Abstracts
1997 Digestive Disease Week

Bile reflux in benign and malignant Barrett's esophagus and effect of Nissen fundoplication.

HJ Stein, WKH Kauer, H Feussner, JR Siewert. Department of Surgery, Klinikum rechts der Isar, Technische Universitat Munchen, Germany.

Combination of acid and bile reflux has been implicated in the pathogenesis and malignant degeneration of Barrett's esophagus. We assessed acid and bile reflux in patients with gastroesophageal reflux disease (GERD) with and without esophageal mucosal injury and in patients with Barrett's esophagus with and without high grade dysplasia (HGD) or early cancer.

Material and Methods: Ambulatory esophageal measurement of acid and bile reflux was performed with the previously validated fiberoptic bilirubin monitoring system (BILITEC 2000) combined with a pH probe in 19 asymptomatic volunteers, 15 patients with GERD but no mucosal injury, 24 patients with GERD and erosive esophagitis, 25 patients with Barrett's esophagus and no evidence of carcinoma or HGD on multiple biopsies and 12 patients with Barrett's esophagus with HGD or early invasive adenocarcinoma (T1 on endoscopic ultrasound). Barrett's esophagus was defined by the endoscopic documentation of a columnar epithelial lining of the distal esophagus over at least 3 cms and the histologic confirmation of specialized columnar epithelium. 12 GERD patients volunteered for repeat studies 6 months after laparoscopic Nissen fundoplication.

Results: The mean esophageal acid and bile exposure time showed an exponential increase from GERD patients without esophagitis to those with erosive esophagitis and benign Barrett's esophagus and was highest in patients with HGD or early carcinoma in Barrett's esophagus (p<0.01). Pathologic esophageal bile exposure was documented in none of the asymptomatic volunteers, 1/15 (7%) GERD patients without esophagitis, 5/24 (21%) patients with erosive esophagitis, 15/27 (55%) patients with benign Barrett's esophagus and 10/12 (83%) patients with early adenocarcinoma or HGD in Barrett's esophagus. Bile reflux occurred primarily during the postprandial and supine monitoring periods and was usually associated with episodes of acid reflux. Nissen fundoplication resulted in complete suppression of acid and bile reflux in 11/12 studied patients.

Conclusion: Bile reflux into the esophagus increases exponentially with increasing severity of esophageal mucosal injury in patients with GERD and is particularly prevalent in patients with Barrett's esophagus and HGD or early cancer. Acid and bile reflux into the esophagus can be completely suppressed by laparoscopic Nissen fundoplication.