstructive jaundice syndrome, were calculated. Thus, the concentration range of AST was 5-8.8 U/l, ALT - 0-2.6 U/l, ALP - 1065-2828 U/l. It should be noted that, with the exception of bilirubin and alkaline phosphatase, the average values of the studied parameters are higher in blood serum. At the same time, the average value of total bilirubin in bile is 3 times higher than the norm for hepatic bile (170-340 µmol/l [17]), and in blood serum - more than 8 times. When comparing blood and bile parameters, an inverse average relationship for ALP and an inverse strong relationship for cholesterol levels were revealed (Table 2).
Table 2. Correlation coefficient of the level of the studied parameters in blood serum and bile
Plotting the function of alkaline phosphatase concentration at the time of decompression shows an inversely proportional relationship between the level of this enzyme in the blood serum and bile of patients. Thus, a decrease in the concentration of alkaline phosphatase and bile cholesterol below normal can serve as an additional diagnostic test of the functional state of the liver. The concentration of ALT and AST in bile changes slightly, which does not allow their use for diagnostic purposes. It should be noted that the alkaline phosphatase level takes values close to normal (no more than 60 IU/l) after 13.63±2.39 days of decompression. After decompression, the decrease in the concentration of total blood bilirubin has a linear appearance. In bile, from the 1st to the 4th day, the concentration of total bilirubin increases, the decrease begins after 5.33 ± 0.70 days.
With early introduction of bile into the gastrointestinal tract (days 1-2), 26 (17.9%) patients noted discomfort (from moderate - 2 points to severe - 5 points) according to dyspeptic and diarrheal syndromes on the GSRS scale. When bile was administered after the beginning of a decrease in the level of total bilirubin, 4 (11.8%) patients indicated the presence of such symptoms, while the level of discomfort was rated by patients from 1 point (insignificant) to 3 (moderate) ( p
<0.05).
24 (16.6%) patients in the comparison group showed signs of toxic damage to the central nervous system: 15 (10.3%) had a latent stage of encephalopathy, 6 (4.1%) stage I and 3 (2%) stage II. When bile was administered after the beginning of a decrease in the level of total bilirubin in bile, the presence of symptoms was noted in 4 (11.8%) patients: in 3 (8.8%) latent stage, in 1 (2.1%) stage I ( p
<0.05 ). In our opinion, this is an indicator of bile toxicity in the first days after external drainage of the bile ducts in patients with obstructive jaundice. Thus, reinfusion of bile should be carried out on the 5.33±0.70th day of decompression of the biliary tract, and before this point the diverted bile should be disposed of.
Treatment
Treatment should be comprehensive and include measures to normalize lifestyle, diet and diet, as well as drug therapy. If possible, eliminate physical and emotional stress that negatively affects the motility of the gastrointestinal tract. Long breaks in meals, consumption of fatty, extractive foods, marinades, smoked meats, and coffee are unacceptable. Avoid smoking, drinking alcohol and carbonated drinks. Drug therapy is selected by a gastroenterologist depending on the severity of symptoms and examination results.
Duodenogastric reflux, or the reflux of duodenal contents back into the stomach, is an extremely common digestive disorder. The symptoms that indicate this pathology are subjectively interpreted by many as “heartburn” or “indigestion,” which indicates their low specificity. An accurate diagnosis can only be made by a specialist after a thorough examination. If you experience discomfort associated with eating, we recommend that you contact Professor Gorbakov’s Clinic for specialized help.
Normally, food enters the oral cavity, moves down the esophagus into the stomach, and then enters the duodenum. Here it mixes with bile, which ensures the emulsification (breakdown) of fats and the absorption of most of the nutrients. The unilateral evacuation of food into the duodenum is supported by the reflexive opening and closing of the pyloric sphincter (pylorus). It also prevents retrograde (backward) flow of the bolus.
Improper functioning of the sphincter (its insufficient locking), as well as hypertension in the duodenum associated with chronic duodenitis, can cause bile to flow back into the stomach - duodenogastric reflux.
Often this disorder provokes the presence of inflammatory processes in the stomach (gastritis), duodenum (duodenitis), gallbladder (cholecystitis, biliary dyskinesia), pancreas (pancreatitis), and surgical interventions, namely:
- cholecystectomy;
- gastric resection;
- vagotomy;
- gastroenterostomy;
- enterostomy.
Material and methods
The study is based on assessing the results of treatment of 179 patients with obstructive jaundice of tumor etiology who were hospitalized at the Chelyabinsk Regional Clinical Hospital from 2009 to 2021. The criterion for including patients in the study was the presence of obstructive jaundice caused by a tumor lesion in the biliopancreatoduodenal zone. The exclusion criterion from the study was the presence of purulent-septic complications requiring emergency surgical intervention upon admission to the clinic, general contraindications to surgical treatment, and limitation of treatment to external drainage of the biliary tract.
The study consisted of 2 stages. At the first stage (comparison group), an analysis was carried out of 145 medical histories of patients treated at the Chelyabinsk Regional Clinical Hospital No. 1 from 2009 to 2013. Among those examined there were 72 (49.7%) men and 73 (50.3%) women aged 36 up to 84 years old. The most common cause of obstructive jaundice was a tumor of the head of the pancreas - 110 (75.9%) cases. In the remaining cases, cancer of the terminal common bile duct (TCC) occurred - 19 (13.1%), cancer of the major duodenal papilla - 16 (11.0%). At the start of treatment, 55 (37.9%) patients were diagnosed with stage IV cancer, 58 (40%) - stage III, 27 (18.6%) - stage II, and only 5 (3.4%) patients were diagnosed Stage I of cancer. All patients underwent various types of surgery. In 116 (80%) cases, palliative interventions were performed to form biliary bypass anastomoses, 29 (20%) patients underwent radical pancreaticoduodenectomy (RPR).
At the second stage (the main group - 34 patients), a prospective study was carried out, which, according to the same criteria, included patients who were treated at the Chelyabinsk Regional Clinical Hospital No. 1 from 2013 to 2021. Unlike the comparison group, the patients additionally underwent a biochemical study of bile obtained from decompression drainage before surgery, and determined specific criteria for the timing of biliary decompression and return of bile to the gastrointestinal tract. Bile reinfusion in the main group of patients began on the 5th day after decompression. The unloading stage in this group of patients lasted on average 13.1±2.3 days, and the criteria for its end were the level of hyperbilirubinemia less than 50 µmol when planning a radical operation, less than 80 µmol/l with the proposed biliodigestive bypass, as well as the levels of AST and ALT in blood serum less than 60 IU/l.
The results of analyzes of bile samples were studied. Among the patients in this group, men predominated - 19 (55.9%). The age of the patients ranged from 41 to 87 years. Among the tumors that caused obstructive jaundice, cancer of the head of the pancreas predominated - 25 (73.5%) cases; TOX cancer - 3 (8.8%) and cancer of the major duodenal papilla - 6 (17.6%) were less common. In terms of the prevalence of the tumor process, early stages (I-II) were registered in 7 (20.6%) patients, the rest had locally advanced and generalized forms of malignant neoplasms (MN). Radical operations were performed in 7 (20.6%) patients, bypass biliodigestive anastomoses - in 27 (79.4%).
Thus, both study groups were comparable in terms of gender, age, localization and stages of cancer, volume of surgical interventions ( p
>0.05). Before surgery, all patients of both groups underwent various methods of external biliary decompression with subsequent return of bile to the gastrointestinal tract, and underwent a comprehensive laboratory and instrumental examination. Patients were admitted to the Chelyabinsk Regional Clinical Hospital No. 1 both at the height of obstructive jaundice and with external drainage of the bile ducts already performed in medical institutions of the 1st-2nd level. In the Chelyabinsk Regional Clinical Hospital No. 1, percutaneous transhepatic cholangiostomy (PTCHS) was performed in 51 (28.5%) patients and laparoscopic cholecystostomy in 42 (23.5%) patients to relieve jaundice. In medical organizations of the 1st-2nd level, cholecystostomy was performed from a mini-access in 82 (45.8%) patients; 4 (2.2%) patients were admitted after preliminary laparotomy and external drainage of the common bile duct.
In the postoperative period, the number of specific and general surgical complications, deaths, and the relationship of these indicators with the results of preoperative examinations were assessed.
The patients' blood serum and bile obtained from drainage were examined, the level of total and direct bilirubin in the blood, the concentration of ALT, AST, alkaline phosphatase (ALP) in the blood serum, as well as the level of total protein were determined. Similar indicators were assessed in bile at various stages of decompression. Laboratory parameters were assessed using a Cobas Integra 400 apparatus. AST and ALT levels were determined by the kinetic method with a set of reagents IFCC, without P5P (method without peridoxal phosphate), ALP - by the kinetic method with the formation of paranitrophenol, total protein by the diurethane method, total and direct bilirubin - with using the diazo method. In addition to laboratory parameters, at various stages of decompression and reinfusion of bile, the presence of dyspeptic symptoms (decreased appetite, nausea, vomiting, upset stool) and toxic encephalopathy (headache, dizziness, general weakness) was assessed. The assessment of dyspeptic symptoms was based on the results of the GSRS quality of life questionnaire (Russian version) [15]. The questionnaire allowed us to evaluate various gastroenterological syndromes: AP - abdominal pain syndrome, IS - dyspeptic syndrome, DS - diarrhea syndrome, CS - constipation syndrome and the total result. The severity of symptoms ranged from 0 points (not bothersome) to 6 points (very severe discomfort). The severity of encephalopathy symptoms was assessed using a descriptive symptom scale (assessment of consciousness, intelligence, behavior, neuromuscular disorders) [16]. A unified electronic database was created in Microsoft Excel 2010. Mathematical processing of the results was performed using the IBM SPSS Statistics 17.0 program. To describe quantitative characteristics with a normal distribution, the arithmetic mean ± standard deviation was used. Statistical processing of data was carried out using t
-Student's t-test.
For small sample sizes and nonparametric distribution, U
test was used.
To identify the relationship between characteristics, regression analysis and calculation of the Spearman rank correlation coefficient were performed. Differences were accepted as statistically significant at p
<0.05.