Duodenoastric reflux is the throwing of the contents of the duodenum into the stomach cavity. As an independent disease is rare, it is much more often a symptom of another pathology of the gastrointestinal tract. It is manifested by pain and dyspeptic syndromes: there are indefinite diffuse abdominal pains, heartburn, belching, nausea, vomiting, yellowish plaque on the tongue. Diagnosis is not difficult: for this purpose, EGDS, electrogastroenterography, round-the-clock intragastric pH-metry are used. In the complex of treatment, prokinetics, drugs to reduce stomach acidity, antacids are used.
Duodenal-gastric reflux is a condition that is not always a sign of pathology of the digestive tract, the throwing of duodenal contents into the stomach is detected in about 15% of the healthy population, mainly at night. This condition is considered pathological if, with daily intragastric pH-metry, there is an increase in the acidity of gastric juice above 5, unrelated to food intake and persisting for more than 10% of the time.
Duodenoastric reflux accompanies many diseases of the initial parts of the digestive tract, however, in about 30% of patients it can be considered as an isolated pathology. The condition accompanies functional and organic diseases of the gastrointestinal tract, also often develops in the postoperative period of cholecystectomy, suturing of the ulcer of the duodenum. Some authors note that the disorder occurs in 45-100% of all chronic diseases of the stomach and duodenum. Men and women suffer equally.
Causes of duodenoastric reflux
Several factors are important in the development of duodenoastric reflux: insufficiency of the pyloric part of the stomach with a yawning of the pylorus, impaired motility of the stomach and duodenum, increased pressure in the initial parts of the small intestine, aggressive effect of the contents of the duodenum on the gastric mucosa.
Bile acids and pancreatic enzymes damage the protective barrier of the gastric mucosa; provoke the reverse diffusion of hydrogen ions into the deep layers of the stomach wall (this leads to an increase in acidity); stimulate the production of gastrin by antral glands and damage the lipid membranes of cells, increasing their sensitivity to the components of gastric juice. In addition, due to the retrograde casting of the duodenal contents, the pressure in the stomach cavity increases.
Throwing the contents of the duodenum into the stomach often accompanies diseases such as chronic gastritis, gastric ulcer and duodenal ulcer, stomach cancer, violation of the tone of the Oddi sphincter, duodenostasis. Often the condition occurs in patients who have undergone gallbladder removal surgery, duodenal ulcer suturing. Violation of the motility of the stomach and the initial parts of the small intestine is the primary cause of reflux in functional diseases of the gastrointestinal tract, and in organic pathology, motor disorders are secondary.
Discoordination of motility leads to a violation of the evacuation of the contents of the stomach and the duodenum, which leads to gastro- and duodenostasis, reverse peristalsis, and the throwing of duodenal masses into the stomach cavity. Dysmotor disorders can be observed in various parts of the digestive tract, combined with the pathology of the gatekeeper: normal stomach tone, accompanied by pylorospasm and duodenostasis, or hypotension of the stomach in combination with yawning of the pylorus, hypertension of the duodenum.
Previously, it was believed that the condition is a protective reaction to the inflammatory process in the stomach and the increased acidity of the gastric juice entering the duodenum: allegedly, duodenal juice, when it enters the stomach, alkalizes its contents, which prevents further damage to the duodenal mucosa.
However, to date, it has been proven that bile acids contained in duodenal juice not only damage the gastric mucosal barrier, but also provoke reverse diffusion of hydrogen ions into the submucosal layer, stimulate gastrin secretion by the antral glands, which leads to an even greater increase in acidity in the stomach. Thus, the ulcerogenic effect of duodenoastric reflux was substantiated and the theory of its protective nature was refuted.
Symptoms of duodenoastric reflux
The symptoms of duodenoastric reflux are nonspecific and are inherent in many diseases of the gastrointestinal tract. First of all, these are diffuse indefinite pains in the upper abdomen, most often spastic, occurring some time after eating. Patients complain of increased flatulence, heartburn (with any acidity of the stomach), regurgitation with acid and food, belching with air, vomiting with an admixture of bile. A feeling of bitterness in the mouth, a yellowish coating on the tongue is mandatory. Long-term reflux can cause serious changes in the stomach and esophagus.
Initially, an increase in pressure in the stomach cavity leads to the development of gastroesophageal reflux disease. In the future, bile acids and pancreatic enzymes cause specific changes in the esophageal mucosa, intestinal metaplasia, which can lead to the development of adenocarcinoma – one of the most malignant tumors of the esophagus. The most likely outcome of the condition with untimely diagnosis and lack of rational treatment is toxic-chemical gastritis type C. The occurrence of this disease is predisposed by the constant throwing of bile into the stomach and chemical damage to the mucous barrier.
The diagnosis of duodenoastric reflux at the consultation of a gastroenterologist can be difficult, since this disease has no specific signs. Quite often, the condition is detected accidentally during examinations for other diseases of the digestive tract.
To verify the diagnosis, a consultation of an endoscopist is required: only he will be able to determine the necessary scope of examination, make a differential diagnosis with other pathology of the stomach and duodenum (gastritis with high acidity, erosive gastritis, duodenitis, stomach ulcer). It should be remembered that esophagogastroduodenoscopy itself can cause reflux. A distinctive feature of induced EGDS and pathological reflux will be the presence of bile in the stomach in the second case.
The most reliable diagnostic method is round-the-clock intragastric pH-metry. During the study, all fluctuations in the acidity of gastric juice are recorded, especially not related to meals. To obtain more accurate results, the study of the pH fluctuations of gastric juice is carried out during the night, when the patient does not take food and does not experience physical exertion.
electrogastrography, antroduodenal manometry will help to confirm the diagnosis – during these studies, discoordination of the motility of the stomach and duodenum, hypotension of the initial parts of the digestive tract can be detected. Gastric juice is also examined to detect digestive enzymes of the pancreas and bile acids in it. To exclude other diseases of the digestive system that have symptoms similar to duodenoastric reflux (acute cholecystitis, pancreatitis, cholangitis, cholelithiasis, etc.), ultrasound of the abdominal cavity will help.
Treatment of duodenoastric reflux
Usually, the patient’s condition does not require hospitalization in a hospital, however, a short-term stay in the gastroenterology department may be necessary to conduct a full-fledged examination. Clear clinical recommendations regarding the treatment of this condition have been developed. They include the appointment of drugs that normalize the motility of the initial parts of the digestive tract, modern selective prokinetics (enhance peristalsis of the stomach and duodenum, improving the evacuation of their contents), bile acid inhibitors, proton pump blockers and antacids.
However, one drug treatment is not enough, the patient must be warned about the need for a radical change in lifestyle. You should give up smoking, drinking alcohol, coffee. Uncontrolled medication intake is also a predisposing factor for the development of reflux, therefore, it is necessary to warn the patient against unauthorized intake of NSAIDs, choleretic drugs and other medications.
Of great importance in the development of the condition is poor nutrition and the resulting obesity. To achieve the desired therapeutic effect, it is necessary to normalize body weight and prevent obesity in the future. It is necessary to abandon spicy, fried and extractive foods. In the acute period of the disease, compliance with a special diet is required: food should be consumed in small portions, at least 4-5 times a day. After each meal, you should maintain an upright position for at least an hour, avoid heavy physical exertion. In the diet, preference is given to low-fat varieties of meat, cereals, fermented dairy products, vegetables and sweet fruits.
Prognosis and prevention
The prognosis with timely diagnosis and careful compliance with all recommendations of the gastroenterologist is favorable. Prevention consists in observing a proper diet that ensures normal motility of the gastrointestinal tract. Of great importance in the prevention of this disease is the refusal of alcohol and cigarettes.