Acid and bile reflux in erosive, non-erosive reflux disease and barrett's esophagus

ABSTRACT

GERD may occur with acid, bile or in a mixed form. Endoscopic injury and mucosal metaplasia are a known sequlae to pathological GERD to study the contribution of acid and duodenogas-troesophageal reflux [DGER] to endoscopic severity in patients with GERD and Barrett's esophagus. Ninety-one patients [60 males, 31 females; mean age 36.12 +/- 12.65 years] complaining of reflux symptoms underwent upper gastrointestinal endoscopy and graded to non-erosive reflux disease [NERD], erosive reflux disease [ERD] and Barrett's esophagus [BE]. Esophageal manometry and simultaneous ambulatory 24-h esophageal pH and bilirubin monitoring [Bilitec 2000] were done to all patients. Seventy one patients [78.0%] had ERD [Savory-Miller [grade I-III], 11 patients [12.1%] had NERD and 9 patients [9.9%] had BE by endoscopy. Combined 24-h esophageal bilirubin and pH monitoring revealed that 39 patients [42.9%] had mixed acid and bile reflux, 16[17.6%] had pathological acid reflux only, 18 [19.8%] had bile reflux only and 18 patients [19.8%] had no evidence of abnormal reflux. The percentage of the total time that bilirubin absorbance was 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 BE patients had abnormal esophageal bile reflux [3 bile alone and 6 mixed bile and acid]; 44 of 71 patients [61.97%] with ERD had abnormal esophageal bile reflux [13 bile alone and 31 mixed bile and acid]; meanwhile 15 of them [21.2%] had abnormal acid exposure alone. Despite having NERD, 4 patients [36.4%] had abnormal esophageal bile reflux, two of them mixed with acid. Mixed reflux [acid and bile] is the chief pattern of reflux in GERD patients. Bile reflux either alone or in a mix with acid reflux contributes to severity of erosive, non-erosive reflux disease as well as in Barrett's esophagus