Bile reflux measurement and its contribution to the severity of reflux esophagitis

BACKGROUND/AIMS: Gastroesophageal reflux disease (GERD) may occur with acid, bile or in a mixed form. Endoscopic injury and mucosal metaplasia are a known sequelae to pathological GERD. The aim of the study was to determine the contribution of acid and duodenogastroesophageal reflux to endoscopic severity in patients with GERD and Barrett's esophagus (BE). MATERIALS AND METHODS: Ninety-one patients complaining of reflux symptoms were studied with upper gastrointestinal endoscopy and graded to nonerosive reflux disease (NERD), erosive reflux disease (ERD) and BE. Esophageal manometry and simultaneous ambulatory 24-h esophageal pH and bilirubin monitoring (Bilitec 2000) were performed in all patients. RESULTS: Seventy-one patients (78.0%) had ERD (Savary-Miller (grade I-III), 11 patients (12.1%) had NERD and 9 patients (9.9%) had BE, which were suspected endoscopically and diagnosed by histological esophageal biopsy. Combined 24-h esophageal bilirubin and pH monitoring revealed the following: 39 patients (42.9%) had mixed acid and bile reflux, 16 (17.6%) had pathological acid reflux alone, 18 (19.8%) had bile reflux alone and 18 patients (19.8%) showed no evidences of abnormal reflux. The percentage of the total time of the bilirubin absorbance > 0.14 in 71 patients with ERD was (8.18+/-11.28%) and in 9 patients with BE was (15.48+/-30.48%), which was significantly greater than that in 11 patients with NERD (4.48+/-8.99%), P<0.05 and P=0.01 respectively. All the BE patients had abnormal esophageal bile reflux (bile alone (3 patients)); and mixed bile and acid (6 patients)); 44 of 71 patients (61.97%) with ERD had abnormal esophageal bile reflux (alone (13 patients) and mixed bile and acid (31 patients)); meanwhile, 15 of them (21.2%) had abnormal acid exposure alone. Despite 11 patients having NERD, four patients (36.4%) had abnormal esophageal bile reflux and two of them had mixed reflux of bile with acid. CONCLUSION: We believe that the Bilitec method reliably identifies the presence of bilirubin and quantitatively detects the duodenogastroesophageal reflux of bile. Mixed reflux (acid and bile) is the chief pattern of reflux in our GERD patients. Bile reflux either alone or along with acid reflux contributes to the severity of erosive and nonerosive reflux diseases as well as in BE.