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Gallstone disease is the most common risk factor for cholangitis. In an anatomically normal bile duct system, cholangitis does not occur without the presence of stones. Endoscopic retrograde cholangiography with papillotomy and stone extraction is a well-established curative therapy for gallstones in the common bile duct. More important, papillotomy prevents recurrent episodes. The present case report describes a 73-year-old male with recurring cholangitis in a clear bile duct system after previous papillotomy. An etiology of duodenal reflux into the common bile duct due to heavy lifting is proposed.

BackgroundInvestigations of molecular mechanisms behind the progression of neoplastic changes in the esophagus have uncovered the role of the COX & 5-Lox pathways. Human squamous esophageal mucosa produces relatively large amounts of eicosanoids in the presence of inflammation. Laboratory and epidemiological data suggest that aspirin and non-steroidal anti-inflammatory drugs may be chemo preventive through their inhibitory effect on COX25, 10. Cell culture studies have shown that the members of the mitogen activated protein (MAP) kinase family plays an important role in the development of bile acid-induced carcinogenesis. Differences in MAPK pathways activated by bile exposure were also noted in esophageal squamous cell lines and biopsies from patients with GERD. The protective role of aspirin and its molecular mechanism is not well understood.Aims1.The effect of duodenal reflux on esophageal mucosa.2.The role of aspirin in preventing duodenal reflux induced esophageal mucosa changes.3.If it is proven to be preventive, the mechanism of its action. A duodenal reflux rat animal model was used by an end- to-side esophago duodenostomy.MethodsTotal of 56 rats was included. 3 were "Naive control" animals which did not undergo the surgical procedure. The remaining animals were divided into two groups: Surgery alone (experimental) and Surgery + aspirin [therapy group], esophagoduodenostomy. At 40 weeks, the rats were euthanized and appropriate esophageal samples were analysed for histopathology and p38 & ERK MAP kinases, VEGF, protease activity and caspase 3 activities.ResultsThe presence of gross mucosal nodularity was seen in 21 and 10 rats of the experimental and therapy group respectively (p = 0.03; Table 1). Reflux-associated changes such as basal cell hyperplasia were more common in the experimental group, however this association did not reach statistical significance (p = 0.15; Table 1). Epithelial hyperplasia was seen more in the experimental group, which was prevented by aspirin [p

OBJECTIVE: To assess the long-term results of the duodenal switch operation made for pathologic transpyloric duodenogastric reflux (DGR). SUMMARY BACKGROUND DATA: DGR symptoms and lesions are poorly responsive to medical treatment. METHODS: A duodenal switch operation was made on 48 patients suffering from pathologic transpyloric DGR either unrelated (n = 28) or secondary (n = 20) to previous upper gastrointestinal (GI) surgery, including cholecystectomy or vagotomy. The diagnosis was based on the combination of several objective arguments: a long history of gastric symptoms (ie, nausea, epigastric pain, and/or bilious vomiting) poorly responsive to medical treatment (48 of 48), gastroesophageal reflux symptoms unresponsive to proton-pump inhibitors (PPI) (23 of 29), gastritis on upper GI endoscopy (37 of 48) and/or at histology (28 of 41), presence of a bilious gastric lake at >1 upper GI endoscopy (30 of 48), DGR at diisopropyl iminodiacetic acid (DISIDA) scintigraphy scanning (7 of 13), pathologic 24-hour intragastric bile monitoring with the Bilitec device (40 of 41), and absence of Helicobacter pylori antral infection (39 of 41). RESULTS: At follow-up (median, 81 months), gastric symptoms were nil, had improved, and remained unchanged in 29 (60.4%), 16 (33.3%), and 2(4.2%) patients, respectively, and 1 patient experienced symptomatic recurrence after a 92-month symptom-free period (2.1%). Among the 44 patients who had postoperative upper GI endoscopy, 42 (95.5%) had no gastritis whereas 5 (11.3%) had an ulcer at the duodenojejunostomy. Gastric exposure to bile at postoperative 24-hour intragastric Bilitec test in 36 patients was nil, within the normal range, and still slightly pathologic in 15 (41.7%), 19 (52.8%), and 2 (5.5%), respectively. CONCLUSIONS: The duodenal switch operation made on patients in whom diagnosis of pathologic transpyloric DGR is supported by several objective arguments provides most of them with symptomatic and endoscopic improvement parallel to abolishment or normalization of gastric exposure to bile. Postoperative PPI therapy during a 2-month period is to be recommended to prevent the development of an anastomotic ulcer.

Warm Water Ampullary Washing: A Potential Needle-Knife Sphincterotomy Sparing Technique Emilio De la Morena, Elena Perez de Arellano, Yago Gonzalez-Lama, Esperanza Tomas-Moros Background: Needle-knife sphincterotomy (NKS) is an alternative endoscopic sphincterotomy (ES) technique used when selective biliary canulation (SBC) fails, but it is difficult to learn and is an independent risk factor for postERCP pancreatitis. Easier and safer canulation, NKS sparing, handlings are thus desirable. Objective: To report our preliminary results with a new canulation facilitating technique, the warm water ampullary washing (WAW). Method: WAW is performed when guide-wire assisted SBC fails and sphincter of Oddi spasm is one major presumptive cause of the failure. The ampoule is washed with 50 cc of tap water empirically titrated at 38-40 C using a canulotome inserted a few millimetres in the papillary orifice caring not to nail the tip to permit the duodenal reflux of the water and prevent pancreatic injection. After WAW a second SBC attempt is tried and if it fails again a NKS is performed. Results: Along one year 66 ES were indicated in 75 patients. Initially CSB and ES were performed in 54 (82%) and NKS in 5. WAW was tried in 7 and allowed CSB and ES in 4. Thus the final number of ES performed was 58 (88%) and the theoretic 12 (18%) NKS dropped to the real 8 (12%) (pZNS). The 4 WAW issues had healthy papillae (HP) (2 normal and 2 mild papillitis) whereas the 3 WAW failures had ill papillae (IP) (2 severe papillitis, 1 impacted stone). All 8 patients who required NKS had IP. Among the 3 WAW failures 1 mild pancreatitis was registered. Compared with 225 historical controls NKS dropped from 16% to 12% (pZNS). However NKS in IP patients rose from 7% to 12% (pZNS) and NKS in HP patients fell from 9% to 0 (pZ0.00002). Conclusion: With these results we hypothesise that WAW facilitates the SBC and allows ES in HP patients sparing NKS in them and limiting it to IP patients.

Pyloric function after Ramstedt's pyloromyotomy was assessed in seven patients aged five to eleven years and compared to that in sixteen normal children. Gastric emptying (T 1/2) of liquid, as measured by the double sampling test, was faster in patients than in normal children. Duodenal reflux was calculated from the sodium content in gastric aspirates. At rest, it was greater in patients than in normal children. In the poststimulatory state, there was no difference. Gastric acid secretion was similar in both groups. Rapid gastric emptying might explain the high incidence of peptic ulcer reported in several series of long-term follow-up patients. Increased duodenal reflux at rest might account for a similar increased incidence in gastritis and dyspepsia.

Serum gastrin has been studied in dogs with and without surgically produced duodenal reflux. Fasting levels and the gastrin response to a standard meal have been assayed using a radioimmunoassay technique. Duodenal reflux caused no significant change in fasting serum gastrin immuno-reactivity but led to a markedly elevated and prolonged gastrin response to a standard meal.

Forty patients with signs and symptoms of gastro-oesophageal reflux were studied with cholescintigraphy, a noninvasive method, to detect duodenogastric reflux. 150 patients subjected to cholescintigraphy for various medical reasons served as controls. Ten per cent of the patients wit signs and symptoms of gastro-oesophageal reflux and 14% of the control patients had duodenogastric reflux. Of the four patients with gastro-oesophageal and duodenogastric reflux three had ulcers or strictures on oesophagoscopy, whereas one had normal endoscopic appearance. The differences in the frequency of duodenogastric reflux between these groups are not statistically significant.

Twenty-one stomachs resected for carcinoma were studied histologically using the ‘Swiss-roll’ technique. Chronic gastritis with epithelial hyperplasia was present in all. There were two types of distribution of the gastritis. In 17 instances it extended continuously from the pylorus proximally up to or beyond the carcinoma. This type of gastritis could be due to reflux of duodenal contents into the stomach. In 4 stomachs the gastritis occurred only in the vicinity of the tumour but did not extend from the pylorus and could therefore not be the result of duodenal reflux. It is postulated that there may be two kinds of carcinoma. One type is associated with the epithelial hyperplasia of chronic gastritis, possibly resulting from duodenal reflux into the stomach, The other is also associated with chronic gastritis but the distribution does not suggest duodenal reflux.

Hourly measurements of bile acids, bacterial flora, and pH were made from gastric aspirates collected over 24 hours in subjects taking a controlled diet. Significantly higher concentrations of total bile acids were found following truncal vagotomy and antrectomy (TV+A), 2.73±1.16 SEM mmol/l, than after truncal vagotomy and pyloroplasty (TV+P), 0.88±0.56 mmol/l (p

Pfeffer loops were created in ten dogs. Duodenal pressure was increased until pancreatic reflux occurred or until the experiment was terminated. Pressures above 125 cm of water were required to produce reflux of duodenal contents. Histologic changes, manifest by papillary parenchymal hemorrhage, occurred in the pancreatic duct papilla, suggesting that structural damage to the papilla from prolonged pressure is necessary for the occurrence of duodenal reflux.