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This prospective study involving 24 patients operated for postoperative reflux gastritis spanned over the period between 1974 and 1987. Diagnosis by exclusion was based on clinical, endoscopic and histological findings collected a few months to 16 years following surgery, the outcome of which was either alteration or destruction of the antropyloric sphincteral mechanism. All patients had Y-loop gastrojejunostomy performed according to Roux's procedure (at 50 cm). The clinical results as assessed on the basis of Visick's score and by gastroscopy were good. Anatomopathological examination of pre- and postoperative bioptic specimens blind-collected by a single operator indicated that foveolar hyperplasia is a good indicator of enterogastric reflux.

The possibility has been explored in dogs that the effects of chronic enteral reflux on the gastric mucosa may be modified by highly selective vagotomy (HSV). In both the innervated and the vagotomized stomachs, Roux-en-Y duodenogastrostomy induced mucosal hyperaemia and foveolar hyperplasia; the mucosa regained normal morphology after the elimination of reflux. Duodenogastrostomy without HSV did not influence basal serum gastrin but resulted in a significant increase in mucosal histamine. After duodenogastrostomy with HSV basal serum gastrin decreased significantly and mucosal histamine was not affected. It is concluded that foveolar hyperplasia is a reversible reaction of the mucosa to potentially damaging agents like enteral contents. It is also suggested that the combination of chronic enterogastric reflux, abnormal gastrointestinal motility and HSV might have an inhibitory effect on gastrin release.

The gastric emptying of a liquid meal (10% dextrose solution) and a semi-solid meal (minced meat, peas, potatoes and milk) was measured in the sitting position; both meals were 400 ml. Duodenogastric reflux was assessed supine after intravenous injection of 75 MBq of 99 mTc HIDA and cholecystokinin. Patients were ajudged reflux positive (R+), or reflux negative (R-) by looking at gamma camera pictures. Thirty-two duodenal ulcer patients (DU), 22 patients after truncal vagotomy and pyloroplasty (TV+P) and 21 after proximal gastric vagotomy (PGV) were studied. In DU sufferers the mean volume of early liquid emptying in R+ patients (74 ml) was similar to R- patients (78 ml). After TV+P early liquid emptying was greatly increased (mean 176 ml) but no difference was found between R+ and R- patients. After PGV excessive early emptying was less common but emptying was significantly greater in R+ patients (R+ mean = 132 ml, SD = 48 n = 8; R- mean = 63 ml, SD = 21, N = 13: t = 4.2 p less than 0.001). There was no difference in solid meal emptying between R+ and R- patients in any group.

The present study was undertaken to examine the ultrastructure of antral foveolar epithelium of dogs submitted to long term duodenogastric reflux. Minimal ultrastructural alterations (swelling of the cellular organelles, shortening of the microvilli, irregularity of the secretory granules) were observed. Total necrosis of isolated cells was rare. The lesions appeared in all dogs including the controls, and were not always reversed by the elimination of reflux. The significance of these findings is not clear and is probably not dependent on continuous exposure to duodenogastric reflux.

Using 99mTc diethyl HIDA, we have examined patients with duodenal and gastric ulceration for the effect of naso-gastric intubation on bile reflux. Fourteen patients with duodenal ulceration were studied supine under a gamma camera. Activity from the stomach area showed no significant change before and after naso-gastric intubation (Mann-Whitney U = 0.18). Nineteen patients with gastric ulceration were investigated for bile reflux using two techniques. One method used the gamma camera but without naso-gastric intubation. The other method involved passing a naso-gastric tube and aspirating aliquots of a liquid meal which were analysed for 99mTc HIDA content. The incidence of bile reflux in patients with gastric ulceration was the same when the results of the two methods were compared. We conclude that investigation of groups of patients for duodeno-gastric reflux by naso-gastric aspiration of gastric contents is a valid technique.

In the course of a long-lasting experiment on entero-gastric reflux in the dog, we examined with the SEM the gastric mucosal surface epithelium in 22 animals chronically exposed to any type of enteral diversion to the stomach, associated in one group to a highly selective vagotomy. Tissue samples were collected at the time of corrective surgery and at sacrifice in the survivors. The control group was composed of 4 dogs with Roux-en-Y loops. At remedial surgery, about half the dogs failed to display any cellular alteration, regardless of the group they belonged to. The isolated biliary reflux group alone showed fundic erosions in 100% of the dogs. In the antral area, the isolated pancreatic reflux appeared to be the most damaging. Similar erosions were found in the antrum and the fundus of the majority of control dogs. Six to twelve months after suppression of the reflux, the erosions showed a tendency to incomplete regression, and more often to progression. We advocate the protective role of the chronic alkaline reflux on the gastric mucosa to explain our results.

Thirty-six volunteers, asymptomatic 7 to 22 years after various operations for duodenal ulcer, were screened for enterogastric reflux by external scanning following injection of 99mTc HIDA; they also had endoscopy for measurement of the fasting juice pH, and multiple biopsies. In patients with a pH above 4 there was an association between a positive bile reflux test and the presence of pre-malignant changes in the gastric mucosa. Carcinoembryonic antigen in the gastric mucosa was found in all patients and was not, therefore, a useful screening test for stump cancer. Blind examination of two sets of endoscopic biopsies obtained 6 weeks apart in symptomatic patients with post-operative reflux gastritis showed that histological assessment remained reproducible. Gastric biopsies obtained from 16 patients before, and a year after, Roux-en-Y gastro-jejunostomy demonstrated that foveolar hyperplasia tended to regress after bile diversion.

Using 99mTc diethyl HIDA, a gamma camera was used to assess duodenogastric reflux of bile in the supine position in control patients and patients with active duodenal ulceration. Cholecystokinin was injected intravenously during the test to contract the gall bladder. Patients with benign gastric ulcers, and a group of age matched controls, were investigated for duodenogastric bile reflux in the sitting position by a nasogastric aspiration technique after a 10% dextrose meal. Of 60 patients with duodenal ulceration 32 (53%) were reflux positive, and of 13 control patients 6 (46%) were positive. Of 30 patients with gastric ulceration 17 (53%) were reflux positive, and 8 out of 15 (53%) control subjects were positive. The incidence of duodenogastric reflux assessed supine in the fasting state, and seated after a liquid meal, was similar in patients with peptic ulceration and in normal controls.

Reflux gastritis is a controversial topic. On the basis of clinical, experimental and endoscopic data, most authors regard it as a possible sequel of any operation that abolishes antro-pyloric continence; they treat it by a 50 cm Roux-en-Y-loop. However several recent publications have questioned the very existence of this syndrome. Contrary to initial hopes, quantitation of reflux by 99mTc HIDA cholescintigraphy has not settled this debate. Scintigraphy seems to be of limited value in selecting patients likely to be improved by the surgical correction of reflux. In the future, the environment into which reflux occurs should be investigated more thoroughly.

The gastric mucosa of 19 mongrel dogs was submitted to a bilio-pancreatic, isolated biliary or isolated pancreatic reflux. With an isolated biliary reflux, there is a more rapid and more severe hyperaemia and foveolar hyperplasia of the mucosa of the fundus than with an isolated pancreatic reflux. There was no significant change in the basal serum level of gastrin with any of these different types of alkaline reflux, but we observed a statistically significant increase in the level of histamine in the gastric mucosa. Hyperaemia and foveolar hyperplasia of the fundic mucosa both disappeared when the alkaline reflux was suppressed, and there was a statistically significant decrease in the basal serum level of gastrin and in the level of histamine in the gastric mucosa.