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Abstract & Commentary
Synopsis: Acid, not bile, is the determinant of most symptomatic gastroesophageal reflux. It remains clear that acid control is the mainstay of GERD therapy.
Source: Koek GH, et al. Am J Gastroenterol. 2001;96: 2033-2040.
Mixed reflux of acid and duodenal contents frequently can be found in gastroesophageal disease (GERD), and many surgeons have strongly supported the view that so-called "bile reflux" is particularly important in GERD pathogenesis. More importantly, they have stated that such "bile reflux" cannot be eliminated by antisecretory therapy. This Dutch study used pH monitoring and simultaneous assessment of duodenogastric reflux in 72 symptomatic patients using the Bilitech® system. Five hundred forty-four symptom episodes were identified. Of these symptoms, 28% were temporarily associated with acid reflux, 9% with duodenal gastroesophageal reflux (DGER), and 12% with mixed reflux. A positive symptom-association probability for acid reflux was present in 22% of patients, for DGER in 7% of patients, and for mixed acid and "bile" reflux in 10% of patients. Koek and colleagues conclude that there is little likelihood that DGER ("bile reflux") will prove to be clinically important in symptom causation for many patients.
Comment by Malcolm Robinson, MD, FACP, FACG
Controversy has raged about the importance of "bile reflux" in the pathogenesis of GERD, particularly severe GERD including Barrett’s esophagus. This study seems to put this notion to rest once and for all. Only 7% of all reflux episodes involved DGER as measured by the Bilitech probe. In a number of previous studies, it has been pointed out that severity of GERD depends on the total duration of reflux, particularly prolonged in Barrett’s esophagus. Barrett’s patients do have more DGER than patients with lesser degrees of GERD but they also have more acid reflux. Indeed, Richter and his colleagues at the Cleveland Clinic have shown that PPI therapy decreases DGER as much as it does acid reflux (presumably by the profound effects of PPI administration on gastric volume).1 It is clear from the present study, done by well-known European investigators, that symptoms of GERD are mostly acid related and not likely to represent any sort of "bile reflux." It would seem to be a rational corollary that aggressive antisecretory therapy remains the mainstay of GERD treatment.
1. Richter JE. Dig Dis. 2000-2001;18(4):208-216.