bile reflux gastritis



OVERVIEW

Definition

Bile reflux gastritis, or alkaline reflux gastritis, is a disease in which the duodenal contents reflux into the stomach due to a variety of causes and work in conjunction with gastric acid to disrupt the gastric mucosal barrier, leading to chronic inflammation of the gastric mucosa.

Types

Bile reflux gastritis can be categorized into two types according to the cause.

Primary bile reflux gastritis

This refers to non-surgical causes of bile reflux gastritis.

Delayed gastric emptying, decreased pyloric pressure or incomplete closure of the pylorus, and impaired coordination between the stomach, pylorus, and duodenum can cause bile to flow from the duodenum into the stomach, where it stays and is not easy to be removed, resulting in bile reflux gastritis.

Secondary bile reflux gastritis

This refers to bile reflux gastritis after gastrectomy. For example, if you have undergone gastric resection for gastric ulcer, gastric cancer or other diseases.

Incidence

Prevalence: There are no statistics on the prevalence of bile reflux gastritis, but some data show that bile reflux gastritis accounts for about 23% of all chronic gastritis.

Trends in prevalence: With the popularization of gastroscopy and other screening methods in recent years, the number of detections of bile reflux gastritis has increased significantly, and as a result, the prevalence has also risen.

Causes

Causes

Bile reflux gastritis is an inflammatory injury of the gastric mucosa caused by the reflux of bile, pancreatic juice and other duodenal contents into the stomach. The main causes are as follows.

Gastric-duodenal motility dysfunction

Duodeno-gastric reflux that occurs in normal people on an empty stomach and after a meal has no effect on the human body, and if gastro-duodenal motility dysfunction occurs, then pathologic duodeno-gastric reflux will occur.

Frequent episodes of duodeno-gastric reflux with a high flow rate over a long period of time can lead to bile reflux gastritis.

Subtotal gastrectomy

After surgery, the pylorus, which is an anti-reflux mechanism, is lost and the emptying of the stomach is impaired, making duodenal reflux very likely to occur, which can lead to cholestatic reflux gastritis.

Cholecystectomy

If cholelithiasis or cholecystectomy, bile will be continuously discharged into the duodenum, and bile reflux increases during fasting and causes the disease.

Functional dyspepsia

Functional abnormalities of the pylorus with frequent spontaneous relaxation can also lead to reflux of duodenal contents.

Psychosomatic factors

Mental factors such as anxiety and depression can affect visceral sensitivity, leading to abnormal bile excretion and eventually causing the development of bile reflux gastritis.

Triggering and aggravating factors

Binge drinking, high-fat diet, overfeeding at dinner, and strong tea and coffee can induce or aggravate bile reflux gastritis.

Pathogenesis

Reflux

After partial gastrectomy or vagus nerve trunk amputation, there is deformation of the pylorus of the stomach or sphincter dysfunction, resulting in a large amount of alkaline digestive fluids, such as bile, pancreatic fluid and intestinal fluid, refluxing from the duodenum into the stomach.

Damage to the gastric mucosa

Alkaline digestive fluid in the stomach stimulates the secretion of gastric acid, the combination of bile salts and other chemicals with gastric acid continues to damage the mucous membrane of the gastric wall, and stimulates the secretion of inflammatory stimulating factors by mast cells of the gastric mucous membrane, resulting in inflammatory pathological changes of the gastric mucous membrane, such as congestion, edema, erosion, and so on.

Symptoms

Most patients show persistent burning pain in the middle and upper abdomen, which is aggravated after meals and cannot be relieved by alkaline drugs.

A few may present with retrosternal burning pain associated with reflux esophagitis.

Bilious vomiting is the characteristic manifestation.

Anemia, emaciation and malnutrition may occur.

Typical symptoms

Abdominal or chest pain: presents as epigastric pain, or retrosternal pain. It is characterized by a persistent burning pain, which is obvious in the morning and is aggravated by eating and lying down.

Vomiting: Vomiting may occur in severe cases, mostly at night, and the vomit contains food and yellowish-green liquid. Some patients have blood in the vomit, and feel bitter in the mouth after vomiting.

Nausea, sometimes abdominal distension, belching (commonly known as burping), loss of appetite, eating less but feeling full easily.

Other symptoms

Anemia: When the disease progresses, anemia symptoms such as pale skin and easy exertion may also occur and gradually worsen.

Gastrointestinal bleeding: As the disease progresses, vomiting blood and black stools may occur.

Mental symptoms: some of them may be accompanied by mental symptoms such as restlessness, impatience, dizziness, palpitation, insomnia, mental depression, and so on.

Complications

The following complications may occur if bile reflux gastritis is not treated promptly and scientifically.

Gastroesophageal reflux disease (GERD)

Gastroesophageal reflux disease (GERD) is a series of symptoms caused by the reflux of stomach contents into the esophagus, mouth, throat, trachea and/or lungs. The main manifestations are as follows.

Heartburn and acid reflux:: Heartburn is a burning sensation behind the sternum and under the xiphoid process and is the most common symptom of the disease.

Painful swallowing and dysphagia: Painful swallowing can occur when there is severe esophagitis or esophageal ulcer.

Hoarseness, pharyngeal discomfort or foreign body sensation.

Reflux pharyngitis

Reflux pharyngitis is a common chronic symptom or mucosal damage in the pharynx. It is a condition caused by the reflux of substances from the stomach into the pharynx and irritation of the pharyngeal mucosa, also called pharyngeal reflux. The clinical symptoms of reflux pharyngitis lack specificity, and those with milder conditions often have no obvious clinical manifestations, and when they develop to a certain extent, the following typical clinical symptoms can occur.

The most common is hoarseness, but also can appear throat discomfort, such as throat obstruction, foreign body sensation, burning pain and other abnormal sensations.

Some patients also show increased secretion in the throat, mostly caused by reflux material irritating the mucous membrane of the throat.

A few patients may also experience acid reflux, heartburn and other manifestations of reflux gastroesophagitis.

Consultation

Department of Medicine

Gastroenterology

Gastroscopy reveals bile reflux, or recurrent abdominal pain and bloating, loss of appetite, nausea and vomiting, and regurgitation of acidic belching, prompt consultation is recommended.

Preparation for medical treatment

Preparation for consultation: registration, preparation of documents, FAQs

Tips

Try to keep a record of symptoms, duration, etc., before going to the doctor.

Preparation checklist

Pay particular attention to the time of onset of symptoms, special manifestations, etc.

What is the discomfort? How long has it lasted?

Any abdominal pain or bloating? How long has it lasted?

Any nausea, vomiting, acid reflux, belching, etc.?

Have you had any tests such as gastroscopy, H. pylori test, etc.?

Are there any medical conditions, such as gallbladder stones?

Any recent abdominal surgery, etc.?

Any previous or immediate family members with diseases such as peptic ulcer, chronic gastritis, etc.?

Test results in the last six months, which can be brought to the doctor’s appointment

Gastroscopy

¹³C, ¹⁴C urea breath test, fecal Helicobacter pylori antigen (HpSA) test

Routine blood test, routine stool test

Abdominal ultrasound or CT, etc.

Medication use in the last 3 months, bring the box or package with you to the doctor’s office if available

Acid suppressants: omeprazole, lansoprazole, pantoprazole, rabeprazole, famotidine

Gastric mucosal protectants: bismuth potassium citrate, colloidal bismuth pectin, aluminum thiosulfate

Non-steroidal anti-inflammatory drugs: aspirin, clopidogrel, ibuprofen, indomethacin

Gastric stimulants: mosapride, domperidone

Diagnosis

Diagnosis is based on

Medical History

If your doctor suspects bile reflux gastritis, he or she will ask a number of history-related questions. The presence of Helicobacter pylori infection, gallbladder disease, and any recent stomach or gallbladder surgery.

Past medical history is crucial to the diagnosis of bile reflux gastritis.

Clinical manifestations

The presence of recurrent abdominal pain, bloating, loss of appetite, nausea and vomiting, acid regurgitation and belching, and even vomiting of blood or black stools can be judgmental about the condition.

Laboratory tests

Urea breath test is one of the “gold standards” for the detection of Helicobacter pylori, which is non-invasive and highly accurate, and is widely used in clinical practice.

Using radioactive ¹³C, ¹⁴C-labeled urea (taken orally) is broken down by the urease enzyme produced by H. pylori, resulting in the production and exhalation of CO2 containing the labeled carbon atoms, and the presence of H. pylori infection can be determined by measuring the concentration of CO2.

Bile and refluxed duodenal fluid are alkaline and can be neutralized with gastric acid causing an increase in the pH of gastric juice.

Gastric fluid pH helps in the diagnosis of bile reflux gastritis. A gastric fluid pH >4 is diagnostic of bile reflux.

Fasting and postprandial gastric juices are drawn and the amount of bile acids in them is measured; if the fasting basal gastric acid secretion is below 3.5 mmol/L and the bile acid level is above 30 μg/ml, bile reflux gastritis is usually identified.

Intragastric bilirubin measurement can directly reflect the concentration of bile in the stomach, and can assist in the diagnosis of bile reflux when the bilirubin absorbance value is above 0.14.

Routine blood tests are helpful to help the doctor determine whether there is any blood loss and other conditions.

If the blood test shows a low hemoglobin count, it may help the doctor diagnose intestinal tuberculosis.

There is no need to abstain from food or water before the blood test, but you should be careful not to drink alcohol.

A fecal occult blood test may be done to see if there is any gastrointestinal bleeding.

A positive fecal occult blood test, for example, indicates the presence of gastrointestinal bleeding.

There is no need to fast or drink before the stool test, but the specimen needs to be sent in a special container in a timely manner and must not be mixed with urine or other impurities.

Endoscopy

Gastroscopy is the method of diagnosing the disease, through which the reflux in the stomach can be directly observed, and congestion and erosion of the gastric mucosa can also be seen.

In addition to direct observation, gastroscopy can also take material at the lesion for pathologic examination.

Histopathologic examination

After the biopsy tissue is processed by sectioning and other pathology, if pathological manifestations of atrophic gastritis such as epithelial hyperplasia of the gastric lesser concavity and loss of gastric glands are observed under the microscope, the diagnosis of the disease can be supported.

Radionuclide scanning examination

It is a non-invasive test that allows monitoring of the bile flow trajectory throughout and also determines the extent of reflux.

Differential diagnosis

Gastric cancer

Similarities: Both may present with decreased appetite, epigastric discomfort, fullness, and anemia, and the X-ray signs of a few cases of sinus gastritis are also very similar to those of gastric cancer.

Differences: Differential diagnosis can be made by endoscopy and tissue biopsy.

Functional dyspepsia

Similarity: both of them may have symptoms such as abdominal pain and bloating, belching, decreased appetite and early satiety.

Differences: Differential diagnosis can be made by gastroscopy.

Treatment

Aims of treatment

Eliminate symptoms and improve general condition.

Treatment method

General treatment

Correct bad living habits and regular work and rest schedules.

Reasonable and balanced diet.

Exercise properly.

Avoid stimulating food.

Medication

There are different types of medication, and different medications should be chosen according to the specific condition and cause of the disease. All medications should be used in accordance with medical advice and should not be adjusted or discontinued on their own.

Suitable people: It can improve the epigastric symptoms related to meals, and is often preferred by patients whose main symptoms are abdominal fullness, early satiety and belching.

Drugs: Domperidone, Mosapride, etc.

Precautions: Need to be taken before meals. Adverse reactions such as diarrhea and abdominal pain may occur, which can usually be relieved on their own after stopping the drug.

Effects: The application of drugs to inhibit gastric acid secretion aims to relieve pain, promote ulcer healing and prevent complications.

Commonly used drugs: drugs to inhibit gastric acid secretion include proton pump inhibitors such as omeprazole, rabeprazole, lansoprazole, epprazole and so on; H2 receptor blockers such as cimetidine, ranitidine, famotidine and so on.

Protective drugs for gastric mucosa can form high viscosity sol under acidic environment, which can produce strong affinity to the ulcer surface and form a strong protective film on the surface of gastric mucosa, which has good therapeutic effect on peptic ulcer and chronic inflammation.

Protective drugs for gastric mucosa include aluminum and bismuth preparations.

If combined with Helicobacter pylori infection, radical treatment of H. pylori is needed.

The most commonly used treatment for H. pylori infection is H. pylori quadruple therapy, which includes proton pump inhibitors, two antimicrobial drugs and bismuth.

The main effects are to inhibit gastric acid secretion, protect gastric mucosa and control infection.

A regular course of treatment is 10 to 14 days.

The bile boiling and drugs can bind with bile salts in the stomach so that they can bind bile acids in the stomach in an acidic environment, and then separate from the bile acids when the conjugate enters the alkaline environment of the intestinal lumen, thus accelerating its elimination from the stomach.

Commonly used drugs are drugs such as colesevelam and magnesium aluminum carbonate.

It can competitively inhibit the absorption of endogenous toxic bile acids in the ileum, change the composition of bile, and reduce bile reflux and the damage of refluxed bile to the gastric mucosa.

Commonly used drugs are ursodeoxycholic acid.

Warm Stomach Relief Granules is a kind of proprietary Chinese medicine, which is synthesized by Codonopsis, Chen Pi, Astragalus, Chinese yam, hawthorn, epimedium, cinnamon, atractylodes, umeboshi, and sand nuts and other Chinese medicinal ingredients into granular proprietary Chinese medicine.

It is mainly used for the relief of stomach pain and upset stomach caused by chronic gastritis, as well as stomach symptoms caused by eating cold and raw food.

Surgical Treatment

Indications: Surgery is an option for those who have severe symptoms and have not responded to medication. There are many different types of surgeries, and the doctor should decide which one to use according to the specific situation.

Commonly used surgical methods: Billroth I, Roux-en-Y, jejunostomy, Tanner’s surgery.

Prognosis

Cure

The cure of bile reflux gastritis is related to a number of factors, such as the presence of symptoms and complications, underlying physical condition, and surgical history.

With early and standardized treatment, symptoms can be relieved, but eradication is difficult and recurrence is easy.

Some bile reflux gastritis can be cured.

Hazards

The main dangers of bile reflux gastritis are that it affects daily life, causes serious complications, and increases the risk of cancer.

Impact on daily life

Because of the long course of the disease, there are often symptoms such as upper abdominal discomfort, acid reflux and loss of appetite, which cause inconvenience to normal life, work and study.

Causes serious complications

When bile reflux is serious, complications such as gastric bleeding and gastric perforation can occur, which can be life-threatening in severe cases. Therefore, it is necessary to go to the hospital for consultation and treatment in time to control the condition, which can reduce the risk of complications.

Risk of cancer

Bile reflux can damage gastric mucosa, if not treated, long-term bile reflux can lead to esophagitis, gastric mucosal erosion, gastric ulcer, etc., and even prompt atrophy, enterosis, gastric intraepithelial neoplasia, and even gastric cancer. Therefore, bile reflux gastritis may lead to cancer.

Daily

Bile reflux gastritis is more prone to recurrence. Daily life management is as important as treatment to minimize recurrence. This includes dietary modification, proper rest, careful use of medications, weight control and follow-up visits as prescribed by the doctor.

Daily management

Dietary management

Avoid prolonged consumption of irritating foods, such as rough, hard, cold, hot and spicy foods.

Eat small and frequent meals, avoid overeating, and eat regularly at regular intervals.

Avoid drinking strong tea, coffee, etc.

Prohibit alcohol consumption during treatment.

Work and rest management

Work and rest on time, do not stay up late, and ensure sufficient sleep.

Psychological management

Keep in a good mood, avoid bad emotions.

Drug management

Avoid long-term use of drugs that damage the gastrointestinal mucosa.

Weight management

Obese people have greater intra-abdominal pressure and are more prone to reflux than normal-weight people, so obese people should control their weight through nutrition and exercise.

Follow-up examination

Importance of follow-up examination: Regular follow-up examination helps to find out whether there are complications in time, which is crucial to the treatment effect of the disease.

Follow-up time: Follow the doctor’s instructions for regular follow-up; if you have symptoms such as epigastric discomfort, loss of appetite, fullness after eating and acid reflux, it is recommended to consult the doctor in time.

Tests to be done during follow-up: H. pylori test, gastric fluid analysis, gastric acid and bile acid measurement, and intragastric bilirubin measurement may be needed during follow-up.

Prevention

Strictly follow the doctor’s instructions for treatment and recovery after gastrointestinal surgery, and review regularly.

Actively treat cholecystitis, cholelithiasis and other biliary tract system diseases.

If infected with Helicobacter pylori, follow your doctor’s advice and try to take the quadruple method of eradication.

Through a healthy diet, good living habits.

Eat a light diet, no greasy or fried food.

You should chew slowly and avoid overeating.

Avoid smoking, drinking strong tea or coffee and eating spicy, too cold, too hot and rough food.