Bile in the oesophagus contributes to the development and complications of gastro-oesophageal reflux disease

Objective: To clarify the relationship between duodenogastro- oesophageal reflux (DGOR) and gastro- oesophageal reflux disease (GORD) and its complications.

Methods: As persons who have had their gallbladders removed have been shown to have an increased incidence of duodenogastric reflux, one would expect them to have an increased incidence of DGOR. Two epidemiological studies, one case-control and one population based, attempted to show an association between cholecystectomy and oesophageal cancer. Furthermore, patients with reflux symptoms twice weekly or more, for at least 6 months, and healthy volunteers were recruited and examined. Upper gastrointestinal endoscopy, circadian oesophageal acidity values, bilirubin levels, oesophageal motility and a study of gastric emptying using a scintigraphic method, were performed to assess DGOR, GORD and foregut motility parameters.

Results: A 30% increase in standard incidence ratio was found for cholecystectomised patients as regards to the risk for developing adenocarcinoma of the oesophagus. This increase was not seen for squamous cell carcinoma of the oesophagus. Neither did nonoperated patients with gall-stone disease show any increased risk for the two cancers. The amount of bilirubin detected in the oesophagus showed a significant correlation to impaired oesophageal motility, as measured by the degree of efficiency of its peristaltic contractions. In a multivariate analysis it was found that this effect was correlated to bile reflux but not to acid reflux. Gastric emptying parameters, proximal and total, showed no differences in patients with DGOR compared to a normal material. No correlation was found between the degree of acid or bile reflux in the oesophagus and gastric emptying parameters. Finally, a noramal control group was descriped for combined ambulatory recordings of pH, bilirubin and oesophageal motility.

Conclusions: DGOR is of importance in GORD. An increased risk for adenocarcinoma of the oesophagus following cholecystectomy may result from an increase in DGOR. This increased risk is small and does not necessitate any change in our current management of gall stone disease. Impaired oesophageal motility seen with GORD is associated with DGOR but not with acid reflux, however it does not improve after correction for DGOR It is not clear if this impairment is due to structural changes in the oesophageal wall as a result of DGOR or a preexisting condition. There seems to be no general disturbance of foregut motility with DGOR and no correlation between gastric emptying and biliary reflux. DGOR should be taken into consideration when treating patients with reflux disease.

List of scientific papers

I. Freedman J, Lagergren J, Bergstrom R, Naslund E, Nyren O (2000). Cholecystectomy, peptic ulcer disease and the risk of adenocarcinoma of the oesophagus and gastric cardia. Br J Surg. 87(8): 1087-93.
https://pubmed.ncbi.nlm.nih.gov/10931056

II. Freedman J, Ye W, Naslund E, Lagergren J (2001). Association between cholecystectomy and adenocarcinoma of the esophagus. Gastroenterology. 121(3): 548-53.
https://pubmed.ncbi.nlm.nih.gov/11522738

III. Freedman J, Lindqvist M, Hellstrom PM, Granstrom L, Naslund E (2002). The presence of bile in the oesophagus is associated with less effective oesophageal motility. Digestion. [Accepted]

IV. Freedman J, Gryback P, Lindqvist M, Granstrom L, Lagergren J, Hellstrom PM, Jacobsson H, Naslund E (2002). Gastric emptying and duodeno-gastroesophageal reflux in gastroesophageal reflux disease. Digestive and Liver Disease. [Accepted]

V. Freedman J, Lindqvist M, Melcher A, Granstrom L, Naslund E (2002). Normal values for ambulatory combined 24-h pH, bile and manometric monotoring of the oesophagus in males and females. [Manuscript]