Clinical, Endoscopic and Pathologic Manifestations of Bile Reflux Esophagitis
A.S. FARIVAR, MOHAMMAD
FARIVAR, CARITAS NORWOOD HOSPITAL and BOSTON UNIVERSITY
SCHOOL OF MEDICINE, NORWOOD, MA
Background: Bile induced esophagitis may be present in patients who have undergone
a total gastrectomy without a subsequent Roux procedure, in patients with a
Billroth II procedure, and in those suffering from atrophic gastritis associated
with achlorhydria. The pancreatic enzyme trypsin and uncoaugated bile salts
are suspected to be the cause of mucosal damage to the esophagus.
Patients and Methods: We retrospectively reviewed the medical records of 12
of our patients with documented bile induced gastroesophageal reflux disease.
There were six males and six females, ranging in age from 47-82 years. Eleven
patients had had a Billroth II performed 6-42 years prior to endoscopic evaluation;
eight for peptic ulcer disease and three for carcinoma of the stomach. One
patient suffered from atrophic gastritis associated with achlorhydria.
Clinical Symptoms: Six patients (50%) suffered from recurrent heartburn, eructation
and regurgitation; six patients (50%) complained of recurrent nausea and bilious
emesis; five patients (42%) had chest and upper abdominal pain; four patients
(33%) complained of occasional dysphagia; two patients (16%) were repeatedly
admitted for aspiration pneumonia; and one patient (8%) complained of a dry
Endoscopic Findings: Eleven patients (92%) had a patulous lower esophageal
sphincter; two patients (17%) had Barrett's Esophagus; three patients (25%)
had linear erythema and erosions (grades I and II erosive esophagitis); one
patient (8%) had a Schatzki's ring associated with linear erythema; and two
patients (17%) had a diffuse exudative esophagitis secondary to an efferent
loop obstruction. In nine instances, a gastric aspirate pH was measured, with
eight patients recording a pH of 8, and one patient had a reading of 6. Pathology:
Pathology confirmed Barrett's Esophagus in two patients. Two patients who were
suffering from severe bile reflux were reported to have an acute inflammatory
exudate and granulation tissue on pathology. Nine patients were noted to have
focal hyperplasia of the basal layer, coupled with mild acute and chronic inflammation.
Conclusion: In patients with bile reflux esophagitis, the clinical, endoscopic
and pathologic findings are similar to those seen with acid reflux esophagitis.
When reflux symptoms are present and studies such as 24 hour pH monitoring
is normal, consider ambulatory bilirubin monitoring or the use of isotope meal
to confirm the presence of bile induced gastroesophageal reflux disease.