Investigation of oesophageal reflux symptoms after gastric surgery with combined pH and bilirubin monitoring

Background: Little is known about the role of bile in gastro-oesophageal reflux disease in patients with previous gastric surgery. This has partly been due to a lack of suitable techniques for identifying bile reflux objectively. Methods: Some 28 patients with reflux symptoms and previous gastric surgery underwent oesophageal manometry, and 24-h ambulatory oesophageal pH and bilirubin monitoring. Results: A wide variety of operations had been performed, most commonly Polya gastrectomy (seven patients), vagotomy and pyloroplasty (six) and vagotomy and gastrojejunostomy (four). Three patients had isolated acid reflux, eight had isolated bile reflux, six had combined acid and bile reflux, and 11 patients had no reflux. Two-thirds of heartburn symptoms were not associated with reflux. However, one-quarter were associated with acid ref-lux and only 7 per cent with bile reflux. Erosive oesophagitis was present in five patients: two with combined acid and bile reflux, and three with isolated bile reflux. Conclusion: Acid and/or bile reflux can be present after a wide variety of gastric operations. Symptoms are more frequently associated with acid reflux than with bile reflux. Erosive oesophagitis can occur in the presence of isolated bile reflux. Combined pH and bilirubin monitoring determines the nature of the refluxate, and may help in the management of these patients.