Bile Gastritis Research Articles

Outcome of Biliary-enteric Reconstruction with Hepaticoduodenostomy Following Choledochal Cyst Resection: A Prospective Study.

The two most commonly performed methods of biliary-enteric reconstruction following choledochal cyst resection are Roux-en-Y hepaticojejunostomy (HJ) and hepaticoduodenostomy (HD). There is a lack of consensus regarding the better technique between them. This study aimed to evaluate the outcomes, efficacy and early complications of HD as a mode of biliary reconstruction after surgical resection of a choledochal cyst. This was a multi-institutional prospective study carried out in high-volume tertiary care teaching institutes from January 2010 to December 2022. All children managed with HD following choledochal cyst resection were analysed for their early complications and outcomes. A total of 74 patients were included in this study. There were 59 (79.73%) females and 15 (20.27%) males. Thirty-nine (52.70%) patients had jaundice at the time of presentation. Magnetic resonance cholangiopancreatography was performed in 57 (77.03%) patients following ultrasonography. Intraoperatively, malrotation was present in 2 (2.70%) patients. In our study, operating time ranged from 60 to 195 min (mean: 118 min). Hospital stays ranged from 8 to 17 days (mean: 11.5 days). The post-operative biliary leak was seen in 7 (9.50%) patients, out of which 6 (8.11%) minor leaks were managed conservatively. Roux-en-Y HJ was performed on 1 (1.35%) patient with a major leak. In our series, 4 (5.40%) patients developed cholangitis; post-operative haemorrhagic nasogastric aspirate 5 (6.76%), post-operative pancreatitis 3 (4.05%) and wound infection 4 (5.40%) were observed and managed conservatively. None of the patients in our study developed an anastomotic stricture, bile gastritis and adhesive small bowel obstruction. Resection of choledochal cyst with HD reconstruction is safe and feasible with short operative time. HD is a viable option for operative management of choledochal cyst with low complication rates and faster recovery.

23 GASTRIC BYPASS AS REVISION SURGERY FOR FAILED FUNDOPLICATIONS

Abstract Laparoscopic fundoplication as anti-reflux technique has emerged and widely expanded as a cost effective alternative to life-long medical treatment in patients with gastroesophageal reflux disease (GERD). Long-term success rate ranges from 80–90% with this procedure, but side effects still exist even with experienced surgeons. Patients with a failed anti-reflux procedure are becoming a more common problem nowadays. Although most of these patients can be managed medically, still some of them will require revisional surgery. Methods We presented our experience from January 2015 to June 2019 facing cases of failed fundoplications. 59 cases with failed fundoplication requiring revision were included in the study. Redo fundoplications were decided preoperatively or intraoperatively to be difficult or unsafe to be done for these cases. Revision surgery for these cases was done using either distal gastrectomy and RY gastro-jejunostomy (22 cases) when the hiatal dissection was not feasible or unsafe due to obscure anatomy or Truncal vagotomy and RY gastro-jejunostomy (37 cases) when the hiatal dissection was easy and feasible. Results Laparoscopy was used in 49 cases and was successfully completed in 42cases (%) and 7conversion (%). Improvement of symptoms: Recurrent reflux or dysphagia was noted in 19 cases (32%) and complete disappeared in 26 cases (44%). One case had leak from the GJ and another one got hematemesis. Both cases were managed conservatively. Nine patient (15%) had bile gastritis with abdominal pain. Five patients (8.5%) complained of dumping symptoms. No mortality was recorded. Conclusion RY gastro-jejunostomy for failed fundoplications is a valid, feasible surgical option when redo fundoplication is difficult to be done or if associated with possible or expected complications.

Comparison of Surgical Outcomes for Finsterer and the Roux-en-Y Reconstruction after Distal Gastrectomy for Gastric Carcinoma.

Objective There have been surgical procedures to reconstruct the gastrointestinal continuity after distal gastrectomy. This study is aimed at comparing the surgical outcomes of reconstructing gastrointestinal continuity by the method of Finsterer and Roux-en-Y after distal gastrectomy due to cancer. Materials and methods. 86 patients, who underwent distal gastrectomy due to cancer, were divided into 2 groups for reconstructing gastrointestinal continuity from March 2014 to August 2018 at Viet Duc Hospital: group 1 (44 patients) by the Finsterer method and group 2 (42 patients) by the Roux-en-Y method. Results The concentrations of bilirubin and amylase in gastric liquid after first flatus were 97.6 mmol/l and 20016 mmol/l for group 1 and 0.5 mmol/l and 152 mmol/l for group 2 (p = 0.01), respectively. The rate of reflux with clinical manifestations was 45.7% for group 1 and 9.4% for group 2 (p = 0.001). The average operation time was 155.7 ± 25.9 (90-200) minutes for group 1 and 170.3 ± 22.3 (120-215) minutes for group 2 (p = 0.007). The number of lymph nodes was 19.1 ± 4.8 (13-37) for group 1 and 20.3 ± 4.5 (12– 33) for group 2 (p = 0.243). There was 1 case of mesenteric bleeding in group 2 (2.4%). The dumping syndrome occurred in group 1 (20%) and group 2 (9.4%) (p = 0.31). Conclusion The Finsterer and Roux-en-Y methods proved to be equally effective in their feasibility and safety. However, the Roux-en-Y method was better than the Finsterer method at limiting bile reflux and gastritis.

Comparison between hepaticojejunostomy and hepaticoduodenostomy after excision of choledochal cyst in children: a cohort study

ObjectiveHepaticojejunostomy (HJ) and hepaticoduodenostomy (HD) are commonly used biliary reconstruction techniques after choledochal cyst excision. HD has been suggested to be a more physiologic alternative during reconstruction. The objective of...

Assessment of Gastric Sensitivity and Symptom Patterns in Patients With Functional Dyspepsia With or Without Bile Gastropathy

Introduction: The pathophysiology of patients with functional dyspepsia remains unclear. Our aim was to evaluate the effects of bile gastropathy on gastric sensation in dyspeptic patients compared with those without bile gastropathy and healthy controls. Methods: Patients presenting with symptoms (>1 year) of functional dyspepsia (Rome III) completed an abdominal symptom assessment on a 0-3 point Likert scale assessing the intensity, duration and frequency prior to gastric barostat study. A 3-sensor manometry probe with compliant balloon was placed through the mouth into the stomach. Stepwise graded balloon distensions were performed in 3-mmHg increments until maximum tolerable pressure or 24 mmHg was reached. Gastric sensory responses were evaluated in fasting and post-prandial states after infusion of a liquid meal. Gastric sensory responses were compared with healthy controls. All subjects underwent endoscopies with biopsies for bile gastropathy. Results: Based on endoscopy and biopsies, patients were categorized as bile gastropathy (BG; n=15; f=13; age=37.5yrs) or no bile gastropathy (NBG; n= 15; f=10; age=36.7). Control data was obtained from 12 asymptomatic controls (n=12; f=6; age=32.3yrs). Mean symptoms scores of belching (4.1 vs 2.9), indigestion (7.1 vs 5.1) and gas (5.4 vs 3.9) were not significantly different in BG and NBG groups. In pre-prandial states, both BG (2.79 mmHg, 5.67 mmHg, 7.77 mmHg; all p<0.05) and NBG groups (3.27mmHg, 7.00 mmHg, 10.7 mmHg; all p<0.05) demonstrated lower thresholds for first sensation, moderate sensation, and discomfort compared to healthy controls (9.5 mmHg, 15.5mmHg, 18.5mmHg), respectively, as shown in Table 1. In post-prandial states, both BG (1.50 mmHg, 4.00 mmHg, 5.79 mmHg; p<0.05) and NBG groups (1.67mmHg, 3.20 mm Hg, 6.13 mmHg, all p<0.05) demonstrated lower thresholds for first sensation, moderate sensation, and discomfort compared to healthy controls (9.75 mmHg, 16.25mmHg, 20.25mmHg). While most sensory thresholds in the BG group were lower in pre or post-prandial states compared to NBG, these differences were not significant (p=NS). Conclusion: Functional dyspepsia is associated with significant gastric visceral hypersensitivity in both the fasting and post-prandial state when compared to healthy subjects. However, our study did not reveal significant differences in sensory thresholds amongst dyspeptic patients with or without bile gastropathy.433 Figure 1. Mean pressure thresholds (mmHg) for first, moderate and discomfort sensations in patients with bile gastritis (BG), no bile gastritis (NBG), and controls, *indicates significant difference (p<0.05) in sensory thresholds between respective groups and controls.

Bile Gastritis Following Laparoscopic Single Anastomosis Gastric Bypass: Pilot Study to Assess Significance of Bilirubin Level in Gastric Aspirate.

Laparoscopic single anastomosis gastric bypass (SAGB) is increasingly performed for morbidly obese patients. This pilot study aims primarily at evaluating the incidence of bile gastritis after SAGB. The occurrence of reflux oesophagitis and reflux symptoms were also assessed. This study included 20 patients having no reflux symptoms. All patients underwent a SAGB as a primary bariatric procedure by a single surgeon. Patients included consented to have an upper GI endoscopy done at 6months postoperatively. Gastric aspirate was sent for bilirubin level assessment. Gastric and esophageal biopsies were submitted for histopathology and campylobacter-like organism (CLO) test. In our study, the rate of bile gastritis was 30%. In 18 patients, the level of bilirubin in gastric aspirate seems to be related to the degree of mucosal inflammation. The remaining two patients had microscopic moderate to severe gastritis with normal aspirate bilirubin level. Two patients with bilirubin level in aspirate more than 20mg/dl had severe oesophagitis, gastritis with erosions, and metaplasia. Relationship between bilirubin level and histopathological findings of gastric biopsy examination was statistically significant with a P value of 0.001. The incidence of bile gastritis in this cohort is higher than reported in the literature, and this may be worrying. The correlation between endoscopic findings and patients' symptoms is poor. Bilirubin level and pH in aspirate might be useful tools to confirm alkaline reflux. Its level might help to choose candidates for revision surgery after SAGB. This needs further validation with larger sample size.

Does She Have a Double Stomach?

Introduction: A 33-year-old female with history of GERD, Nissen fundoplication with truncal bilateral vagotomy, pyloroplasty, and gastrojejunostomy presented to our clinic with a history of gastroparesis, constipation, severe post-prandial abdominal pain, bloating, nausea, and vomiting that started after her gastrojejunostomy. Physical examination was significant for an abdominal succussion splash and mild epigastric tenderness. Labs were unremarkable. We recommended an EGD with duodenal aspirates, smart pill study, and antroduodenal manometry. EGD demonstrated severe bile gastritis, a large dilated stomach with absent motility, partially intact Nissen fundoplication, widely patent pyloroplasty, patent gastro-jejunostomy, and a 15-20 cm jejunal loop connecting back to the distal duodenum in a Roux-en-Y anastomosis. The smart pill demonstrated delayed gastric emptying and delayed whole gut/small bowel transit time. An increase in pH was noted upon entry of the smart pill into the small bowel, with a transient decrease in pH to gastric levels approximately 8 hours after entering the small bowel. The patient’s altered anatomy likely accounted for the smart pill entry into the jejunostomy, followed by entry into the duodenum approximately 20 cm distal to the pylorus as seen on EGD. The pill may have encountered an increased acidic environment at this point due to known pyloroplasty or secondary to transient retrograde movement back into the gastric antrum. The smart pill is an orally ingested, non-digestible data recording device that enables measurement of gastric emptying, and small bowel, colonic, and whole gut transit times, as well as pH, pressure, and temperature. The test was selected for this patient to evaluate gastroparesis refractory to medical therapy. The smart pill provided a single transit study to assess transit times and determine the presence of delayed gastric emptying throughout her GI tract. Furthermore, the pill demonstrated tracings consistent with altered anatomy status-post gastrojejunostomy, a possible cause for this patient’s gastroparesis with retrograde movement of food demonstrated by two distinct pH drops. This information was significant as it allowed us to appropriately direct therapy and provided improved causal understanding of her symptoms, as well as preventing the pursuit of therapeutic interventions that might worsen her symptoms, such as repeat surgery.Figure 1

Use the Duodenum, It’s Right There

This is the largest series to date comparing end-to-side biliary reconstruction for all indications performed using either the duodenum or jejunum and with at least 2-year follow-up. To demonstrate that duodenal anastomoses for biliary reconstruction are at least as safe and effective as Roux-en-Y jejunal anastomoses, with the benefits of operative simplicity and ease of postoperative endoscopic evaluation. Retrospective record review with telephone survey of patients undergoing nonpalliative biliary reconstruction in the hepatopancreatobiliary surgery division of a high-volume tertiary care facility. Biliary reconstruction via either end-to-side Roux-en-Y jejunal anastomosis or direct duodenal anastomosis. The primary end points were anastomosis-related complications (leak, cholangitis, bile gastritis, or stricture), and the secondary end points were overall complications, endoscopic or radiologic interventions, readmissions, and death. Ninety-six nonpalliative biliary reconstructions were performed between February 1, 2000, and November 23, 2011 for bile duct injury, cholangiocarcinoma, choledochal cysts, or benign strictures; the procedures included 59 duodenal reconstructions and 37 Roux-en-Y jejunal reconstructions. The groups were similar with regard to demographics, operative indications, postoperative length of stay, and mortality rates. However, anastomosis-related complications (leaks, cholangitis, or strictures) were fewer in the duodenal than the jejunal cohort (7 patients [12%] vs 13 [35%]; P = .009). Of patients with stricture, 5 of 9 in the jejunal cohort required percutaneous transhepatic access for management compared with only 1 of 2 in the duodenal cohort. Duodenal anastomosis is a safe, simple, and often preferable method for biliary reconstruction. This anastomosis can successfully be performed to all levels of the biliary tree with low rates of leak, stricture, cholangitis, and bile gastritis. When anastomotic complications do occur, there is less need for transhepatic intervention because of easier endoscopic access.

Forty years without symptoms after choledochogastrostomy

Introduction: The preferred surgical procedures for internal biliary drainage are choledochojejunostomy and choledochoduodenostomy. Cholangiogastrostomy is not recommended because of the potential risk of bile gastritis, and because reflux of gastric fluid into the biliary tree might occur and cause complications in the long run. Cholangiogastrostomy by surgery, endoscopy or by a combined fluoroscopic, endoscopic and laparoscopic approach have been described. However, these procedures were mostly used in patients with advanced malignant diseases and therefore data concerning the long-term risks of biliary drainage into the stomach are limited. To our best knowledge this is the first report about a patient who was free of symptoms during a follow-up period of several decades after choledochogastrostomy.

Experimental antral ulcer and several protective drugs

Antral ulcer may result from infection of Helicobacter pylori, duodenal bile reflux or gastritis. Several animal antral ulcer models were used to evaluate protection of drugs. Chemicals used to induce antral ulcer were diethyldithiocarbamate, indomethacin and strong acid solutions. Because these treatments produce damage of gastrointestinal tissues other than the antrum, most of these ulcer models cannot satisfactorily mimic the spontaneously occurring antral ulcer in human. Strong hydrochloride in refed rats also produce severe corpus lesions that might result from severe gastric oxidative stress. Oxyradical scavengers, including superoxide dismutase and allopurinol, improved antral ulcer healing. Other gastrointestinal drugs, such as prostaglandins, pirenzepine and lafutidine also were effective. Lysozyme, a mucolytic agent exerted remarkable inhibition of hemorrhagic antral and corpus ulcers in refed rats that had received strong hydrochloride. Mucolysate derived from the action of lysozyme produced elimination of gastric acid back-diffusion, which plays a pivotal role in gastric hemorrhage and antral ulceration.

A Technique for Converting the Roux-en-Y Gastric Bypass to a Modified Biliopancreatic Diversion.

Our group has performed the Roux-en-Y gastric bypass (RYGB) in 1450 patients since 1983: 805 patients had primary operations, and 645 were converted from previous gastroplasty procedures, i.e. horizontal gastroplasty, vertical banded gastroplasty, and gastrogastrostomy. Within the last 2 years, 38 patients who failed the RYGB were converted to a modified biliopancreatic diversion (BPD) using a technique that did not require dismantling a major portion of the original gastric exclusion. A 24-month follow-up has demonstrated a significant and sustained weight loss in all patients. In addition, the modified BPD completely eliminated the problem of reflux bile gastritis in those patients with a short Roux-en-Y jejunal limb.

Myoelectric effects and histology after stapled occlusion of the small bowel.

Braun enteroenterostomy with stapled occlusion of the afferent limb has been advocated to treat bile gastritis and to avoid the motility effects of Roux-en-Y gastrojejunostomy. However, the motility effects of stapled occlusion are unknown. Myoelectric activity and histologic features were studied after stapled occlusion of the small bowel in a canine model. A 35 cm "recirculating loop" was created with a side-to-side anastomosis, beginning 25 cm from the ligament of Treitz. Serosal electrodes were placed at 5 cm intervals on the loop; at a second operation in one dog and simultaneously in three dogs, the bowel was occluded midway between two electrodes with 4.8 mm staples. Fasting recordings were obtained at weekly intervals to 6 months after surgery and were analyzed for slow wave frequency proximal and distal to the staple line and for propagation time of phase 3 of the migrating myoelectric complex across the staple line. The side-to-side anastomosis did not alter myoelectric activity. However, after stapled occlusion of the small bowel, the slow wave frequency dropped from a mean of 18.2 +/- 0.4 cpm proximally to 15.4 +/- 1.0 cpm distally (p less than 0.05). This correlated with loss of myogenic continuity in three of four animals. Propagation of phase 3 slowed across the staple line (115 +/- 27 seconds versus 47 +/- 9 seconds) (p less than 0.02). The bowel lumen recannulated in all animals. Stapling across the small bowel alters myoelectric activity, and occlusion of the bowel lumen may not be permanent.

The prevalence of Campylobacter pylori gastritis: a study of symptomatic nonulcer dyspepsia and bile gastritis.

We assessed the prevalence of Campylobacter pylori in various forms of endoscopic gastritis, including ulcer and nonulcer dyspepsia and bile gastritis and correlated it with histological evidence of inflammation. Multiple biopsy specimens were taken from 120 patients, including four normal controls, who underwent upper gastrointestinal endoscopy for evaluation of upper abdominal pain and discomfort, nausea, bilious vomiting, weight loss, and anemia. The patients included 58 men and 62 women, with a mean age of 53 years. Of these, 16 patients had gastric ulcers, 19 had duodenal ulcers, 26 had reflux gastritis (after either gastric surgery or cholecystectomy), one had a gastric polyp, one had Barrett's esophagus, and the remaining 53 had gastritis due to unspecified causes. Campylobacter-like organisms were demonstrated by light and electron microscopy in 50 of 69 patients of the nonbile gastritis group (72%) and in seven of 15 patients of the bile gastritis group (47%) (p0.05). The presence of bacteria in both groups correlated with histologically significant inflammation (particularly chronic active gastritis); similar histologic changes were noted in both major groups of nonbile gastritis and bile gastritis. Campylobacter pylori is common in all forms of gastritis in association with histologic inflammation.

Diagnosis of symptomatic alkaline reflux gastritis and prediction of response to bile diversion operation by intragastric alkali provocation

Because accurate diagnosis of the alkaline reflux gastritis syndrome has been elusive, surgical treatment has had a high failure rate, particularly with respect to relief of pain. We have used intragastric infusion of alkali as a provocative test in 147 patients with symptoms and endoscopic findings suggestive of bile gastritis and in 19 asymptomatic control subjects. Subjects received saline solution, 0.1 normal hydrochloric acid, and 0.1 normal sodium hydroxide solutions, as well as their own gastric aspirates in random blinded fashion by a nasogastric tube. There were no complications. A positive test result was defined as pain with sodium hydroxide but not with saline solution or hydrochloric acid infusion. All of the control subjects had negative test results. A total of 87 percent of the symptomatic patients have been followed (mean 4.3 years, minimum 1 year); 47 of those 128 had a Roux-Y gastrojejunal reconstruction to divert duodenal contents from the stomach. Correlation of the test results and the subsequent clinical status showed 87 percent of those with negative test results improved spontaneously or with other treatment versus 15 percent if the test results were positive (p less than 0.001), and 78 percent of those with positive test results had lasting relief of pain after surgical diversion versus a 30 percent success rate if the test results were negative (p less than 0.01). We conclude that positive alkali infusion test results predict that symptoms will likely respond best to surgical diversion of duodenal contents, and that negative test results should be a strong deterrent to surgical diversion. The test is safe, simple, and deserves further trial.

Searching for the best weight reduction operation.

At the University of Minnesota under the supervision of one staff surgeon both jejunoileal bypass (JIB) and gastric bypass (GIB) operations have been performed for weight reduction in morbidly obese individuals. During the last 14 years 727 patients underwent end-to-end (40 to 4 cm) JIB and more than 570 patients underwent GIB. This report is based on a comparison of 205 JIBs performed between July 1975 and July 1979, 106 Alden-loop type GIBs (GIB-loop) performed between July 1975 and July 1979, 53 loop GIBs with enteroenterostomies between the limbs of the loop (GIB-EE) performed between May 1980 and May 1981, and 57 Roux-en-Y GIBs (GIB-Roux) performed between May 1981 and May 1982. Adequate weight loss occurred in 80% of the patients who returned for follow-up in all groups. The percentage of excess body weight loss was similar for the first year (65% for JIB, 62% for GIB-loop, 69% for GIB-EE, and 71% for GIB-Roux). The operative mortality and the immediate morbidity rates were uniformly low. The long-term complications for JIB were 37.7% arthralgia, 7.1% oxalate urolithiasis, 5.6% incisional hernia, and 1.4% liver failure. The complications for GIB-loop were 10.2% nausea/vomiting, 1.9% bile reflux gastritis, and 2.8% anastomotic problems; for GIB-EE 23% nausea/vomiting, 7% bile gastritis, 4.6% incisional hernia, and 3.7% anastomotic problems; and for GIB-Roux 16% nausea/vomiting and 1.7% anastomotic problems. The anastomotic problems consisted of afferent loop obstructions and stomal stenosis; there were no leaks. At 1 year plasma cholesterol reduction for JIB averaged 42% (p less than 0.001), GIB-loop 14% (p less than 0.001), GIB-EE 7% (NS), and GIB-Roux 17% (p less than 0.001). One year after operation 49% of 88 JIB patients showed progression of liver disease on sequential biopsy specimens and 20% improvement. In the 78 GIB patients with sequential biopsies, liver disease progressed in 8% and improved in 65%. In summary, comparable therapeutic weight reduction occurred with all the assessed procedures; however, the GIB-Roux was associated with far fewer serious long-term complications. At this time the GIB-Roux procedure is the weight reduction operation we recommend.

The histologic pattern of bile gastritis

Various nonspecific histologic findings have been described in gastric biopsies from patients with bile gastritis. In an attempt to identify any characteristic or specific histologic changes in such cases, we have blindly compared gastric biopsies from 23 symptomatic postgastrectomy patients with macroscopic gastritis with biopsies from 17 patients with macroscopic gastritis associated with peptic ulcer. It was shown that in bile gastritis the prominent histologic features were translucency of the surface epithelium, edema of the upper portion of the lamina propria, decrease of the parietal cells, and presence predominantly of neutral mucus in the cells of the surface epithelium and of the neck of the glands.

Alkaline reflux gastritis and esophagitis.

Alkaline reflux (bile) gastritis and esophagitis result from mucosal injury by duodenal contents. Bile gastritis occurs after gastric surgery, cholecystectomy, ampullary sphincteroplasty, and, rarely, in nonoperated patients. Diagnostic features include chronic, continuous epigastric pain, exacerbated by eating, bilious vomiting, weight loss, iron deficiency anemia, achlorhydria, gastritis, and intragastric bile. The pathophysiology probably relates to excess enterogastric reflux and bile-induced mucosal damage. There is no perfect diagnostic test, but chemical and scintigraphic documentation of enterogastric reflux, as well as provocative testing with alkali solutions, are promising new techniques. Medical therapy with antacids, H2 antagonists, bile salt absorbants, and metoclopramide has been without significant benefit. Prostaglandins and sucralfate are now being evaluated. Surgical therapy that diverts duodenal contents away from the stomach is usually of benefit in appropriately selected patients. Alkaline reflux esophagitis shares many features with alkaline gastritis.

Prevention of sepsis in gastroesophageal surgery.

AbstractSepsis is a common complication of gastric operations, particularly in hypochlorhydric patients such as those with gastroesophageal carcinoma, gastric ulcer, or if revision gastric surgery is required for bile gastritis. By contrast, the risks of sepsis are small for patients with a duodenal ulcer having a proximal gastric vagotomy. The risks of endogenous sepsis are determined by the preoperative bacterial flora of the stomach. High preoperative bacterial counts are rare if the fasting pH is less than 4.0, hence cimetidine therapy given immediately before operation could increase the risk of endogenous sepsis. Systemic antimicrobial prophylaxis with a broad‐spectrum cephalosporin or penicillin is advised for all patients receiving cimetidine before operation, for all patients requiring gastric resection or revision gastric operations, and for any others in whom the preoperative gastric pH is 4.0 or more.

Intragastric alkali infusion: a simple, accurate provocative test for diagnosis of symptomatic alkaline reflux gastritis.

Alkaline reflex gastritis is a disabling clinical syndrome, occurring most often after gastric surgery. It is characterized by abdominal pain and bilious vomiting, and, presumably, is due to gastric irritation by regurgitated duodenal contents. The only known effective treatment is by surgical diversion to prevent the duodenal reflux. Unfortunately, the clinical diagnosis is difficult to prove, and the results of surgery are too often disappointing because of inaccurate patient selection. This is a report of a new test for distinguishing patients with symptomatic bile reflux gastritis. The test consists of blind sequential infusion into the stomach, via nasogastric tube, of 20 ml of 0.1 N HCl, normal saline, 0.1 N NaOH, and the patient's own gastric contents. Each solution is given twice. A positive test is defined as reproduction of the patient's usual pain by NaOH, and/or gastric contents, but not by acid or saline. Fifteen of 21 patients with clinical symptoms and endoscopic findings suggesting bile gastritis had a positive alkali infusion test, while only one of 18 normal controls and none of 17 controls with other causes of abdominal pain had a positive test (p less than 0.001). Of the 21 patients with clinical-endoscopic bile gastritis, 15 have had surgical treatment by Roux-en-Y gastrojejunostomy. Nine of ten patients with positive test had excellent symptomatic relief after surgery. Zero of five patients with a negative test were relieved of pain after the operation. Tis simple test appears to be a sensitive, specific, and accurate means for selecting patients for surgical treatment of alkaline reflux gastritis.

Double choledochus with ectopic drainage into the stomach—A rare congenital anomaly of the biliary ductal system

A patient with an accessory bile duct originating from the left common hepatic duct and emptying into the stomach along the lesser curvature presented with periodic symptomatic bile gastritis. Reimplantation of the accessory duct into the duodenum relieved his symptoms.