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Background It has been suggested that symptoms from bile reflux gastritis are related to the frequency and degree of enterogastric reflux (EGR). Methods Patients with history of upper gastrointestinal surgery or cholecystectomy as well as control patients were studied. Presence of EGR, degree of EGR, and gastric bile emptying time were assessed and quantified via 99mTC scintillation imaging and then compared between symptomatic and asymptomatic patients. Results Patients with vagotomy and pyloroplasty, Billroth I, Billroth II, and cholecystectomy demonstrated statistically higher degrees of EGR compared with controls. Although asymptomatic and symptomatic patients with a history of upper gastrointestinal or biliary surgery demonstrated no statistically significant differences between incidence of EGR and degree of EGR, there was a statistically significant difference in gastric emptying time. Conclusions Delayed gastric emptying time, not frequency or extent of EGR, was associated with the symptoms of bile reflux in patients who had previous upper gastrointestinal or biliary operations.

background Exclusion of the duodenum by means of transection and Roux-Y duodenojejunostomy has been practiced for the treatment of complicated duodenal diverticulum. However, this method does not divert bile away from the diverticulum, hence the possibility of pancreaticobiliary complications is not eliminated. methods Roux-Y Choledochojejunostomy and duodenojejunostomy, for the diversion of bile and food, has been applied for the treatment of pancreaticobiliary complications of duodenal diverticulum in 4 patients. Postoperatively, all patients had endoscopy, HIDA-scintigraphy for the measurement of enterogastric reflux, and assessment of gastric emptying. results One year postoperatively, there were no recurrent symptoms of cholangitis or pancreatitis, no anastomotic ulceration was found on endoscopy, there were no complaints of gastric stasis, and enterogastric reflux was not significant. conclusions Roux-Y Choledochojejunostomy and duodenojejunostomy for the treatment of the complicated duodenal diverticulum is associated with satisfactory results. Postoperative symptoms attributed to anastomotic ulceration, bile reflux, or gastric stasis are also absent.

Distension-evoked gastric reflexes were studied by intracellular recording from circular muscle cells in the gastric fundus, corpus and antrum in the isolated guinea-pig stomach. Localised electrical stimulation, 2 mm circumferential to the recording electrode, evoked inhibitory junctions potentials in all three gastric regions, sometimes followed by depolarisations in the antrum. In the mid corpus, the inhibitory responses were substantially reduced by Nw-nitro-L-arginine (100 microM), unmasking excitatory junction potentials. Residual hyperpolarisations were blocked by apamin (0.5 microM) which also enhanced the amplitude of excitatory junction potentials. These excitatory junction potentials were abolished by hyoscine (1 microM). Thus transmission from inhibitory motor neurons is mediated by both nitric oxide and an apamin-sensitive mechanism. Transmission from excitatory motor neurons to the circular muscle is mediated by acetylcholine via muscarinic receptors. Balloon distension of 10 s duration of the fundus or antrum elicited inhibitory junction potentials in circular muscle cells of the mid corpus. These inhibitory junction potentials were blocked by tetrodotoxin (0.6 microM) and were greatly reduced by Nw-nitro-L-arginine (100 microM). The residual hyperpolarisations were blocked by apamin (0.5 microM). This indicates the presence of ascending and descending inhibitory reflex pathways in the stomach. In 3 out of 7 experiments, following blockade of inhibitory transmission, small nerve-mediated excitatory junction potentials were evoked by antral distension indicating the presence of an additional ascending excitatory reflex pathway. Distension of the corpus elicited prominent inhibitory junction potentials, sometimes followed by large depolarisations, in circular muscle cells in the fundus, but not in the antrum. This suggests that there is also an ascending inhibitory reflex pathway from the corpus to the fundus but no distension-sensitive descending reflex pathway from the corpus to the antrum. These results demonstrate that within the stomach there are reflex pathways which can be activated by localised distension and project at some distance orally and aborally within the gastric wall. It is likely that the inhibitory reflex pathways are involved in gastric adaptive relaxation which occurs when the intact, isolated stomach is distended. The excitatory reflex pathways from the antrum to the corpus are likely to be involved in the intrinsic excitatory reflex responses observed in the isolated intact stomach to distension and thus be involved in the mixing and emptying of gastric contents.

Pylorus-preserving pancreaticoduodenectomy represents an important advance in the history of pancreatic surgery. The operation can be performed with a low operative mortality and morbidity, is technically easier than the standard Whipple resection, and it minimizes the long-term physiological disturbance to the patient. Clinical and experimental evidence has substantiated the view that preservation of the pylorus reduces the incidence of marginal anastomotic ulceration following pancreatectomy. Although gastric emptying may be prolonged transiently in the immediate postoperative period, this complication is easily managed, and is hardly a frequent long-term problem. PPPD is associated with a lower incidence of enterogastric reflux, dumping and diarrhoea than the classical Whipple operation, and patients who have had PPPD are more likely to regain their preoperative and preillness weight. Initial concerns about the use of PPPD in malignant disease have not been borne out, and should now be considered for curative or palliative resections of lesions in the periampullary region including the head of the pancreas. Present data suggest that PPPD does not compromise the long-term survival in patients with periampullary cancers. There is little doubt that the excellent results reported with this procedure as with other forms of major pancreatic surgery, are not simply related to improvements in surgical technique but to establishment of specialist pancreatic surgery.

Initially, scintigraphy was established as a valid method for detecting and quantitating enterogastric reflux. A new, tubeless technique for the measurement of enterogastric re flux was developed. 99mTc bound to [(2,6 dimethylphenylcarbamoylmethyl) iminodiacetic acid] (5 mCi) was administered intravenously to visualize the liver and biliary tract. One hour later, a standard liquid meal labeled with 111 In bound to diethylene-triamine penta-acetic acid (250 μCi) was given. The 99mTc and 111In activities were recorded simultaneously for 1-min periods at 15-min intervals for 2 hr over liver, gallbladder, and gastric areas of interest. Enterogastric re flux indices were determined. Ten normal subjects and 13 patients with vagotomy, hemigastrectomy, and Bilroth II gastrojejunostomy were evaluated. The enterogastric reftux index in asymptomatic postsurgical patients was increased significantly to 24.6 ± 4.7 compared with 8.2 ± 6.0 (P

Plasma gastrin concentrations and gastric acid output were measured during graded balloon distention of the gastric fundus and body in 20 patients with duodenal ulcer. Acid output rose stepwise with increasing distention volumes but plasma gastrin remained unchanged. During intragastric neutralization in 5 of these subjects, fundic distention did not elicit a significant rise in plasma gastrin, whereas the acid response was similar to that observed in the control study when the gastric contents were acid. In 8 of the 20 patients, proximal gastric vagotomy profoundly suppressed the acid response to fundic distention. Basal plasma gastrin concentrations were elevated after vagotomy, but were unchanged during graded fundic distention. The results suggest that neural reflex activation of the oxyntic glands is the main mechanism by which fundic distention stimulates acid secretion in man. The failure of fundic distention to release gastrin does not, however, completely rule out the existence of an oxyntopyloric distention reflex for gastrin release in man. Fundic distention in man seems to both stimulate acid secretion and induce an inhibitory mechanism acting on acid secretion. This inhibitory mechanism may, purely speculatively, also mask the effect of an oxyntopyloric reflex for gastrin release. The present study and earlier work suggest that in man distention of the stomach is a poor stimulus for release of gastrin, regardless of whether the pyloric or the oxyntic gland area, or both, are distended.

This is a report of 21 patients presenting with epigastric pain, bilious vomiting, upper gastrointestinal bleeding, iron-deficiency anemia, and weight loss, who had undergone Billroth II gastrectomy from 3 to 35 yr earlier. Eighteen of 21 patients were found to have significant enterogastric reflux indices varying from 60% to 95% demonstrated by 99mTc HIDA scintigraphy. Thirteen patients had diversion antireflux surgery in the form of a Roux-en-Y procedure, and 1 patient had a Henley loop jejunal interposition. Postoperative 99mTc HIDA scintigraphic studies showed the enterogastric reflux indices to have decreased significantly to a range of 2%-26% (p less than 0.00001). There was marked improvement of symptoms, including correction of anemia and weight gain in those patients who had been anemic or who had sustained earlier weight loss. The enterogastric reflux indices of 10 asymptomatic control patients after Billroth II gastrectomy ranged from 4% to 45%. 99mTc HIDA scintigraphy is useful in evaluating patients before and after bile diversion surgery, and demonstrates the quantitative decrease in enterogastric reflux after such surgery.

Reflex responses of the lower oesophageal sphincter (l.o.s.) to distension of the stomach were studied by electromyographic and manometric techniques. Distension of the fundus and gastric antrum by inflation of a balloon elicited two types of reflex response of the l.o.s. Thus, whereas excitatory responses were recorded following slight distensions, larger distensions resulted in inhibitory responses. Splanchnic fibres and sympathetic fibres originating from the stellate ganglion, as well as vagal fibres served as the efferent pathways for the excitatory reflex response. The efferent pathways for the inhibitory response involved only vagal fibres.

Gastric responses to electrical stimulation of the vagus and splanchnic nerves and to esophageal distension were observed in studies of the reflex control of the gastric motility in anesthetized guinea pigs in vivo. The gastric motility was inhibited by both vago-vagal and splanchno-vagal reflexes through the activation of non-adrenergic inhibitory nerve fibers and by splanchno-splanchnic reflex through the inactivation of the intramural cholinergic excitatory neurons. Distension of the lower esophagus caused a relaxation of the stomach which was mediated by an intrinsic reflex via intramural non-adrenergic inhibitory neurons. Furthermore, stimulation of the splanchnic nerve innervating the stomach seems to activate adrenergic inhibitory, cholinergic excitatory and probably some non-adrenergic inhibitory fibers.

In order to identify the mechanisms responsible for the inhibition of gastric secretion observed during acidification of the duodenal bulb, dogs were prepared with a gastric fistula (GF), Heidenhain pouch (HP), and pancreatic fistula. The duodenal bulb (5 cm) was separated from the stomach by a mucosal septum at the pyloric end and was brought to the surface in a mucocutaneous fistula distally. After the first series of experiments were completed, the dogs were reoperated and the duodenal bulb was completely separated from the stomach. The experiments were then repeated. Perfusion of the innervated duodenal bulb with 8 mEq of HC1 per hr resulted in 50% inhibition of pentagastrin (2 μg per kg-hr) -induced acid secretion from the GF and slight stimulation of pancreatic volume, bicarbonate, and protein output. Acid and pepsin secretion from the HP were unchanged by acidification of the bulb. A small dose of synthetic secretin (0.2 U per kg-hr) increased pancreatic secretion more than did bulbar acidification but did not inhibit acid secretion. A larger dose of secretin (1.6 U per kg-hr) caused 50% inhibition of acid secretion from both the GF and HP. Following the surgical separation of the duodenal bulb from the pylorus, acidification of the bulb failed to inhibit gastric secretion from the GF as well as from the HP. We interpret these results as evidence for the existence of a neural reflex, triggered by acid in the duodenal bulb, and inhibiting gastric secretion. Earlier studies by several groups have shown that acidification of the bulb inhibited HP secretion, thus indicating a hormonal mechanism. We cannot explain the failure to find evidence of such a mechanism in this study.

Adequate electrical stimulation of the central cut end of the abdominal vagus invariably raises the blood pressure 30 mm Hg due to visceral and somatic vasoconstriction without change of heart rate. This response is accompanied by a reflex gastric relaxation which persists at reduced amplitude after abdominal vagotomy, an increase of respiratory amplitude without change of rate, and by inhibition of the knee-jerk reflex. The receptors for the pressor reflex respond to distension of the esophagus, cardia, stomach or pylorus, while those for the gastric reflex respond to distension of the pylorus and to changes of pH in the duodenum.