Recent studies have shown that reflux of the duodenal content to the esophagus plays an important role in esophageal mucosal damage. The aim of the study is to compare the duodenogastroesophageal (DGER) reflux with the severity of
reflux esophagitis and evaluate its response to either medical and/or antireflux surgery.
METHODOLOGY: Ninety-six patients with DGER were subjected to thorough history, upper GI endoscopy,
barium study, esophageal manometry and 24-hr esophageal pH metry combined with Bilitec 2000. Medical treatment was given for all, while Nissen
fundoplication was done for 28 patients. All patients were evaluated after Nissen
fundoplication and treatment.
RESULTS: The age of studied patients was 36.26+/-12.7 years with male to female ratio 2:1. The chief symptom was
heartburn in 73 (76%) patients. Upper GI endoscopy revealed, 30 (31.2%) patients had grade I reflux, 30 (31.2%) patients had grade II reflux, 7 patients had grade III reflux, 5 patients had grade VI reflux,
Barrett's esophagus in 14 patients (14.5%),
hiatus hernia (HH) in 26 (27%) patients.
Barium study revealed that, 40 (41.6%) patients had evidence of reflux, while 34 (35.4%) patients had reflux with HH. Esophageal motility revealed the mean LESP (12.7+/-7.6), 68 patients (70.8%) had normotensive body while ineffective esophageal body motility was encountered in 28 (29.1%) patients. Esophageal 24-hr pH study and Bilitec 2000 revealed that 54 (56.2%) patients had
bile reflux with pathological
acid reflux, while 42 (43.7%) patients had
bile reflux in alkaline pH. Medical treatment gave excellent to good response in 68 (70.8%) patients, while Nissen
fundoplication was done for 28 (29.2%) patients. Endoscopic examination 6 months after Nissen
fundoplication showed marked improvement in endoscopic injury.
Barium study after Nissen
fundoplication revealed repair of HH and control of
GERD in all patients except one. Esophageal motility, 24 hr pH study and Bilitec 2000, after 6 months of Nissen shows high significant increase in LESP, decrease in
acid and
bile reflux. No significant difference between open or laparoscopic
fundoplication in LESP,
acid and
bile reflux.
CONCLUSIONS: DGER in
acid medium is more injurious to the esophagus than DGER in alkaline pH. The severity of esophageal injury does not correlate with the severity of
acid or
bile reflux but has a direct correlation with impaired distal esophageal motility. Medical treatment gives satisfactory control of symptoms and healing of esophageal lesion in 70% of DGER. The response to medical treatment does not depend on the severity of esophageal injury but depends on the severity of bile and
acid reflux. Nissen
fundoplication in refractory patients, either open or laparoscopic, was effective in control of
heartburn in 95% of patients contrary to 50% in mixed symptoms.