Bile Acid Composition in Patients with and without Symptoms of Postoperative Reflux Gastritis Thomas Ft. Gadacz, MD, Baltimore, Maryland George D. Zuidema, MD, Baltimore, Maryland
The incidence of gastritis varies from 64 to 96 per cent after operations for duodenal ulcer [I], with the highest incidence occurring after Billroth II reconstruction. Despite the reflux of duodenal contents into the gastric remnant and the frequent presence of chronic gastritis, the development of clinically significant problems is probably low [2]; however, the actual incidence is not known. Although all the factors that cause gastric mucosal damage and their relationship to the development of symptoms are not known, bile has been incriminated as a possible cause in initiating mucosal damage resulting in symptoms [3,41. Studies [5-101 have demonstrated that bile acids damage the gastric mucosa. Although the presence of bile reflux had been demonstrated in the postoperative ulcer patient, no information is available concerning the bile composition of patients with symptoms and findings characteristic of postoperative alkaline reflux. The present study is designed to compare the composition and concentration of bile acids in a group of asymptomatic and symptomatic patients with bile reflux after operation for duodenal ulcer. Material and Methods Patient Description. Two groups of male patients were identified after undergoing truncal vagotomy and Billroth II operation for duodenal ulcer. Four patients (group A) aged fifty-two to fifty-four years (mean, 53 years) were asymptomatic and considered as having a good result. All had bile reflux into the gastric pouch. Three patients (group B) aged fifty to fifty-nine years (mean, 55 years) had reflux of bile in the gastric remnant and abdominal discomfort described as a burning sensation. All had bilious vomiting. None had diarrhea and none were anemic. This From the Department of Surgery, The Johns Hopkins Hospital, and Veterans Administration Hospital, Baltimore, Maryland. This work was supported by the Medical Research Service. Veterans Administration Hosoital. MO, Surgical Reprint requests shcukl be ail&es&to ThomasFt.Gadacz: Service, Veterans Administration Hospital, 3900 Loch Raven Boulevard, Baltimore, Maryland 21219. Read in part before the Association of Veterans AdministrationSurgeons, Nashville, Tennessee, May 3, 1977. Presented at the Society for Surgery of the Alimentary Tract, Toronto, Ontario, Canada, May 24-25,1977.
40
group of patients had gastric analysis, upper gastrointestinal series, and endoscopy. All were treated for varying periods of time with antacids and cholestyramine without success. Although all seven patients had a history of alcoholism, none had abnormal liver function tests or other significant gastrointestinal diseases. One patient in group A underwent cholecystectomy for cholelithiasis. Analytical Procedures. All bile samples were fasting gastric aspirates or were collected at the time of endoscopy. The samples were either immediately frozen at -40°C or diluted in a 1:9 (vol:vol) ratio with ethanol and stored at 4oc. Quantitative Analysis. Total bile concentration was determined by an enzymatic method using steroid dehydrogenase [II]. Cholesterol does not interfere with the determination. The final bile acid concentration is expressed in millimoles. Qualitative Analysis. One milliliter aliquots of the diluted bile samples were evaporated to dryness and hydrolyzed with 2 N sodium hydroxide and 50 per cent methanol for 4 hours at 120°C. After acidification, the bile acids were extracted with ether and methylated using diazomethane [12]. After acetylation, the samples were analyzed by gas-liquid chromatography. The samples were injected into a 6 foot glass column packed with 3 per cent OV-17 on SO/l00 Gas-chrom Q. The column temperature was 273’C and hydrogen gas (Hz) flow was 30 ml/min. The identification of individual bile acids of each sample was determined by comparing the retention time with standards of cholic, chenodeoxycholic, deoxycholic, and lithocholic acids. Composition percentage was calculated by measuring the areas of the peaks. Breath Test. Two patients in group B had a standard 6 hour cholyl-glycine breath test to assess bacterial overgrowth. Results
All of the patients were male, and there was no significant age difference between the two groups. The barium studies in both groups demonstrated a slight delay in emptying, but no stoma1 obstruction or dilated afferent or efferent loops. None had jejunal diverticula. In group B gastric analysis revealed achlorhydria with histalog stimulation. Endoscopy confirmed reflux of bilious material into the stomach,
The American Journal of Surgery
Postoperative
and the patients in group B had gastritis with mucosal erythema and friability. The inflammatory changes in the stomach were diffuse and not confined to the stoma1 area as in group A. No patient had a marginal ulcer. Two of the patients in group B were operated on and had a Roux-en-Y or Tanner 19 procedure to divert bile for the stomach. Both had a favorable result. The results of the quantitative determination of total bile acids of patients in group A ranged from 0.34 to 2.14 mM (mean, 1.23 mM) and of those in group B from 1.12 to 2.26 mM (mean, 1.75 mM). There was no statistically significant difference between the two groups. The results of qualitative analysis of the bile samples in each group are given in Table I. The mean of the primary bile acids (cholic and chenodeoxycholic acids) was 86.8 per cent in group A and 63.7 per cent in group B, and of the secondary bile acids (deoxycholic and lithocholic acids) 13.2 per cent in group A and 36.3 per cent in group B. Deoxycholic acid accounted for this increase, and lithocholic acid was only slightly changed. The difference in secondary bile acids between group A and group B is statistically significant (p < 0.05). The cholyl-glycine breath test was negative in the two patients tested from group B, indicating that there was no appreciable bacterial overgrowth in the proximal bowel. Comments
Postoperative alkaline reflux gastritis has been characterized by Van Heerden et al [3]. The main features of this syndrome are abdominal discomfort, hypochlorhydria or achlorhydria, exclusion of marginal ulceration, and endoscopic evidence of reflux and gastritis. Medical treatment with antacids or cholestyramine was generally unsuccessful, however, diversion of duodenal contents from the stomach by a Roux-en-Y loop was successful in 84 per cent of the patients. The actual incidence of postoperative reflux gastritis after operation for duodenal ulcer disease is unknown, although it may be as high as 13 per cent [13] to 20 per cent [2]. The factors that determine which patients will develop clinically significant problems are unknown, but bile has received the most attention [S-10]. Although reflux of bile into the gastric remnant is common after ulcer operation, the mere presence of bile cannot account for the development of reflux gastritis, since only a few patients with reflux develop symptoms. These studies were undertaken to determine if the concentration or composition of bile refluxed into the stomach was
vdume185,Jalnlq11978
TABLE I
Qualitative Profile of Bile Acids
Group (n) A (4) B (3)
Reflux Gastritis
C 33-64 31-33
Composition (%) DC CDC 32-50 16-41
3-17 19-44
Note: C = cholic acid; CDC = chenodeoxycholic deoxychob acid; LC = lithocholic acid.
LC 1-13 6-9 acid: DC =
different in patients without symptoms of gastritis compared with those with symptoms. The concentration of bile acids refluxed into the stomach in groups A and B of the present study is within the concentration range reported in other studies [4,8]. Although bile acids are present in the gastric remnant, their presence does not necessarily result in significant problems, as confirmed by group A of this study. The bile concentration in group A is similar to that in group B and suggests that increased concentrations may not be the major determinant of gastric injury as suggested by Ritchie and Shearburn [8]. One of the parameters we did not assess was volume. It is possible that although the concentration of bile was similar, the total amount of bile acids was different and might be a factor in producing injury. The composition of bile acids was also analyzed. The composition of bile for normal individuals as reported by Sjovall [14] is cholate 41 per cent, chenodeoxycholate 37 per cent, and deoxycholate 22 per cent and as reported by Miettinen and Peltokallio [.~5] is cholate 55 f 12 per cent, chenodeoxycholate 32 f 7 per cent, and deoxycholate 15 f 6 per cent. The percentage of deoxycholic acid in group A patients is in the lower range of these reported values. Although a decrease in deoxycholic acid has been reported for patients with cirrhosis [IS], none of the patients in either group had evidence of cirrhosis. The composition of bile acids in group B shows a marked increase in secondary bile acids, especially deoxycholic acid. Increases in secondary bile acids are also present in stagnant loop syndrome, jejunal diverticulosis, and other conditions predisposing to bacterial overgrowth and result from dehydroxylation [17,18]. Barium studies and endoscopy eliminated the first two causes as potential sources. A negative breath test indicated that significant bacterial overgrowth in the proximal small bowel was not occurring. These observations are consistent with other reports [17,18]. The conversion of cholic acid to deoxycholic acid requires 7-a-dehydroxylation. In patients with partial gastrectomy, this conversion, although variable, is generally low [18]. In contrast, deconjugation by radioisotope technics is significant in this same group of
49
Gadaczand Zuidema
patients; however, aspirates from the proximal jejunum were mostly conjugated [la]. Deconjugation in the distal small bowel or rapid absorption of unconjugated forms from the upper tract may explain this discrepancy. The increase in deoxycholic acid and the normal breath test in group B suggest that neither deconjugation nor dehydroxylation occurs in the proximal small bowel. The bacteria that usually colonize the proximal small bowel do not have the metabolic capability to deconjugate or dehydroxylate. The increase of secondary bile acid in group B could be on the basis of increased intestinal absorption or a relative decrease in hepatic synthesis. The effects of bile acids on the gastric mucosa have been investigated by others [5-101. Most of the observations on the toxicity of bile acids on the stomach have been described in acute studies in which acid secretion is an important factor in producing injury. In our study, an increase in deoxycholic acid was found in the symptomatic group. Whether the increase in deoxycholic acid or the alteration in the relative composition of bile is the important factor is not known. There are several studies demonstrating the toxicity of deoxycholic acid. Silen and Forte [9] reported that deoxycholic acid was more potent on a molar basis than cholic acid in damaging the amphibian mucosal membrane. Dawson and Isselbacher [18] also reported that deoxycholic acid as compared with cholic acid was capable of not only inhibiting esterification but also caused dissolution and necrosis of jejunal villi. In another study, the potential toxicity of deoxycholic acid in the small bowel was emphasized [19]. In contrast to these reports, greater changes in gastric ionic flux in normal human subjects were observed with taurocholic acid than with taurodeoxycholic acid [6]._However, all these observations were recorded for normal subjects; our group of patients are not comparable since they have chronic gastritis and are achlorhydric. The increase in deoxycholic acid may be a factor that results in the development of reflux alkaline gastritis, and it is in this group of patients that diversion of bile from the stomach will be highly successful.
Summary
Reflux of bile into the stomach is common after surgery for duodenal ulcer disease; however, only a minority of patients may develop significant gastritis and pain. Gastric aspirates from two groups of patients after operation for duodenal ulcer were quantitatively and qualitatively analyzed. Group A patients were asymptomatic and the bile composition
50
was normal. Group B patients were symptomatic and had a significant increase in the secondary bile acid, deoxycholic acid. The concentration of bile acid was similar in the two groups. This alteration in bile acid composition, with an increase in deoxycholic acid, may be an important factor in determining which patients with bile reflux develop gastritis. Acknowledgment: Dean Burns gave valuable assistance with the bile acid analysis. References 1. Wall AJ, Ungar B, Baird CW, et al: Malnutrition after partial gastrectomy. Am J Dig Dis 12: 1077, 1967. 2. Berardi RS, Siroospour D, Rub R, et al: Alkaline reflux gastritis. A study in forty postoperative duodenal ulcer patients. Am J Surg 132: 552, 1976. 3. Van Heerden JA, Phillips SF, Adson MA, Mcllrath DC: Postoperative reflux gastritis, Am J Surg 129: 62, 1975. 4. Rhodes J, Barnard0 D, Phillips S, Roulestad R, Hoffman A: Increased reflux of bile into the stomach in patients with gastric ulcer. Gestroenterology 57: 241, 1969. 5. Davenport HW: Absorption of taurocholate 24°C through the canine gastric mucosa. Proc Sot Exp Biol Med 125: 670, 1967. 6. lvey KJ, DenBesten L, Clifton JA: Effect of bile salts on ionic movement across the human gastric mucosa. Gastroenterology 59: 663, 1970. 7. DenBesten L, Hamza KN: Effect of bile salts on ionic permeability of canine gastric mucosa during experimental shock. Gastroenterology 62: 417, 1972. 8. Ritchie WR, Shearburn EW: Acute gastric mucosal ulcerogenesis is dependent on the concentration of bile salt. Surgery 80: 98, 1976. 9. Silen W, Forte G: Effects of bile salts on amphibian gastric mucosa. Am J Physiol228: 637.1974. 10. Eastwood GL: Effect of pH on bile salt injury to mouse mucosa. A light- and electron-microscopic study. Gestroenterology 68: 1456, 1975. 11. Admirand WH, Small DM: The physiochemical basis of cholesterol gallstone formation in man. J C/in /west 47: 1043, 1968. 12. Schlenk H, Gellerman JL: Esterification of fatty acids with diazomethane on a small scale. Anaf Chem 32: 1412, 1960. 13. Goligher JC, Pulvertaft CN. Irvin TT, Johnson D, Walker B, Hall RA, Willson-Pepper Jr, Matheson TJ: Five to eight year results of truncal vagotomy and pyloroplasty for duodenal ulcer. Br Med J 1: 7, 1972. 14. Sjovall J: Bile acids in man under normal and pathological conditions. C/in Chem Acta 5533, 1960. 15. Miettinen TA, Peltokallio P: Bile salt, water, and vitamin B-12 excretion after ileostomy. &and J Gastroenterol6: 543, 1971. 16. Voshida T, McCormick WC, Swell L, Vlahcevic ZR: Bile acid metabolism in cirrhosis. IV. Characterization of the abnormality in deoxycholic acid metabolism. Gastroenterology 68: 335, 1975. 17. Midtvedt T, Norman A, Nygaard K: Metabolism of glycocholic acid in gastrectomized patients. Stand J Gestrobnterol5: 237, 1970. 18. Dawson AM, lsselbacher KJ: Studies on lipid metabolism in the small intestine with observations on the role of bile salts. J C/in Invest 39: 730, 1960. 19. Lamabadusuriya SP. Guiraldes E, Harries JT: Influence of mixtures of taurocholate, fatty acids, and monolein on the toxic effects of deoxycholate in rat jejunum in vivo. Gestroenterology 69: 463, 1975.
The American Journal of Surgery
Postoperative Reflux Gastritis
Discussion Lawrence W. Way (San Francisco, CA): Certainly we need to learn more about this puzzling clinical problem. The observations discussed have implications regarding etiology, diagnosis, and even therapy. However, the number of patients is so small that the conclusions must be regarded as very tentative. I have several questions. One unsolved problem is the diagnostic criteria for alkaline gastritis. On what basis was the diagnosis made in these patients? Was the degree of gastritis quantifiable and clearly different between the patients in group A and group B? Was biopsy of the gastric mucosa performed in both of these grou&? Was operation performed on the patients in group B, and if so, what was the outcome? There are several other questions regarding the comparability of the two groups. Some of the patients in group B received cholestyramine. Had they received this drug recently? Had antibiotics been administered to either group recently? Did any of these patients have biliary disease or had they had biliary surgery? It was noted that the patients in group B were achlorhydric, which might affect the relative distribution of bile acids. How about group A? What was their gastric acid secretion? Lastly, I would ask the authors if they think that the increased concentration of deoxycholate can be implicated with certainty as a cause of the lesion or is it an effect of another cause? Since the breath tests did not demonstrate bacterial overgrowth, then what is the explanation for increased deoxycholate concentrations in the patients with alkaline reflux? Malcolm Stanley (Hines, IL): Did you separate conjugated and nonconjugated bile acids in your analysis? Free bile acids are more likely to produce tissue injury than conjugated bile acids; probably both bacterial deconjugation and 7-a-dehydroxylation, with formation of secondary bile acids, would occur in an infected afferent loop. Incidentally, did you culture the afferent loop? The breath test would not necessarily be positive if your labeled bile acids administered by mouth bypassed the contaminated afferent loop and went through the gastrojejunostomy directly into the small bowel which was not overgrown. Frank G. Moody (Salt Lake City, UT): To reiterate Doctor Way’s question, 1 have had two patients who developed problems with bile gastritis after cholecystectomy. 1 wonder if in some way the cholecystectomy might have contributed to the bile residing in the duodenal loop overnight, this being a nocturnal problem, possibly with the production of secondary bile acids. I would like to have a specific answer regarding whether any of these patients had cholecystectomies. Kevin P. Morrisey (New York, NY): 1 do not think, as has already been asked, that these groups are comparable. 1 can partially answer Doctor Moody’s question as to how
voluma
199. Janu8rv
1979
many of these patients have had cholecystectomies. It is known that cholecystectomy will increase the percentage of secondary bile acids in favor of deoxycholic and lithocholic acid. 1 am also curious about where the secondary bile acids are formed. Are they formed in the gastric pouch or are they the result of increased bacterial overgrowth in the colon? 1 think it would be difficult to get a pure bile sample from these patients, but one might be able to measure their fecal bile acid concentration and see whether the increase in deoxycholic acid is actually coming from the bowel. It might make a difference in considering antibiotic treatment rather than a completely new operation in caring for these patients. William A. Altemeier (Cincinnati, OH): Did any of these patients undergo an antecolic Billroth 11type of operation in addition to cholecystectomy? It has been my observation in patients with bile gastritis, particularly group Ill patients in whom there is the most severe biopsy evidence of inflammation of the gastric mucosa, that they have previously undergone tin antecolic long-loop Billroth 11operation. Correction of this by resection of the previous gastroenterostomy and development of the formation of a retrocolic short-loop gastrojejunostomy resulted in the disappearance of the symptoms and of evidence of the bile gastritis. M. M. Eisenberg (Denver, CO): The implications of bile gastritis after surgery for duodenal ulcer may extend well beyond the immediate and early postoperative period. We have recently collected more than forty cases of gastric carcinoma occurring in the remnant of subtotal gastrectomy patients twenty or more years after operation, and 1 wonder if the authors would care to speculate on the possible long-term carcinogenic effects of bile acids bathing the gastric mucosa and the possible implications of the histamine-fast achlorhydria observed in these patients. Thomas R. Gadacz (closing): 1 agree with the criticism that the number of patients is small. Whether the elevation of deoxycholic acid is a causative or associative factor is not certain; however, we are studying other well documented cases of reflux gastritis. At present, we are taking bile samples at the time of operation. We are going to try to follow these sequentially to see if the alteration in bile composition is initially present or if the change occurs later. Correlation of the change in composition with the onset of symptoms should provide additional information concerning the importance of our observations. The main reason we had such a smail group of patients is that many of the patients referred to us for evaluation for bile gastritis really did not have it. Many had bile in the gastric remnant but they also had other things-stoma1 dysfunction, a long afferent loop, and chronic pancreatitis. Those we are reporting on were evaluated for other postgastrectumy problems as well as the characteristic findings of reflux gastritis.
51
Gadacz and Zuidema
Although there may not be a good correlation between the reflux of bile, the endoscopic appearance of gastritis, and symptoms, two of the patients in group A had biopsies which showed chronic gastritis. There were two differences between the groups that underwent endoscopy and biopsy. All of those in group B, the symptomatic patients, had bile reflux and their entire gastric mucosa was inflamed, reddened, and friable. Biopsy showed acute as well as chronic gastritis. The patients in group A did have stoma1 erythema, but the process did not involve their entire gastric mucosa. The two who were biopsied showed only chronic gastritis. None of the patients in group B had cholecystectomy. One patient in group A had cholecystectomy but had no problems. Cholecystectomy in a patient who was previously doing well after an ulcer operation may result in reflux gastritis. Although this is a well recognized clinical observation, this was not observed in our small group of patients. The patients in group B were treated with cholestyramine for several months or as long as they could tolerate it, and treatment was discontinued several months before
52
bile samples were collected. All the patients in group B had been followed for six months to two years by the gastroenterologists. We did not do gastric analysis on the patients in group A, although their pH was neutral. All of the patients in group B had standard gastric analyses and were achlorhydric. Bacterial deconjugation and dehydroxylation does not seem to occur in the proximal small bowel. Some preliminary work indicates that the changes in bile composition are not the result of bacterial overgrowth in the afferent loop or gastric remnant. Samples from the gastric remnant were cultured aerobically and anaerobically. The isolates were incubated in bile acid media, and deconjugation and dehydroxylation was not observed. This correlates with the normal cholyl-glycine breath test results. Whether bile reflux predisposes to cancer is very speculative. It has been shown that certain bile acids are toxic to gastric and small bowel mucosa, but the changes they produce are usually inflammatory and not neoplastic. All the patients in both groups had vagotomy and retrocolic Billroth II operation.
The American Journal of Surgery
The incidence of gastritis varies from 64 to 96 per cent after operations for duodenal ulcer [I], with the highest incidence occurring after Billroth II reconstruction. Despite the reflux of duodenal contents into the gastric remnant and the frequent presence of chronic gastritis, the development of clinically significant problems is probably low [2]; however, the actual incidence is not known. Although all the factors that cause gastric mucosal damage and their relationship to the development of symptoms are not known, bile has been incriminated as a possible cause in initiating mucosal damage resulting in symptoms [3,41. Studies [5-101 have demonstrated that bile acids damage the gastric mucosa. Although the presence of bile reflux had been demonstrated in the postoperative ulcer patient, no information is available concerning the bile composition of patients with symptoms and findings characteristic of postoperative alkaline reflux. The present study is designed to compare the composition and concentration of bile acids in a group of asymptomatic and symptomatic patients with bile reflux after operation for duodenal ulcer. Material and Methods Patient Description. Two groups of male patients were identified after undergoing truncal vagotomy and Billroth II operation for duodenal ulcer. Four patients (group A) aged fifty-two to fifty-four years (mean, 53 years) were asymptomatic and considered as having a good result. All had bile reflux into the gastric pouch. Three patients (group B) aged fifty to fifty-nine years (mean, 55 years) had reflux of bile in the gastric remnant and abdominal discomfort described as a burning sensation. All had bilious vomiting. None had diarrhea and none were anemic. This From the Department of Surgery, The Johns Hopkins Hospital, and Veterans Administration Hospital, Baltimore, Maryland. This work was supported by the Medical Research Service. Veterans Administration Hosoital. MO, Surgical Reprint requests shcukl be ail&es&to ThomasFt.Gadacz: Service, Veterans Administration Hospital, 3900 Loch Raven Boulevard, Baltimore, Maryland 21219. Read in part before the Association of Veterans AdministrationSurgeons, Nashville, Tennessee, May 3, 1977. Presented at the Society for Surgery of the Alimentary Tract, Toronto, Ontario, Canada, May 24-25,1977.
40
group of patients had gastric analysis, upper gastrointestinal series, and endoscopy. All were treated for varying periods of time with antacids and cholestyramine without success. Although all seven patients had a history of alcoholism, none had abnormal liver function tests or other significant gastrointestinal diseases. One patient in group A underwent cholecystectomy for cholelithiasis. Analytical Procedures. All bile samples were fasting gastric aspirates or were collected at the time of endoscopy. The samples were either immediately frozen at -40°C or diluted in a 1:9 (vol:vol) ratio with ethanol and stored at 4oc. Quantitative Analysis. Total bile concentration was determined by an enzymatic method using steroid dehydrogenase [II]. Cholesterol does not interfere with the determination. The final bile acid concentration is expressed in millimoles. Qualitative Analysis. One milliliter aliquots of the diluted bile samples were evaporated to dryness and hydrolyzed with 2 N sodium hydroxide and 50 per cent methanol for 4 hours at 120°C. After acidification, the bile acids were extracted with ether and methylated using diazomethane [12]. After acetylation, the samples were analyzed by gas-liquid chromatography. The samples were injected into a 6 foot glass column packed with 3 per cent OV-17 on SO/l00 Gas-chrom Q. The column temperature was 273’C and hydrogen gas (Hz) flow was 30 ml/min. The identification of individual bile acids of each sample was determined by comparing the retention time with standards of cholic, chenodeoxycholic, deoxycholic, and lithocholic acids. Composition percentage was calculated by measuring the areas of the peaks. Breath Test. Two patients in group B had a standard 6 hour cholyl-glycine breath test to assess bacterial overgrowth. Results
All of the patients were male, and there was no significant age difference between the two groups. The barium studies in both groups demonstrated a slight delay in emptying, but no stoma1 obstruction or dilated afferent or efferent loops. None had jejunal diverticula. In group B gastric analysis revealed achlorhydria with histalog stimulation. Endoscopy confirmed reflux of bilious material into the stomach,
The American Journal of Surgery
Postoperative
and the patients in group B had gastritis with mucosal erythema and friability. The inflammatory changes in the stomach were diffuse and not confined to the stoma1 area as in group A. No patient had a marginal ulcer. Two of the patients in group B were operated on and had a Roux-en-Y or Tanner 19 procedure to divert bile for the stomach. Both had a favorable result. The results of the quantitative determination of total bile acids of patients in group A ranged from 0.34 to 2.14 mM (mean, 1.23 mM) and of those in group B from 1.12 to 2.26 mM (mean, 1.75 mM). There was no statistically significant difference between the two groups. The results of qualitative analysis of the bile samples in each group are given in Table I. The mean of the primary bile acids (cholic and chenodeoxycholic acids) was 86.8 per cent in group A and 63.7 per cent in group B, and of the secondary bile acids (deoxycholic and lithocholic acids) 13.2 per cent in group A and 36.3 per cent in group B. Deoxycholic acid accounted for this increase, and lithocholic acid was only slightly changed. The difference in secondary bile acids between group A and group B is statistically significant (p < 0.05). The cholyl-glycine breath test was negative in the two patients tested from group B, indicating that there was no appreciable bacterial overgrowth in the proximal bowel. Comments
Postoperative alkaline reflux gastritis has been characterized by Van Heerden et al [3]. The main features of this syndrome are abdominal discomfort, hypochlorhydria or achlorhydria, exclusion of marginal ulceration, and endoscopic evidence of reflux and gastritis. Medical treatment with antacids or cholestyramine was generally unsuccessful, however, diversion of duodenal contents from the stomach by a Roux-en-Y loop was successful in 84 per cent of the patients. The actual incidence of postoperative reflux gastritis after operation for duodenal ulcer disease is unknown, although it may be as high as 13 per cent [13] to 20 per cent [2]. The factors that determine which patients will develop clinically significant problems are unknown, but bile has received the most attention [S-10]. Although reflux of bile into the gastric remnant is common after ulcer operation, the mere presence of bile cannot account for the development of reflux gastritis, since only a few patients with reflux develop symptoms. These studies were undertaken to determine if the concentration or composition of bile refluxed into the stomach was
vdume185,Jalnlq11978
TABLE I
Qualitative Profile of Bile Acids
Group (n) A (4) B (3)
Reflux Gastritis
C 33-64 31-33
Composition (%) DC CDC 32-50 16-41
3-17 19-44
Note: C = cholic acid; CDC = chenodeoxycholic deoxychob acid; LC = lithocholic acid.
LC 1-13 6-9 acid: DC =
different in patients without symptoms of gastritis compared with those with symptoms. The concentration of bile acids refluxed into the stomach in groups A and B of the present study is within the concentration range reported in other studies [4,8]. Although bile acids are present in the gastric remnant, their presence does not necessarily result in significant problems, as confirmed by group A of this study. The bile concentration in group A is similar to that in group B and suggests that increased concentrations may not be the major determinant of gastric injury as suggested by Ritchie and Shearburn [8]. One of the parameters we did not assess was volume. It is possible that although the concentration of bile was similar, the total amount of bile acids was different and might be a factor in producing injury. The composition of bile acids was also analyzed. The composition of bile for normal individuals as reported by Sjovall [14] is cholate 41 per cent, chenodeoxycholate 37 per cent, and deoxycholate 22 per cent and as reported by Miettinen and Peltokallio [.~5] is cholate 55 f 12 per cent, chenodeoxycholate 32 f 7 per cent, and deoxycholate 15 f 6 per cent. The percentage of deoxycholic acid in group A patients is in the lower range of these reported values. Although a decrease in deoxycholic acid has been reported for patients with cirrhosis [IS], none of the patients in either group had evidence of cirrhosis. The composition of bile acids in group B shows a marked increase in secondary bile acids, especially deoxycholic acid. Increases in secondary bile acids are also present in stagnant loop syndrome, jejunal diverticulosis, and other conditions predisposing to bacterial overgrowth and result from dehydroxylation [17,18]. Barium studies and endoscopy eliminated the first two causes as potential sources. A negative breath test indicated that significant bacterial overgrowth in the proximal small bowel was not occurring. These observations are consistent with other reports [17,18]. The conversion of cholic acid to deoxycholic acid requires 7-a-dehydroxylation. In patients with partial gastrectomy, this conversion, although variable, is generally low [18]. In contrast, deconjugation by radioisotope technics is significant in this same group of
49
Gadaczand Zuidema
patients; however, aspirates from the proximal jejunum were mostly conjugated [la]. Deconjugation in the distal small bowel or rapid absorption of unconjugated forms from the upper tract may explain this discrepancy. The increase in deoxycholic acid and the normal breath test in group B suggest that neither deconjugation nor dehydroxylation occurs in the proximal small bowel. The bacteria that usually colonize the proximal small bowel do not have the metabolic capability to deconjugate or dehydroxylate. The increase of secondary bile acid in group B could be on the basis of increased intestinal absorption or a relative decrease in hepatic synthesis. The effects of bile acids on the gastric mucosa have been investigated by others [5-101. Most of the observations on the toxicity of bile acids on the stomach have been described in acute studies in which acid secretion is an important factor in producing injury. In our study, an increase in deoxycholic acid was found in the symptomatic group. Whether the increase in deoxycholic acid or the alteration in the relative composition of bile is the important factor is not known. There are several studies demonstrating the toxicity of deoxycholic acid. Silen and Forte [9] reported that deoxycholic acid was more potent on a molar basis than cholic acid in damaging the amphibian mucosal membrane. Dawson and Isselbacher [18] also reported that deoxycholic acid as compared with cholic acid was capable of not only inhibiting esterification but also caused dissolution and necrosis of jejunal villi. In another study, the potential toxicity of deoxycholic acid in the small bowel was emphasized [19]. In contrast to these reports, greater changes in gastric ionic flux in normal human subjects were observed with taurocholic acid than with taurodeoxycholic acid [6]._However, all these observations were recorded for normal subjects; our group of patients are not comparable since they have chronic gastritis and are achlorhydric. The increase in deoxycholic acid may be a factor that results in the development of reflux alkaline gastritis, and it is in this group of patients that diversion of bile from the stomach will be highly successful.
Summary
Reflux of bile into the stomach is common after surgery for duodenal ulcer disease; however, only a minority of patients may develop significant gastritis and pain. Gastric aspirates from two groups of patients after operation for duodenal ulcer were quantitatively and qualitatively analyzed. Group A patients were asymptomatic and the bile composition
50
was normal. Group B patients were symptomatic and had a significant increase in the secondary bile acid, deoxycholic acid. The concentration of bile acid was similar in the two groups. This alteration in bile acid composition, with an increase in deoxycholic acid, may be an important factor in determining which patients with bile reflux develop gastritis. Acknowledgment: Dean Burns gave valuable assistance with the bile acid analysis. References 1. Wall AJ, Ungar B, Baird CW, et al: Malnutrition after partial gastrectomy. Am J Dig Dis 12: 1077, 1967. 2. Berardi RS, Siroospour D, Rub R, et al: Alkaline reflux gastritis. A study in forty postoperative duodenal ulcer patients. Am J Surg 132: 552, 1976. 3. Van Heerden JA, Phillips SF, Adson MA, Mcllrath DC: Postoperative reflux gastritis, Am J Surg 129: 62, 1975. 4. Rhodes J, Barnard0 D, Phillips S, Roulestad R, Hoffman A: Increased reflux of bile into the stomach in patients with gastric ulcer. Gestroenterology 57: 241, 1969. 5. Davenport HW: Absorption of taurocholate 24°C through the canine gastric mucosa. Proc Sot Exp Biol Med 125: 670, 1967. 6. lvey KJ, DenBesten L, Clifton JA: Effect of bile salts on ionic movement across the human gastric mucosa. Gastroenterology 59: 663, 1970. 7. DenBesten L, Hamza KN: Effect of bile salts on ionic permeability of canine gastric mucosa during experimental shock. Gastroenterology 62: 417, 1972. 8. Ritchie WR, Shearburn EW: Acute gastric mucosal ulcerogenesis is dependent on the concentration of bile salt. Surgery 80: 98, 1976. 9. Silen W, Forte G: Effects of bile salts on amphibian gastric mucosa. Am J Physiol228: 637.1974. 10. Eastwood GL: Effect of pH on bile salt injury to mouse mucosa. A light- and electron-microscopic study. Gestroenterology 68: 1456, 1975. 11. Admirand WH, Small DM: The physiochemical basis of cholesterol gallstone formation in man. J C/in /west 47: 1043, 1968. 12. Schlenk H, Gellerman JL: Esterification of fatty acids with diazomethane on a small scale. Anaf Chem 32: 1412, 1960. 13. Goligher JC, Pulvertaft CN. Irvin TT, Johnson D, Walker B, Hall RA, Willson-Pepper Jr, Matheson TJ: Five to eight year results of truncal vagotomy and pyloroplasty for duodenal ulcer. Br Med J 1: 7, 1972. 14. Sjovall J: Bile acids in man under normal and pathological conditions. C/in Chem Acta 5533, 1960. 15. Miettinen TA, Peltokallio P: Bile salt, water, and vitamin B-12 excretion after ileostomy. &and J Gastroenterol6: 543, 1971. 16. Voshida T, McCormick WC, Swell L, Vlahcevic ZR: Bile acid metabolism in cirrhosis. IV. Characterization of the abnormality in deoxycholic acid metabolism. Gastroenterology 68: 335, 1975. 17. Midtvedt T, Norman A, Nygaard K: Metabolism of glycocholic acid in gastrectomized patients. Stand J Gestrobnterol5: 237, 1970. 18. Dawson AM, lsselbacher KJ: Studies on lipid metabolism in the small intestine with observations on the role of bile salts. J C/in Invest 39: 730, 1960. 19. Lamabadusuriya SP. Guiraldes E, Harries JT: Influence of mixtures of taurocholate, fatty acids, and monolein on the toxic effects of deoxycholate in rat jejunum in vivo. Gestroenterology 69: 463, 1975.
The American Journal of Surgery
Postoperative Reflux Gastritis
Discussion Lawrence W. Way (San Francisco, CA): Certainly we need to learn more about this puzzling clinical problem. The observations discussed have implications regarding etiology, diagnosis, and even therapy. However, the number of patients is so small that the conclusions must be regarded as very tentative. I have several questions. One unsolved problem is the diagnostic criteria for alkaline gastritis. On what basis was the diagnosis made in these patients? Was the degree of gastritis quantifiable and clearly different between the patients in group A and group B? Was biopsy of the gastric mucosa performed in both of these grou&? Was operation performed on the patients in group B, and if so, what was the outcome? There are several other questions regarding the comparability of the two groups. Some of the patients in group B received cholestyramine. Had they received this drug recently? Had antibiotics been administered to either group recently? Did any of these patients have biliary disease or had they had biliary surgery? It was noted that the patients in group B were achlorhydric, which might affect the relative distribution of bile acids. How about group A? What was their gastric acid secretion? Lastly, I would ask the authors if they think that the increased concentration of deoxycholate can be implicated with certainty as a cause of the lesion or is it an effect of another cause? Since the breath tests did not demonstrate bacterial overgrowth, then what is the explanation for increased deoxycholate concentrations in the patients with alkaline reflux? Malcolm Stanley (Hines, IL): Did you separate conjugated and nonconjugated bile acids in your analysis? Free bile acids are more likely to produce tissue injury than conjugated bile acids; probably both bacterial deconjugation and 7-a-dehydroxylation, with formation of secondary bile acids, would occur in an infected afferent loop. Incidentally, did you culture the afferent loop? The breath test would not necessarily be positive if your labeled bile acids administered by mouth bypassed the contaminated afferent loop and went through the gastrojejunostomy directly into the small bowel which was not overgrown. Frank G. Moody (Salt Lake City, UT): To reiterate Doctor Way’s question, 1 have had two patients who developed problems with bile gastritis after cholecystectomy. 1 wonder if in some way the cholecystectomy might have contributed to the bile residing in the duodenal loop overnight, this being a nocturnal problem, possibly with the production of secondary bile acids. I would like to have a specific answer regarding whether any of these patients had cholecystectomies. Kevin P. Morrisey (New York, NY): 1 do not think, as has already been asked, that these groups are comparable. 1 can partially answer Doctor Moody’s question as to how
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199. Janu8rv
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many of these patients have had cholecystectomies. It is known that cholecystectomy will increase the percentage of secondary bile acids in favor of deoxycholic and lithocholic acid. 1 am also curious about where the secondary bile acids are formed. Are they formed in the gastric pouch or are they the result of increased bacterial overgrowth in the colon? 1 think it would be difficult to get a pure bile sample from these patients, but one might be able to measure their fecal bile acid concentration and see whether the increase in deoxycholic acid is actually coming from the bowel. It might make a difference in considering antibiotic treatment rather than a completely new operation in caring for these patients. William A. Altemeier (Cincinnati, OH): Did any of these patients undergo an antecolic Billroth 11type of operation in addition to cholecystectomy? It has been my observation in patients with bile gastritis, particularly group Ill patients in whom there is the most severe biopsy evidence of inflammation of the gastric mucosa, that they have previously undergone tin antecolic long-loop Billroth 11operation. Correction of this by resection of the previous gastroenterostomy and development of the formation of a retrocolic short-loop gastrojejunostomy resulted in the disappearance of the symptoms and of evidence of the bile gastritis. M. M. Eisenberg (Denver, CO): The implications of bile gastritis after surgery for duodenal ulcer may extend well beyond the immediate and early postoperative period. We have recently collected more than forty cases of gastric carcinoma occurring in the remnant of subtotal gastrectomy patients twenty or more years after operation, and 1 wonder if the authors would care to speculate on the possible long-term carcinogenic effects of bile acids bathing the gastric mucosa and the possible implications of the histamine-fast achlorhydria observed in these patients. Thomas R. Gadacz (closing): 1 agree with the criticism that the number of patients is small. Whether the elevation of deoxycholic acid is a causative or associative factor is not certain; however, we are studying other well documented cases of reflux gastritis. At present, we are taking bile samples at the time of operation. We are going to try to follow these sequentially to see if the alteration in bile composition is initially present or if the change occurs later. Correlation of the change in composition with the onset of symptoms should provide additional information concerning the importance of our observations. The main reason we had such a smail group of patients is that many of the patients referred to us for evaluation for bile gastritis really did not have it. Many had bile in the gastric remnant but they also had other things-stoma1 dysfunction, a long afferent loop, and chronic pancreatitis. Those we are reporting on were evaluated for other postgastrectumy problems as well as the characteristic findings of reflux gastritis.
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Gadacz and Zuidema
Although there may not be a good correlation between the reflux of bile, the endoscopic appearance of gastritis, and symptoms, two of the patients in group A had biopsies which showed chronic gastritis. There were two differences between the groups that underwent endoscopy and biopsy. All of those in group B, the symptomatic patients, had bile reflux and their entire gastric mucosa was inflamed, reddened, and friable. Biopsy showed acute as well as chronic gastritis. The patients in group A did have stoma1 erythema, but the process did not involve their entire gastric mucosa. The two who were biopsied showed only chronic gastritis. None of the patients in group B had cholecystectomy. One patient in group A had cholecystectomy but had no problems. Cholecystectomy in a patient who was previously doing well after an ulcer operation may result in reflux gastritis. Although this is a well recognized clinical observation, this was not observed in our small group of patients. The patients in group B were treated with cholestyramine for several months or as long as they could tolerate it, and treatment was discontinued several months before
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bile samples were collected. All the patients in group B had been followed for six months to two years by the gastroenterologists. We did not do gastric analysis on the patients in group A, although their pH was neutral. All of the patients in group B had standard gastric analyses and were achlorhydric. Bacterial deconjugation and dehydroxylation does not seem to occur in the proximal small bowel. Some preliminary work indicates that the changes in bile composition are not the result of bacterial overgrowth in the afferent loop or gastric remnant. Samples from the gastric remnant were cultured aerobically and anaerobically. The isolates were incubated in bile acid media, and deconjugation and dehydroxylation was not observed. This correlates with the normal cholyl-glycine breath test results. Whether bile reflux predisposes to cancer is very speculative. It has been shown that certain bile acids are toxic to gastric and small bowel mucosa, but the changes they produce are usually inflammatory and not neoplastic. All the patients in both groups had vagotomy and retrocolic Billroth II operation.
The American Journal of Surgery
