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.
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, 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.
We have examined the pharmacokinetics of 99mTc diethyl HIDA in five patients with a T-tube inserted into their common bile duct after choledocotomy. Blood clearance was rapid with 27.5% of the injected dose in the circulation at 2.5 min and 5% at 30 min. The peak bile excretion of 15.4% occurred between 45 and 60 min after injection of the HIDA. By 2 h 69% of the dose was excreted in the bile and 14% in the urine. In a second group of 33 patients a naso-gastric tube was passed after injection of HIDA. The patients drank 400 ml of 10% dextrose and aliquots of the stomach contents were aspirated every 10 min for an hour. In specimens with a pH greater than 4, the amount of HIDA correlated well (p less than 0.01) with the amount of bile acid determined by an enzymatic method.
71 patients participated in a double-blind trial which compared proximal gastric vagotomy (PVG) with vagotomy and antrectomy (V & A). 82 percent of the patients subsequently volunteered for endoscopy 6 to 12 months after operation and 65 percent for measurement of fasting bile reflux (FBR) and peak acid output (PAO). The results of these follow-up assessments are given in this paper. None of the 36 patients who had undergone V & A had a recurrent ulcer; in contrast ulcers or fresh scars were found in 5 of 35 patients after PGV, even in 2 who had no symptoms. Erythema of the gastric mucosa was seen more commonly after V & A than PGV. Such erythema was associated with high levels of fasting bile reflux (an objective measure of reflux of bile into the stomach) and with symptoms of bile vomiting and mild epigastric pain. High levels of fasting bile reflux were not found after PGV. Histological gastritis of the proximal stomach was equally common after both operations in patients without a recurrent ulcer. Gastritis was not related to endoscopic mucosal erythema or fasting bile reflux, but did correlate with peak acid output. These results confirm that bile reflux is associated with mucosal erythema and symptoms after V & A but that significant bile reflux does not occur after PGV. However, bile reflux is not related to gastritis, which appears to be the result of an operation (either PGV or V & A) which successfully reduces peak acid output.
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.
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