Bile (Alkaline) Reflux Gastritis

Daniel T. Dempsey

Indications/Contraindications

Alkaline or bile reflux gastritis is an unusual clinical syndrome consisting of chronic abdominal pain, bilious vomiting, and gastric mucosal inflammation associated with an “abnormal” amount of bilious duodenal contents in the stomach. Primary bile reflux gastritis is thought to be due to the presence of excess duodenal fluid in the stomach, perhaps because of abnormal motility patterns in the antrum, pylorus, and/or duodenum. More common is secondary bile reflux gastritis which occurs after pyloroplasty or gastrectomy with either Billroth I or Billroth II reconstruction. Since many dyspeptic patients (as well as many asymptomatic postsurgical patients) have both histologic gastritis and bilious duodenal contents in the distal stomach, the diagnosis of bile reflux gastritis must be made with care and circumspection. Prior to operation for bile reflux gastritis, an attempt should be made to quantitate enterogastric reflux, and to rule out other possible causes of the patient’s symptoms.

Indications for operation in bile reflux gastritis are intractable chronic symptoms, particularly bilious vomiting (with or without abdominal pain), which are unresponsive to medical treatment including proton pump inhibitors and promotility agents. There should be good evidence of both excessive enterogastric reflux and gastric mucosal inflammation. Relative contraindications to operation are inanition, narcotic addiction, and excessive use of NSAIDs or tobacco. Care should also be exercised in patients with severe gastroparesis, and in asthenic patients. It is prudent for the surgeon contemplating operation for bile reflux gastritis to ask, “how would this patient look 10 to 15 pounds lighter?”, because that is what often happens when an ill-conceived operation is done for this poorly understood functional GI malady.

Preoperative Planning

The differential diagnosis of bile reflux gastritis includes peptic ulcer disease, gastroparesis, mechanical gastric outlet obstruction, gastric remnant carcinoma, partial small bowel obstruction, afferent loop syndrome, and other upper abdominal disorders.
Other causes of gastritis such as helicobacter pylori, alcohol, and NSAIDs should also be considered. Unrecognized marginal ulceration is common in distal gastrectomy patients who are reoperated on for bile reflux gastritis, so retained antrum and gastrinoma should be ruled out; serum gastrin levels consistently above two times the upper limit of normal should prompt a secretin stimulation test. It is important to recognize that some patients sent for surgical evaluation of bile reflux gastritis will have more than one diagnosis, e.g., bile reflux gastritis and gastroparesis; or recurrent peptic ulcer disease and afferent loop syndrome.

In patients considered to be surgical candidates for primary or secondary bile reflux gastritis, the minimum preoperative evaluation should include the following:

upper gastrointestinal series with small bowel follow-through
esophagogastroduodenoscopy with biopsy
HIDA scan
gastric emptying scan
abdominal CT scan
serum gastrin level
review of previous operative notes

An important part of the preoperative management in patients with bile reflux gastritis is the management of postoperative expectations with the patient, family, and referring physician. It is helpful to remind patients that there are expected ups and downs during the recovery period, and that the success of the operation cannot be judged until the 3-month postoperative visit at the earliest. Many patients are unable to take their full nutritional requirements by mouth during the first few postoperative weeks, and it is rare to render patients with bile gastritis asymptomatic with an operation. Though the operations discussed below are quite effective in eliminating bilious vomiting, persistent pain is reported in up to 30% of patients, and 20% of patients develop postoperative delayed gastric emptying. It is important that these patients be managed both preoperatively and postoperatively by a multidisciplinary team including a gastroenterologist, surgeon, dietitian, psychologist/psychiatrist, and pain management specialist.

Choice of Operation

The rare patient with primary bile reflux gastritis (no previous gastroduodenal surgery) should be considered for duodenal switch and highly selective vagotomy (Table 24.1). The duodenal switch operation is inherently ulcerogenic, so it is reasonable to add a parietal cell vagotomy. Alternatively proton pump inhibitors are continued indefinitely after the duodenal switch operation. Cholecystectomy should be considered because after duodenal switch, ERCP may be impossible and cholecystectomy difficult. The duodenal switch operation should be avoided in patients with primary gastroparesis. Success with biliary diversion alone (choledochojejunostomy) has been reported and may be considered in patients with a history of primary common duct stones or sphincter of Oddi dysfunction. If the patient with primary bile gastritis has a significant history of peptic ulcer disease, consideration should be given to vagotomy and hemigastrectomy, with Roux-en-Y gastrojejunostomy, or Billroth II gastrojejunostomy with Braun reconstruction. The latter may be the preferable reconstruction in patients with delayed preoperative gastric emptying.

In patients with secondary bile reflux gastritis after Billroth II gastrectomy, the operations to consider are

Roux-en-Y gastrojejunostomy (60 cm Roux limb)
- Tanner 19 modification
Braun gastrojejunostomy
Henley loop (40 cm isoperistaltic jejunal interposition between the gastric remnant and duodenum)

Conversion of Billroth II to Billroth I gastroduodenostomy alone is not helpful though success has been reported when combined with Roux choledochojejunostomy.

Table 24.1 Choice of Operation for Bile Reflux Gastritis

Previous Operation	Surgical Options	Special Considerations
None (primary enterogastric reflux)	Duodenal switch procedure (consider parietal cell vagotomy and cholecystectomy)	Avoid if primary gastroparesis present
	Roux choledochojejunostomy (if history of primary CBD stones or ampullary dysfunction)	Does not prevent enterogastric reflux of non-bile duodenal contents
Pyloroplasty	Distal gastrectomy with Roux reconstruction	Subtotal gastrectomy if significant gastroparesis
	Duodenal switch procedure (to avoid difficult duodenal stump)	Avoid if primary gastroparesis present
Loop gastrojejunostomy	Takedown gastrojejunostomy (if pyloric channel patent)
	Subtotal gastrectomy with Roux reconstruction or Henley loop	If gastroparesis exists
	Distal gastrectomy with Billroth II and Braun reconstruction	If gastroparesis does not exist
Billroth I distal gastrectomy	Re-resection with Roux or Henley loop reconstruction	Subtotal gastrectomy if gastroparesis exists
Billroth II distal gastrectomy	Roux-en-Y gastrojejunostomy (+/- Tanner 19 modification)	Subtotal gastrectomy if gastroparesis exists
	Braun enteroenterostomy (+/- uncut Roux modification)	May not completely eliminate enterogastric reflux
	Henley loop (isoperistaltic jejunal gastroduodenal interposition)	Subtotal gastrectomy if gastroparesis exists
CBD, common bile duct.

In patients with bile reflux gastritis after Billroth I gastrectomy, conversion to Roux-en-Y gastrojejunostomy or Henley loop interposition should be considered.

The choice of operation for bile reflux gastritis depends on whether there are associated problems such as peptic ulcer disease, outlet stricture and/or gastroparesis. If not, patients with pure secondary bile reflux gastritis following gastric surgery are most easily treated by conversion of Billroth I or II to a Roux-en-Y gastrojejunostomy or Billroth II with Braun enteroenterostomy. Substantial re-gastrectomy is unnecessary. In patients with uncomplicated bile gastritis following loop gastrojejunostomy to an intact stomach, consideration should be given to takedown of the anastomosis if the pylorus and duodenum are patent.

Postgastrectomy and postpyloroplasty patients with bile reflux gastritis and recurrent peptic ulcer disease should be treated with subtotal gastrectomy (70%) and Roux-en-Y gastrojejunostomy. Patients with postsurgical bile reflux gastritis and gastroparesis may benefit from near total gastrectomy with Roux reconstruction. In this difficult subgroup of patients, if the left gastric artery remains intact, construction of a small (5% to 10%) vertically oriented proximal gastric pouch with resection of the fundus and remaining stomach may minimize persistent gastric stasis.

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