REFLUX ALKALINE GASTRITIS* SYRACUSE, NEW YORK

Transcription

1 VOL. 115, No. 2 REFLUX ALKALINE GASTRITIS* By SEUK KY KIM, M.D.,t LLOYD S. ROGERS, M.D.,t and ROBERT E. HEITZMAN, M.D. SYRACUSE, NEW YORK E ARLY physiologists thought that gastric acid was partly controlled by regurgitation of duodenal alkaline juice and claimed that the regurgitation was physiologic. However, in 1947 Lambling and Gosset,2 after their experiments and clinical study, refuted the theory of physiologic duodenal reflux. For the first time they described 3 cases of alkaline gastritis from the regurgitation of the biliary-pancreatic juice. As usual, this new theory of reflux alkaline gastritis aroused only skepticism and was then ignored. There are various annoying complications after gastric surgery for peptic ulcer disease; i.e., dumping syndrome, afferent loop syndrome, stoma! dysfunction, etc. It would seem that surgeons distressed by these postgastrectomy syndromes resurrected the idea of reflux alkaline gastritis and have reported cases of this entity recently. In 1964, Lawson did experimental gastric operations on 12 dogs to allow reflux of duodenal contents into the stomach. The conclusion of this study was that in dogs, reflux of duodenal contents into the stomach causes chronic gastritis. In 1968, Bartlett and Burrington reported 5 cases of bilious vomiting after gastric surgery and 3 of these cases showed reflux alkaline gastritis. In 1969, Henderson et al. reported #{231} cases of reflux alkaline gastritis as a late complication of gastric surgery. The daily output of biliary pancreatic juice in normal individuals amounts to more than 2,000 cc. In a state of hypoacidity or achlorhydria, constant duodenal reflux into the stomach irritates the gastric mucosa resulting in alkaline gastritis. Biliary pancreatic juice is a complicated chemical. Which irritants cause this gastritis is not certain. The juice is alkaline and this gastritis occurs in a state of achlorhydria. It is called reflux alkaline gastritis. The cases reported by Lambling and Gosset2 did not have any gastric surgery. However, alkaline gastritis usually occurs as a late complication of gastric surgery for peptic ulcer. Vagotomy induces hypoacidity which frequently develops into ach!orhydria at an older age. Pyloroplasty and gastroenteroanastomosis may facilitate reflux of duodenal contents into the stomach, allowing constant bathing of gastric mucosa by biliary pancreatic juice. REPORT OF A CASE The patient, a 68 year old white woman, was admitted to the hospital in October 1968 because of epigastric pain and repeated bouts of vomiting for the last 6 months. These symptoms were aggravated by eating and were not relieved by alkalizing agents or milk products. She had a subtotal gastrectomy for antral cancer in 1949, and a cholecystectomy for gallstones in On admission, physical examination was not remarkable except for epigastric tenderness. The hemoglobin was 14 gm. per cent. Gastric analysis revealed histamin fast achlorhydria. The upper gastrointestinal series demonstrated a Billroth II type of gastroenteroanastomosis (Fig. i, p1-c). The gastric pouch was rigid and had prominent folds with polypoid nodules along the stoma. The opening of the anastomotic stoma was unusually wide, which may have allowed free reflux of duodenal juice. The jejunal mucosa appeared to be normal. The roentgenographic impression was recurrent gastric cancer or alkaline gastritis. * Presented at the Seventy-first Annual Meeting of the American Roentgen Ray Society, Miami Beach, Florida, September 29- October 2, From the Department of Radiology, State University Hospital, Syracuse, New York. t Associate Professor of Radiology. Professor of Surgery. Professor of Radiology. 271

2 272 S. K. Kim, L. S. Rogers and R. E. Heitzman JUNE, 1972 HFIG.. (A-C) Billroth II type of gastroenteroanastomosis. A=afferent loop in C. The stoma (black arrows in B) is excessively wide, allowing free reflux of duodenal juice. The gastric pouch is rigid with prominent folds. Polypoid nodules along the stomach are seen (white arrows in C). The jejunal mucosa isintact. Gastroscopy revealed reddened polypoid swelling of the gastric folds at the anastomosis. Gastric biopsy disclosed acute and chronic inflammation. In view of achiorhydria and bilious vomiting, the diagnosis of alkaline gastritis was made. Revision of the gastroenteroanastomosis was done to prevent reflux of biliary pancreatic juice. The afferent loop was amputated and connected to the distal limb of the efferent loop forming a Roux-en Y anastomosis. Postoperatively the patient has been asymptomatic for the last 3 years. One month followup roentgenographic study showed normal folds of the gastric pouch and anastomosis (Fig. 2, ii and B). DISCUSSION This case is unusual in that the gastritis developed after cancer surgery and that the roentgenographic findings were remarkable. The previously reported 8 cases of reflux alkaline gastritis all had gastric surgery for peptic ulcer disease and only I of these cases showed the positive roentgen finding of a lesser curvature ulcer. Diagnosis of reflux alkaline gastritis is usually made by gastric analysis and gastroscopy. Inflammation of gastric mucosa should be observed under the condition of hypoacidity or achlorhydria. Usually gastritis is not well demonstrated by roentgenography. Occasionally, we may observe the roentgenographic changes as we did in this case. In cases of post gastroenteroanastomosis, the target organ of peptic ulceration is the small intestinal mucosa, and that of alkaline irritant is the gastric mucosa. Therefore,

3 VOL. 115, No. 2 Reflux Alkaline Gastritis 273 FIG. 2. (A and B) One month postoperative the follow-up study shows loss of the afferent loop (B, B ). The previously seen prominent gastric folds have disappeared. The gastric pouch is easily distensive with air (B ). so-called marginal peptic ulcers occur at the jejuna! side of the anastomosis. The gastric pouch usually is intact. In contrast, reflux alkaline gastritis involves the gastric side of the anastomosis, and the small bowel is unaffected. Therefore, when we observe a gastric pouch abnormality, such as an ulcer or prominent gastric folds especially along the stoma, the possibility of reflux alkaline gastritis should be entertained. Review of the reported cases2 4 shows that development of alkaline gastritis after gastric surgery varies from 3 to 30 years. The patient with this condition usually suffers from intractable epigastric distress with or without bilious vomiting. Severe gastritis may lead to bleeding and chronic anemia. The symptoms will not be relieved by milk or alkaline agents. Diagnosis is often delayed because this condition is not well recognized by many clinicians. It can be treated only by surgical prevention of the biliary reflux or by acid medications. SUMMARY One of the postoperative complications of gastric surgery is the reflux of pancreatic and biliary secretions, causing alkaline gastritis which develops in the presence of hypoacidity or achlorhydria. The diagnosis is usually made by gastroscopy and biopsy. Inflammation and/or ulceration occurs on the gastric side of the anastomosis in contrast to marginal ulcers which involve the small intestinal mucosa.

4 274 S. K. Kim, L. S. Rogers and R. E. Heitzman JUNE, 1972 These changes can be observed roentgenographically and the diagnosis of alkaline gastritis should be considered. Seuk Ky Kim, M.D. Department of Radiology State University Hospital Syracuse, New York REFERENCES I. BARTLETT, M. K., and BURRINGTON, J. D. Bilious vomiting after gastric surgery. A.M.A. Arch. Surg., 3968, 97, LAMBLING, A., and GOSSET, J. R. Le reflux des s#{233}cr#{233}tions alcalines duod#{233}no-pa ncr#{233}a tico-biliaires en physio-pathologie gastrique. Arch. mal. app. dig., 1947,38, LAWSON, H. H. Effect of duodenal contents on gastric mucosa under experimental condition. Lancet, 3964, I, VAN HEEFDEN, J. A., PRIESTLEY, J. T., FARROW, G. M., and PHILLIPS, S. F. Postoperative alkaline reflux gastritis. Am. 7. Surg., 1969, zz8,

5 This article has been cited by: 1. Romeo S. Berardi, Dawood Siroospour, Raul Ruiz, William Carnes, K.A. Devaiah, Carl Peterson, William E. Becknell, Jose Olivencia Alkaline reflux gastritis. The American Journal of Surgery 132:5, [CrossRef]