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 cough.

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.