Importance of duodenogastric reflux in gastro-oesophageal reflux disease

Background: Bile in the oesophagus occurs frequently in patients with gastro-oesophageal reflux disease (GORD) and has been linked to Barrett's metaplasia and cancer. Although duodenogastric reflux is a prerequisite for bile in the oesophagus, little is known about its importance in GORD. Methods: Some 341 patients with GORD were assessed by simultaneous 24-h gastric and oesophageal bilirubin monitoring. Definitions of increased bilirubin exposure were based on the 95th percentiles in healthy volunteers. The relationship between gastric and oesophageal bilirubin exposure and the correlation with disease severity were analysed. Results: Of the 341 patients with GORD, 130 (38.1 per cent) had increased gastric and 173 (50.7 per cent) had increased oesophageal bilirubin exposure. Of the 173 patients with bile in the oesophagus, 89 (51.4 per cent) had normal and 84 (48.6 per cent) had increased gastric bilirubin exposure. Of these 84 patients, 75 (89 per cent) had oesophagitis or Barrett's oesophagus (P = 0.003). These effects were mainly related to differences in supine reflux. Conclusion: Bile in the oesophagus originates from either normal or increased gastric bilirubin exposure. Patients with increased duodenogastric reflux are more likely to have oesophagitis or Barrett's oesophagus. These findings highlight the role of duodenogastric reflux as an additional factor in the pathogenesis of GORD.