Bile Reflux in GERD: Pathophysiological Mechanism, Clinical Relevance and Therapeutic Implications
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Bile reflux in GERD: Pathophysiological mechanism, clinical relevance and therapeutic implications Citation for published version (APA): Koek, G. H. (2004). Bile reflux in GERD: Pathophysiological mechanism, clinical relevance and therapeutic implications. Maastricht. https://doi.org/10.26481/dis.20040206gk Document status and date: Published: 01/01/2004 DOI: 10.26481/dis.20040206gk Document Version: Publisher's PDF, also known as Version of record Please check the document version of this publication: • A submitted manuscript is the version of the article upon submission and before peer-review. There can be important differences between the submitted version and the official published version of record. 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If the publication is distributed under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license above, please follow below link for the End User Agreement: www.umlib.nl/taverne-license Take down policy If you believe that this document breaches copyright please contact us at: [email protected] providing details and we will investigate your claim. Download date: 08 Oct. 2021 Bile reflux in GERD: Pathophysiological mechanism, clinical relevance and therapeutic implications © Ger H Koek, Maastricht 2004 ISBN 90-9017712-4 Cover design: Rik de Brauwer Production: Datawyse | Universitaire Pers Maastricht Bile reflux in GERD: Pathophysiological mechanism, clinical relevance and therapeutic implications PROEFSCHRIFT ter verkrijging van de graad van doctor aan de Universiteit Maastricht, op gezag van de Rector Magnificus, Prof. Mr. G.P.M.F. Mols, volgens het besluit van net College van Decanen, in het openbaar te verdedigen op vrijdag 6 februari 2004 om 14.00 uur door Ger H Koek Promotores Prof. dr. R.W. Stockbrugger Prof. dr. J. Tack (Leuven) Beoordelingscommissie Prof. dr. J.J. Manni (voorzitter) Prof. dr. J.P. Galmiche, Nantes Dr. J.W. Greve Prof. dr. P.W. de Leeuw Prof. dr. A.J. Smout, Universiteit Utrecht "Lucfor ef Emergo" Ter nagedachtenis aan mijn moeder, Voor mijn voder, Els, Astrid en Clara. Abbreviations ACT = acid clearance time AVCT = acid volume clearance time CCK = cholecystokinin Cmax = maximum count activity COX-2 = cyclooxygenase 2 DC = duodenal content DCCT = duodenal content clearance time DCVCT = duodenal content volume clearance time DGER = duodeno-gastro-esophageal reflux DGR = duodeno-gastric reflux EG = esophago-gastric junction EGF = epidermal growth factor GERD = gastroesophageal reflux disease H2 blockers = histamine 2 receptor antagonist HH = hiatus hernia LES = lower esophagus sphincter MLM = mixed liquid meal MMC = migrating motor complex PPI = proton pump inhibitor SAP = symptom association probability SI = symptom index SSI = symptom-sensitivity index ""Tc-HIDA = ""Tc-[N-(2,6-dimethylphenylcarbamoylmethyl) iminodiacetic acid] TLESR = transient lower esophagus sphincter relaxation UES = upper esophagus sphincter VCT = volume clearance time Contents Chapter 1 Duodeno-gastro-esophageal reflux disease, a review. 9 Chapter 2 Aims of the study and outline of the thesis. 55 Chapter 3 Mechanisms underlying duodeno-gastric reflux in man. 59 Chapter 4 Esophageal clearance of acid and bile: a combined radionuclide, pH and Bilitec" study. 77 Chapter 5 Dietary restrictions during ambulatory monitoring of duodeno-gastro-esophageal reflux. 93 Chapter 6 Analysis of ambulatory duodeno-gastro-esophageal reflux monitoring. Ill Chapter 7 The role of acid- and duodeno-gastro-esophageal reflux in symptomatic gastro-esophageal reflux disease. 125 Chapter 8 Determining factors in the etiology of esophagitis and Barrett's esophagus. 143 Chapter 9 Gastro-esophageal reflux disease refractory to proton pump inhibitors: acid reflux, bile reflux, or both? 169 Chapter 10 GABAg agonist Baclofen reduces gastro-esophageal reflux in patients with therapy resistant duodeno-gastro- esophageal reflux. 187 Chapter 11 General discussion and conclusions. 205 Chapter 12 Summary. 217 Chapter 13 Samenvatting. , 227 Dankwoord. 237 Curriculum vitae. 245 Publications. 249 Chapter i Duodeno-gastro-esophageal reflux disease, a review Chapter 1 10 Duodeno-gastro-esophageal reflux disease Introduction Diseases associated with the reflux of duodenal and gastric contents into the esophagus play an important role in the daily gastroenterological practice. In the Dutch society the general practitioner is the first to be confronted with typical or atypical reflux complaints. Many patients without alarm symptoms and signs as weight loss or dysphagia are treated empirically with proton pump inhibitors (PPIs) for 4-6 weeks. An endoscopist or gastroenterologist only sees those patients who are refractory to therapy or experience recurrent symptoms after stopping therapy. In this chapter a review is given about gastro-esophageal reflux disease (GERD) and duodeno-gastro-esophageal reflux disease (DGER); the signs and symptoms, the pathophysiology, the different methods to investigate reflux and the therapeutical options. Clinical expression of reflux A variety of symptoms are found in patients with reflux disease. The patient's medical history is the cornerstone to differentiate between typical and atypical reflux symptoms. The two most important typical symptoms are heartburn and acid regurgitation. Furthermore a number of atypical symptoms can be attributed to GERD as discussed below. In the clinical signs of reflux disease a difference can be made between esophageal and extra-esophageal manifestations for example esophagitis and asthma, respectively. Typical symptoms Heartburn, a retrosternal burning sensation that radiates towards the throat or mouth, is the most prominent symptom of reflux. It occurs after meals, in supine position and after bending over or heavy lifting. Eating and drinking of hot, spicy, acidic food or drinks often provokes it. Regurgitation is the effortless return of gastric content into the esophagus and frequently into the mouth. This fluid can be acid, food or bitter and can appear during the day or at night. Sometimes it causes acute dyspnea, choking and coughing. Less typical symptoms are chest pain in which a cardiac origin must be excluded and obstructive dysphagia that can be an alarm symptom of a mechanical obstruction. Non-obstructive dysphagia is a frequent sign 11 Chapter 1 — accompanying reflux disease, and is not necessary an alarm sign. Nonspecific upper gastrointestinal symptoms are nausea, dyspepsia, bloating, belching or indigestion.''^ Atypical symptoms Symptoms of reflux disease, which cannot be attributed to the esophagus, are called extra-esophageal or atypical symptoms. They point to involvement of other organs in reflux disease. Pulmonary symptoms that have been attributed to reflux disease include chronic cough, wheezing and dyspnoe at night.^ Reflux-related otorhinolaryngological and oral symptoms are hoarseness'', dysphonia, postnasal drip, globus feeling^, halitosis and water brash. These symptoms are probably caused by nocturnal reflux.* Esophageal manifestations of reflux Erosive esophagitis, esophageal strictures and motility disturbances, Barrett's esophagus^ and esophagus carcinoma® are structural lesions which are at least in part caused by reflux disease. Overwhelming evidence suggests that Barrett's esophagus is an acquired condition secondary to chronic GERD and DGER. Prospective studies in patients with frequent heartburn showed a prevalence of Barrett's esophagus in 11-12%.' With reflux symptoms once a week, a prevalence of Barrett's esophagus was found in 3.5%.' Regarding symptoms, only a few patients with severe Barrett's esophagus have no reflux symptoms. Extra-esophageal manifestations The extra-esophageal manifestations of reflux are now becoming more and more elucidated. Pulmonary expressions of reflux are asthma'°, nonallergic asthma", recurrent aspiration and pulmonary fibrosis. In 39% of the asthmatic patients an esophagitis was diagnosed.'^ Otorhinolaryngological abnormalities like vocal cord disease''*, chronic laryngitis, laryngeal and subglottis stenosis''', chronic middle ear disease'^, laryngeal cancer'*''', sinusitis, pharyngitis and otalgia are more often recognized and successfully treated with proton pump inhibitors. Dental erosions are potential oral complications of reflux.'® 12 Duodeno-gastro-esophageal reflux disease Epidemiology Epidemiological data about the prevalence of GERD are rather scarce. A recent investigation in Belgium showed that the prevalence of heartburn, as the most important GERD symptom, was experienced in 28.4% of the