| Objective:The duodenogastric reflux (DGR) included into the primary DGR and secondary DGR, and the latter existed mostly after cholecystectomy and gastrectomy, and were studied in the world, but little was known about pathogenesis of primary DGR and its effect on the gastric mucosa of the health. The aim of this study was to investigate the characteristics of DGR in the healthy and define a normal values for 24-hour enterogastric bile reflux monitoring with portable Bilitec 2000 and pH monitor, to probe whether DGR result in pathological injury of gastric mucosa, or provide a protection to gastric mucosa. If there was injurious effect on mucosa, we tried to elicit which components in duodenal juice played the important role, and to study the relationship between the alteration of these components and the value of pH and bilirubin absorbance (ABS). Methods:1 DGR was measured using ambulatory bilirubin monitor (Bilitec 2000) and pH monitor in the proximal stomach simultaneously in healthy volunteers. Within three thresholds for absorbance(0.14,0.20,0.25), the total, upright, supine, meal and postprandial period were analyzed with the parameters as follows, the percentage time of bilirubin absorbance ≥threshold(0.14,0.20,0.25), reflux frequency, long reflux frequency, longest reflux time , maximum , mean and median value of absorbance. The simultaneous changes of gastric pH and bilirubin absorbance value were studied to describe the relationship between them. The volunteers had two "jumbo"biopsies taken from the gastric antrum for examination with H&E in order to determine the inflammation of gastric mucoma. 2 Ten patients with primary pathologic DGR was measured for 24 hours using ambulatory bilirubin monitor (Bilitec 2000) and pH monitor simultaneously, combined intraluminal gastric aspiration. The simultaneous changes of gastric intraluminal pH and bilirubin absorbance value were studied to describe the relationship between them. The percentage time of bilirubin absorbance≥0.25, reflux frequency, long reflux frequency, longest reflux time,maximum,mean and median value of absorbance were recorded. According to the relationship with intragastric pH and bilirubin absorbance value (ABS), all data were divided into four phases (A: pH≥4, ABS≥0.14; B: pH≥4, ABS<0.14; C: pH<4, ABS≥0.14; D: pH<4, ABS<0.14). Aspiration was performed hourly and at any time when bilirubin and/or pH monitoring showed signs of DGR. The concentration of bile acid (TBA), and bilirubin in aspirate were measured by automatic biochemistry analyzer, and the relationship of the concentration and gastric pH, bilirubin absorbance were further studied. 3 Fourteen patients with primary pathologic DGR was measured for 24 hours using ambulatory bilirubin monitor (Bilitec 2000) and pH monitor simultaneously, combined intraluminal gastric aspiration. The simultaneous changes of gastric intraluminal pH and bilirubin absorbance value were studied to describe the relationship between them. According to the method mentioned above, all data were divided into four phases. Aspiration was performed hourly and at any time when bilirubin and/or pH monitoring showed signs of DGR. The concentration of amyase (AMY) and lipase (LIP) in aspirate were measured by automatic biochemistry analyzer, and the relationship of the concentration of AMY and/or LIP, gastric pH and bilirubin absorbance were further studied. Results:1 There was a wide range of normal bile exposure within each threshold of ABS(0.14,0.20 and 0.25). The percentages of total period of bile reflux, median values, interquartile ranges, and 95th percentile values for thresholds of 0.14, 0.20 and 0.25 were 32.70%, 19.40%-44.60%, 64.14%; 13.60%, 7.90%-27.08%, 49.24%; 7.60%, 3.60%-16.60%, 33.32%, respectively. Percentages of total period of bile reflux conformed to normal distribution (Kolmogorov-Smimov normal test, P>0.05), therefore, the upper limits of 95% normal range at each thresholds(0.14,0.20,0.25)were 60.81%,41.20%,26.88%. Based on the above results, it was suggested that using 0.25 as the threshold for absorbance of Bilitec 2000, the upper limits of 95% normal range for physiologic DGR in healthy would be a percentage of total time of bile reflux of 26.88%. The following analyses were all based on threshold 0.25. Of all physiologic reflux events, short reflux events (<5min) were common in upright, reflux episodes with duration more than 45min were more frequently seen during supine phases (P<0.05). For all reflux episodes, the mean absorbance was 49.1min with a maximum of 169min.Reflux frequency of upright was more than supine, while longest reflux time in supine was greater than in upright. Comparison of bile and pH recording(absorbance≥0.25 and/or≥4), there were four types of reflux in healthy: Simultaneous increase and decrease of absorbance and pH, increase of absorbance with decrease of pH and pH increase with a decrease of Absorbance. During nighttime, there existed discrepancies between gastric alkalization (pH increase) and bile reflux (bilirubin Absorbance increase). Whether bile reflux episode existed, or gastric alkalization occurred, there was no relationship between them (P>0.05). 2 Analysis of bile components in primary pathological DGR. According to the correlation of pH and ABS , it was divided into four phases .Phases A: pH≥4,ABS≥0.25;Phases B: pH≥4,ABS<0.25;Phases C: pH<4,ABS≥0.25;Phases D: pH<4,ABS<0.25 .The concentration of TBIL in phase A (17.24±9.79μmol/L) was significantly higher than those in other phases (P<0.05). The concentration of TBIL in phase C (10.95±9.67μmol/L) was higher than those in phase B (7.06±5.80μmol/L) and D (8.81±6.62μmol/L). The concentration of DBIL in phase A (12.72±8.51μmol/L) was significantly higher than those in other phases (P<0.05). The concentration of DBIL in phase C (9.14±5.02μmol/L) was higher than those in phase B(3.65±2.16μmol/L) and D(5.39±5.15μmol/L). It is demonstrated that the high ABS phase had a high concentration level of TBIL and DBIL. The concentrations of bile acid (TBA) in phase A (129.20±74.96μmol/L) and phaseC (140.59±83.68μmol/L) were much higher than those in phase B (72.31±62.59μmol/L) and phase D (95.96±73.50μmol/L) (P<0.05). The percentage time of bilirubin absorbance ≥0.25 in primary pathological DGR were 32.55±21.13%,which were significantly greater than physiological DGR(12.67±6.52%) , the long reflux frequency(0.61±0.35) and longest reflux time(116.33±96.67min) in primary pathological DGR were significantly greater than physiological DGR(0.21±0.20 and 49.08±44.34),there were no significant difference between two for reflux frequency , maximum,mean and median value of absorbance. The concentration of TBA in severe gastritis group(165.58±55.02μmol/L)was much higher than those in mild(92.43±42.60μmol/L) and moderate group(102.43±31.35μmol/L), but the other variables had not shown any difference in those groups. That illustrated excessive bile reflux was related to the injured lesion of gastric mucosa. The concentrations of ABS in experimental groups were positively correlated with TBA (r=0.3060, P=0.0476), TBIL (r=0.4015, P=0.0113) and DBIL (r=0.3060, P=0.0482). 3 Analysis of pancreatic contents in primary pathological DGR. The concentration of AMY in phase B (150.68±102.53 u/L) was significantly higher than those in phase A (81.87±58.29u/L), phase C (50.04±33.63 u/L) and phase D (94.91±70.25 u/L) (P<0.05). As far as the concentration of LIP was concerned, there were no differences in phases. The concentrations of AMY in mild, moderate and severe gastritis were 112.83±35.27 U/L, 135.02±50.10 U/L and 134.44±64.07 U/L ,respectively, and those of LIP in three groups were 67.44±35.71 U/L, 72.83±24.75 U/L and 57.24±48.63U/L (P>0.05). There was no difference in those three groups for LIP and AMY. The concentrations of AMY and LIP in daytime were 150.69±102.53 U/L and 94.74 ±55.30U/L, which were higher than those in the nighttime(81.87±69.28 U/L and 40.98±10.24U/L) (P<0.05), whereas the concentrations of TBA,TBIL and DBIL in nighttime were 129.20±74.57μmol/L, 17.23 ±9.78 μmol/L and 12.72 ±8.57 μmol/L, which were respectively greater than those in the daytime(72.31±39.52μmol/L, 8.81±6.20μmol/Land 5.39±3.15μmol/L) (P<0.05). It was showed the pancreatic juice reflux happened more frequently in daytime, whereas bile reflux occurred more frequently during night. The pH in experimental group was positively correlated with concentration of AMY (r=0.452,P=0.001), but not correlated with other indexes, which might result from that the intra-gastric pH was affected by pancreatic juice reflux rather than the bile reflux. Conclusion:1 There was a wide range of physiologic DGR. When DGR was detected by Bilitec 2000, we suggested using 0.25 as the threshold for Absorbance. The upper limits for physiologic DGR among health are percentage of total time of bile reflux of 26.88% (95% normal range). Physiologic DGR in upright phase is characterized by increase of short reflux frequency, and reflux episode usually occurs in supine position. Poor correlation is showed between intragastric pH increase and bile reflux. Mixtures of DGR can consist of bile and bicarbonate, pancreatic juice which may separately contribute to duodenogastric reflux, so bile and bicarbonate,pancreatic juice in stomach may change in different condition. Nocturnal DGR may be related with phase II of MMC and duodenal phase III retroperistalsis and may play a role in protection of the antral mucoma. Physiologic DGR cannot induce inflammation of mucoma. 2 There was positive correlation between the concentration of total bilirubin and bilirubin absorbance, which indicated Bilitec 2000 was a more credible equipment to monitor intragastric bilirubin and bile reflux. Bilitec 2000 can apply to clinical diagnosis, treatment and research of DGR. The concentration of bile acid in group with severe gastritis was much higher than those in groups with mild and moderate gastritis, which illustrated excessive bile reflux was related to the lesion of gastric mucosa. Therefore, bilirubin was a helpful monitoring marker for diagnosis of gastritis with bile reflux, not a factor for resulting in gastritis.
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