Duodenogastric reflux: signs, treatment regimens, diet

In gastroenterology, the flow of contents from the duodenum back into the stomach – through the pyloric sphincter that separates them – is defined as duodenogastric reflux (in Latin, refluxus means “backflow”).

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

Quite often, bile in the stomach is detected during gastroscopy in people with gastritis, stomach ulcers, and gastroesophageal reflux disease.

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Epidemiology

Duodenogastric reflux is not a separate nosological entity (and, accordingly, does not have an ICD-10 code). Some specialists classify it as a syndrome (manifested in diseases of the stomach and duodenum), others - as a cause of functional dyspepsia. They also classify it as a reflux pathology that causes the development of gastroduodenal peptic ulcers and gastroesophageal reflux disease (GERD). Although GERD is the result of dysfunction of the cardiac (lower esophageal) sphincter, which allows the contents of the stomach to enter back into the esophagus.

Studies show that most cases of duodenogastric reflux occur simultaneously with acid reflux, characteristic of GERD. And as an independent pathology, severe duodenogastric reflux

It is diagnosed in no more than a quarter of patients with retrograde gastrointestinal phenomena.

According to the World Journal of Gastroenterology, nearly a third of the population of the United States has some symptoms of gastroesophageal reflux, and the presence of diagnosed duodenogastric reflux does not exceed 10% of patients. However, gastroenterologists find bile in the esophagus in 70% of cases of persistent chronic heartburn and Barrett's esophagus.

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Causes duodenogastric reflux

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

According to gastroenterologists, bile may occasionally be present in the stomach in small amounts and for a very short time – without causing symptoms – for example, due to physiological retrograde peristalsis. But bile reflux that occurs cyclically is a pathology.

And the key causes of duodenogastric reflux are related to:

• with functional insufficiency of the pyloric sphincter (most often due to disturbances in the parasympathetic regulation of contractions of its muscular ring, a genetic defect, a sphincter ulcer, or the presence of a scar at the site of ulceration);
• with increased motility of the duodenum with a hyperkinetic type of its peristalsis;
• with increased pressure in the lumen of the duodenum (duodenal hypertension), which may be caused by lumbar lordosis or prolapse 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 absence or deficiency of hormones (in many cases – gastrin);
• with the presence of long-term inflammation of the duodenum - chronic duodenitis, gastroduodenitis, duodenal ulcer.

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

• due to helminthic invasion or giardiasis;
• due to developmental anomalies of the duodenum;
• in congenital Ladd's syndrome - incomplete rotation of the intestine and short bowel syndrome.

However, in a child or adolescent, retrograde movement of duodenal contents may occur during upper GI endoscopy, and the diagnosis of bile reflux is usually not confirmed by other methods.

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Risk factors

The following risk factors for the development of duodenogastric reflux should be kept in mind:

• overeating, fatty and spicy foods (cause hypersecretion of bile);
• irregular meal times and eating dry food;
• alcohol abuse and smoking;
• long-term use of nonsteroidal anti-inflammatory drugs or antispasmodics;
• old age.

Risk factors also include operations to remove part of the stomach (resection), remove the gallbladder (cholecystectomy), create anastomoses of the stomach and intestines; inflammation of the gallbladder (cholecystitis) and biliary dyskinesia; pancreatic insufficiency and pancreatitis; obesity and diabetes.

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Pathogenesis

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

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

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

Temporary duodenogastric reflux often occurs during pregnancy (in the last trimester), which is caused by the increase in the size of the uterus and its pressure on all abdominal organs, including the duodenum, causing regurgitation of its contents into the stomach cavity.

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Symptoms duodenogastric reflux

The symptoms of duodenogastric reflux are not specific, and clinically this pathology can manifest itself as:

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

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

The manifestations of this pathology and the presence of certain symptoms depend on the degree, which is determined rather conditionally - by the volume of bile acids detected in different parts of the stomach. Thus, duodenogastric reflux of the 1st degree is associated with a minimum amount of bile in the pyloric part of the stomach adjacent to the pylorus. If bile is detected higher (in the antrum and fundus), duodenogastric reflux of the 2nd degree can be determined, and when regurgitation reaches the bottom of the stomach and the lower esophageal (cardiac) sphincter, then this is the 3rd degree of biliary reflux.

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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 has an extremely negative effect on the mucosa. You can find definitions: 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 the reflux of duodenal contents into the stomach cavity.

Also, complications of duodenogastric reflux include:

• gastroesophageal reflux disease;
• erosive gastritis;
• ulceration of the mucous membrane 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 the development of GERD).
• increased risk of precancerous conditions of the mucous membrane and gastric oncology.

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Diagnostics duodenogastric reflux

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

• blood (general and biochemical);
• urine and feces;
• H. hilory breath test.

It is necessary to examine the stomach contents for the presence of bile acids, bilirubin and sodium (using probing). Also, 24-hour pH-metry of the stomach and esophagus is performed.

Instrumental diagnostics using the following is mandatory:

• X-ray examination of the stomach and duodenum;
• ultrasound of abdominal organs;
• endoscopic gastroscopy;
• electrogastrography;
• dynamic scintigraphy;
• antroduodenal manometry.

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Differential diagnosis

Differential diagnostics are performed to determine acid reflux, which, if only the symptoms and complaints of patients are taken into account, can easily be confused with bile reflux.

Treatment duodenogastric reflux

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

The drug Ursofalk (other trade names - Ursachol, Ursolit, Ursolvan, Holacid)

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

Ganaton tablets (Itopride, Itomed, Primer) activate the motility of the digestive tract, which are prescribed one tablet three times a day (one hour before meals). The drug is not used for gastric bleeding, intestinal stenosis, pregnant women in the first trimester and patients under 16 years of age. There may be side effects in the form of intestinal upset and dysuria, epigastric pain, dry mouth, insomnia.

Metoclopramide (Cerucal, Gastrosil) is used to coordinate gastroduodenal motility. The dose for adults is one tablet (10 mg) three times a day; for children over three years old - 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 (first three months) and breastfeeding, as well as children under three years of age. Metoclopramide can cause side effects, in particular: headache, fatigue, depression and anxiety, rapid heartbeat, dry mouth, diarrhea, menstrual irregularities.

The gastroprotective agent Sucralfate (Sukrafil, Sukrat, Ulgastran, etc.) helps to release bile from the stomach and protect its mucous membrane from inflammation. Take 500 mg up to four times a day (before each meal and at night). This drug is contraindicated in the treatment of duodenogastric reflux in case of intestinal stenosis, difficulty swallowing, renal failure, pregnancy and lactation, children under four years of age. Possible side effects include intestinal dysfunction, nausea and dry mouth, headaches, stomach pain, and pain in the lumbar region.

The antispasmodic Trimebutine (Trimedat) can be used by patients over 12 years old - 0.1-0.2 g three times a day; children 5-12 years old - 50 mg, 3-5 years old - 25 mg three times a day. Side effects include skin rashes.

Homeopathy in the treatment of bile reflux is represented by the drug Gastritol (in the form of drops), which contains extracts of medicinal plants such as cinquefoil, chamomile, wormwood, St. John's wort, as well as extracts from the roots of licorice, angelica and milk thistle. The medicine is taken only by patients over 12 years old - 25 drops three times a day (before meals). Drops are contraindicated in high blood pressure, gallstone disease and pregnancy. Side effects include nausea, vomiting, abdominal pain, dizziness.

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

Physiotherapeutic treatment consists of drinking natural alkaline mineral waters (Borjomi, Svalyava, Luzhanskaya, Polyana-Kvasova, etc.).

Surgery may be a last resort if nothing else relieves severe bile reflux symptoms or when precancerous changes in the gastrointestinal tract are detected.

Folk treatment of duodenogastric reflux

What does folk medicine offer to eliminate the main symptoms of duodenogastric reflux? For breakfast, eat oatmeal, natural yogurt or kefir, and baked apples (the pectin they contain neutralizes bile acids). It is recommended to systematically consume honey - in the form of honey water (a teaspoon per glass of lukewarm boiled water), which should be drunk in the evening. And in case of heartburn, drink a glass of warm water in small sips: it will help wash away bile from the gastric mucosa.

It is also recommended to treat duodenogastric reflux with flaxseed 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 treatments can also help relieve bile reflux. First up is chamomile tea (a couple of cups a day). Licorice root is also considered helpful for bile reflux, but it should be noted that licorice contains glycyrrhizin, which is known to reduce testosterone production in men.

Decoctions of marshmallow root or wild mallow (a tablespoon of dry crushed roots per 250 ml of water) coat the gastric mucosa.

The same effect is produced by an alcohol tincture of red elm bark (Ulmus rubra), for the preparation of which you need to take only the inner layer of the bark of this tree.

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Diet for duodenogastric reflux

According to experts, unlike acid reflux, a diet for duodenogastric reflux usually cannot completely control the manifestation of symptoms. However, without changes in diet or lifestyle, it is impossible to do without it.

First of all, you should not overeat. It is also necessary to limit foods with high fat content and spicy foods. For more information, see 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 for erosive gastritis.

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

Special therapeutic exercise for duodenogastric reflux has not been developed, but experts say that one of the best and most accessible means for everyone against excess bile is regularly performed physical exercises. And they recommend practicing Chinese therapeutic and health-improving gymnastics qigong.

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Prevention

To prevent duodenogastric reflux from becoming a cause of chronic gastrointestinal diseases and significant deterioration in health, its prevention is necessary.

The main dietary recommendations were mentioned above. It is also necessary to drink enough water - up to two liters per day.

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

It is not recommended to lie down immediately after eating, so as not to provoke retrograde movement of duodenal contents. Walks before bed are very useful, and you should sleep with your head elevated.

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Forecast

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

And the question of "duodenogastric reflux and the army" is decided by a medical commission depending on the effect of bile reflux into the stomach on the general health. In any case, conscripts with pronounced reflux pathologies are sent for examination, based on the results of which a decision is made on the degree of fitness for military service.

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