Duodenogastric reflux: signs, treatment regimens, diet

In gastroenterology, the entry of the contents of the duodenum back into the stomach - through the pyloric sphincter separating them - is defined as duodenogastric reflux (in Latin refluxus means "back flow").

Since digestion occurs in the duodenum with the participation of bile, and with retrograde movement it also appears in the stomach cavity, this pathology can be called bile or biliary reflux (from Latin bilis - bile).

It is quite often that bile in the stomach is revealed in gastroscopy in people with gastritis, gastric ulcer, gastroesophageal reflux disease.

[1], [2], [3]

Epidemiology

Duodenogastric reflux is not a separate nosological unit (and, accordingly, does not have the ICD-10 code). Some experts refer him to syndromes (manifested in diseases of the stomach and duodenum), others - to the causes of functional dyspepsia. Also, it is considered to be a reflux pathology, which determines the development of gastroduodenal peptic ulcers and  gastroesophageal reflux disease  (GERD). Although GERD is the result of a violation of the functions of the cardiac (lower esophageal) sphincter, which allows the contents of the stomach to get back into the esophagus.

Studies show that most cases of duodenogastric reflux occur simultaneously with acid reflux, characteristic of GERD. And as a self-emerging pathology, pronounced duodenogastric reflux

Is diagnosed in no more than a quarter of patients with retrograde phenomena of the gastrointestinal tract.

According to the World Journal of Gastroenterology, almost a third of the population of the United States have some symptoms of gastroesophageal reflux, and the presence of diagnosed duodenogastric reflux does not exceed 10% of patients. But at the same time gastroenterologists detect bile in the esophagus in 70% of cases of persistent chronic heartburn and  Barrett's esophagus.

[4], [5], [6], [7]

Causes of the duodenogastric reflux

In a normal state, the pyloric sphincter or porcine performs its barrier functions clearly and does not allow the stomach to enter the stomach that has already passed to the next stage of the digestive cycle in the initial section of the small intestine, the duodenum. Here, enzymes of the pancreas (phospholipase, trypsin and lysophosphatidylcholine) and bile are added to the gastric chyme with hydrochloric acid and pepsin.

According to gastroenterologists, occasionally bile in small amounts and very briefly - without causing symptoms - may be present in the stomach, for example, because of physiological retrograde peristalsis. But bile reflux, which occurs cyclically, is a pathology.

And the key causes of duodenogastric reflux are related:

• with functional failure of the pyloric sphincter (most often due to violations of parasympathetic regulation of contractions of its muscular ring, genetic defect, sphincter ulcer or presence of a scar on the site of ulceration);
• with increased motility of the duodenum with hyperkinetic type of her peristalsis;
• with increased pressure in the lumen of the duodenum (duodenal hypertension), which may be due to lumbar lordosis or omission of internal organs (splanchnoptosis), as well as hernias and malignant neoplasms;
• with inconsistency of physiological cycles of contraction and relaxation of the stomach and duodenum (migrating motor complex);
• with the lack or lack of hormones (in many cases - gastrin);
• with the presence of a long-flowing inflammation of the duodenum -  chronic duodenitis, gastroduodenitis, duodenal ulcer.

In addition to the above reasons, duodenogastric reflux in children can develop:

• because of helminthic invasion or giardiasis;
• due to  anomalies in the development of the duodenum;
• with congenital Ledd's syndrome -  incomplete bowel turn  and short bowel syndrome.

However, in a child or adolescent, the retrograde movement of the contents of the duodenum may occur during the endoscopic examination of the upper GI tract, and as a rule, the diagnosis of bile reflux is not supported by other methods.

[8], [9]

Risk factors

It should be borne in mind such risk factors for duodenogastric reflux as:

• overeating, fatty and spicy food (cause bile hypersecretion);
• irregular eating and eating dry;
• alcohol abuse and smoking;
• long-term use of non-steroidal anti-inflammatory drugs or antispasmodics;
• elderly age.

Also, risk factors include surgery to remove part of the stomach (resection), remove the gallbladder (cholecystectomy), superimpose anastomoses of the stomach and intestines; inflammation of the gallbladder (cholecystitis) and dyskinesia of bile ducts; pancreatic insufficiency and pancreatitis; obesity and diabetes.

[10], [11], [12], [13], [14], [15], [16]

Pathogenesis

To date, not all cases of this syndrome can accurately determine its etiology and pathogenesis. However, there is a clear connection between the onset of duodenogastric reflux with changes in the secretory activity of the stomach and duodenum and the violation of gastroduodenal motor reflexes, which are realized through the most complex neuroendocrine system of the gastrointestinal tract and sympathetic innervation from the abdominal ganglia.

The pyloric sphincter is controlled by the vagus nerve, vegetative and parasympathetic nervous system and is mediated by various neurotransmitters and neuropeptide hormones and their receptors. Thus, it maintains the tone of the gatekeeper, regulates gastric secretion and increases peristalsis (including gallbladder) produced in the stomach gastrin. A hormone of the pancreas glucagon and produced in the duodenum cholecystokinin inhibit the closure of the sphincter. In addition, in the activation and inhibition of motor activity, acetylcholine, dopamine, motilin, secretin, histamine and other hormones are involved. In fact, the normal peristaltic activity of all digestive organs depends on their balance.

In some patients after the removal of the gallbladder, mild duodenogastric reflux develops due to impaired motility of the pyloric canal of the stomach and changes in pressure in the duodenum.

Often there is a temporary duodenogastric reflux during pregnancy (in the last trimester), which is due to the increase in the size of the uterus and its pressure on all the organs of the abdominal cavity, including the duodenum, provoking regurgitation of its contents into the stomach cavity.

[17], [18], [19], [20], [21], [22], [23]

Symptoms of the duodenogastric reflux

Symptoms of duodenogastric reflux are not specific, and clinically this pathology can be manifested:

• frequent heartburn;
• periodic nausea;
• belching bitter;
• a bitter taste in the mouth (especially after a morning awakening);
• yellow bloom on the tongue;
• spontaneous vomiting (often with the presence of greenish-yellow impurities of bile in vomit masses);
• deterioration of appetite and weight loss.

The first signs can be felt in the form of a feeling of discomfort and severity in the stomach after eating. And pains with duodenogastric reflux are localized in the upper abdomen, have a recurrent nature and can be quite intense, especially shortly after ingestion - up to a sharp and burning pain in the epigastric region.

The manifestations of this pathology and the presence of these or other symptoms depend on the degree, which is determined quite arbitrarily - by the volume of bile acids, detected in different parts of the stomach. Thus, duodenogastric reflux of the 1st degree corresponds with the minimum amount of bile in the pyloric section of the stomach adjacent to the pyloric. If bile is found higher (in the antrum and fundus), duodenogastric reflux of grade 2 can be determined, and when regurgitation reaches the bottom of the stomach and lower esophageal (cardiac) sphincter, then this is the third degree of biliary reflux.

[24]

Complications and consequences

The main consequences and complications of this pathology are irritation and inflammation of the gastric mucosa, since the combination of hydrochloric acid with conjugated bile acids in the refluxate composition has an extremely negative effect on the mucosa. You can find the definition: reflux gastritis or mixed gastritis duodenogastric reflux, which is also called chemical or bile reflux gastritis or reactive gastropathy. This is the most common consequence of throwing duodenal contents into the stomach cavity.

Also complications of duodenogastric reflux are:

• gastroesophageal reflux disease;
• erosive gastritis;
• ulceration of the mucosa of the pyloric and antral parts of the stomach;
• narrowing of the esophagus and metaplasia of its mucosa with the development of Barrett's esophagus (with grade 3 bile reflux and development of GREB).
• increased risk of precancerous conditions of the mucous membrane and gastric oncology.

[25], [26], [27], [28], [29], [30], [31]

Diagnostics of the duodenogastric reflux

Diagnosis of duodenogastric reflux involves a comprehensive gastroenterological examination, including tests:

• blood (general and biochemical);
• urine and feces;
• respiratory test for N. Hilory.

It is necessary to study the contents of the stomach for the presence of bile acids, bilirubin and sodium (using probing). A 24-hour pH measurement of the stomach and esophagus is also performed.

Instrumental diagnostics with the use of:

• fluoroscopy of the stomach and duodenum;
• ultrasonography of the abdominal cavity organs;
• endoscopic gastroscopy;
• electrogastrography;
• dynamic scintigraphy;
• anthroduodenal manometry.

[32], [33], [34]

Differential diagnosis

Differential diagnosis is performed to determine the acid reflux, which, if you take into account only the symptoms and complaints of patients, is easily confused with bile.

Treatment of the duodenogastric reflux

Conservative treatment of duodenogastric reflux is aimed at reducing the symptoms of this functional disorder. For this purpose, certain drugs are used.

The drug Ursofalk (other trade names - Ursahol, Ursolit, Ursolvan, Cholatsid)

Take one capsule (250 mg) once a day (in the evening). Among its contraindications are indicated acute cholecystitis, dyskinesia of the bile duct, gallstones and pregnancy. And the main side effects are hives, pain in the stomach and mild diarrhea.

Activate the motor system of the digestive tract tablets Ganaton (Itopride, Itomed, Primer), which appoint one tablet three times a day (one hour before meals). The drug is not used for gastric bleeding, intestinal stenosis, pregnant in the first trimester and patients younger than 16 years. There may be side effects in the form of an intestinal and dysuria disorder, epigastric pain, dry mouth, insomnia.

For the coordination of gastroduodenal motility, the drug Metoclopramide (Cerucal, Gastrosil) is used. Dose for adults - a tablet (10 mg) three times a day; for children older than three years - 0.1-0.5 mg per kilogram of body weight. The medicine should be taken 30 minutes before meals. Contraindications include intestinal obstruction, pheochromocytoma, epilepsy, pregnancy (the first three months) and the period of breastfeeding, as well as children under three. Metoclopramide can cause side effects, in particular: headache, fatigue, depression and anxiety, heart palpitations, dry mouth, diarrhea, menstrual irregularities.

Gastroprotective agent Sukralfat (Sukrafil, Sukrat, Ulgastran, etc.) promotes the release of the stomach from bile and the protection of its mucosa from inflammation. It is taken 500 mg to four times a day (before each meal and at night). This drug is contraindicated in the treatment of duodenogastric reflux with intestinal stenosis, difficulty swallowing, kidney failure, pregnancy and lactation, children under four years. Possible side effects are violations of the intestine, nausea and dry mouth, head and stomach pain and pain in the lumbar region.

Spasmolytic Trimebutin (Trimedat) can be used in patients older than 12 years - 0.1-0.2 g three times a day; children 5-12 years - 50 mg, 3-5 years - 25 mg three times a day. Of the side effects noted the appearance of rashes on the skin.

Homeopathy in the treatment of bile reflux is represented by Gastritol (in the form of drops), containing extracts of such medicinal plants as the carrot, chamomile, wormwood, St. John's wort, as well as extracts from the roots of licorice, angelica and thistle. The medication is taken only by patients older than 12 years - 25 drops three times a day (before meals). Drops are contraindicated for hypertension, cholelithiasis and pregnancy. Side effects include nausea, vomiting, abdominal pain, dizziness.

With duodenogastric reflux, vitamins such as E, A, B vitamins and vitamin U (methionine) are especially useful.

Physiotherapeutic treatment consists in the use of natural alkaline mineral waters (Borzhomi, Svaliava, Luzhanskaya, Polyana-Kvasova, etc.).

Surgical treatment can be an extreme measure - if nothing else reduces the severe symptoms of bile reflux or when precancerous changes in the gastrointestinal tract are detected.

Alternative treatment of duodenogastric reflux

What does alternative treatment offer to eliminate the main symptoms of duodenogastric reflux? For breakfast, there is oatmeal, natural yogurt or kefir, as well as baked apples (pectin contained in them neutralizes bile acids). It is advised to systematically use honey - in the form of honey water (a teaspoon per glass of slightly warm boiled water), which should be drunk in the evening. And with heartburn, drink a small gulp of a glass of warm water: it will help wash the bile from the stomach mucosa.

It is also recommended to treat duodenogastric reflux with linseed oil, which contains omega-3 fatty acids (oleic, linoleic and alpha-linolenic). These fatty acids have strong anti-inflammatory properties and, in addition, have a calming effect on the stomach.

Herbal treatment also helps to relieve the condition with bile reflux. In the first place - tea from a chemist's daisy (a couple of cups a day). Licorice root is also considered useful for reflux of bile, but it should be borne in mind that licorice contains glycyrrhizin, which, as is known, reduces the production of testosterone in men.

Cover the mucous of the stomach with decoctions from the root of the althaea or forest mallow (tablespoon of dry crushed roots with 250 ml of water).

The same action is exerted by the alcohol tincture of the red elm bark (Ulmus rubra), for preparation of which it is necessary to take only the inner layer of the bark of this tree.

[35], [36], [37], [38], [39], [40], [41], [42], [43]

Diet with duodenogastric reflux

According to experts, unlike acid reflux, a diet with duodenogastric reflux, as a rule, can not completely control the manifestation of symptoms. However, without changes in the diet or way of life can not do.

First of all, you can not overeat. It is also necessary to restrict foods high in fat and spicy foods. More details - in the publication  Diet for heartburn. It is best to include in your menu dishes that will not overload the stomach. The most suitable menu for duodenogastric reflux is given in the article -  Diet with erosive gastritis.

It is recommended to give up alcohol and carbonated drinks, coffee and chocolate. It is most useful to eat small portions 5-6 times a day: it revitalizes digestion, and also prevents excessive formation of bile. And the last meal should be three hours before bedtime.

Special therapeutic exercise with duodenogastric reflux has not been developed, but experts say that one of the best and available to each remedy against excess bile is regular exercise. And they advise you to practice Chinese Qigong health-gymnastics.

[44], [45]

Prevention

That duodenogastric reflux does not cause chronic diseases of the gastrointestinal tract and a significant deterioration in the state of health, its prevention is needed.

The main dietary recommendations were named above. It is also necessary to use a sufficient amount of water - up to two liters per day.

Alcohol and smoking are enemies of the digestive system and your health!

It is not recommended to lie down immediately after meals, so as not to provoke retrograde movement of duodenal contents. Walking is very useful before going to bed, and you should sleep with a raised headboard.

[46], [47], [48], [49], [50], [51]

Forecast

With the right approach and treatment, duodenogastric reflux can be controlled, and then the prognosis regarding its consequences and complications will be favorable.

And the question "duodenogastric reflux and the army" is decided by the medical board depending on the effect of casting bile in the stomach on the general state of health. In any case, conscripts with severe reflux pathologies are sent for examination, which results in decisions on the degree of fitness for service in the army.

[52], [53], [54],