In order to explain the symptoms of Bile Reflux and how they occur, answering some of the questions below will help you understand the disease more easily.
WHAT IS SAFRA?
Bile is a secretion produced by the liver.
WHAT ARE THE FUNCTIONS OF SAFRA?
Bile has two functions. First, it ensures that substances that undergo decomposition in the liver are eliminated from the body. Its second function is the digestion of fats and the absorption of fat-soluble vitamins (vitamins A, D, E and K) from the intestine.
WHAT IS GALLBLADDER?
The gallbladder is a pear-shaped, hollow, bag-like organ attached to the right lobe of the liver, 7-8 cm long and 3-4 cm wide at its widest point.
WHAT ARE THE BILE TRAINS?
Bile ducts are the name given to the channel system that ensures the flow of bile produced in the liver to the gallbladder and/or intestine, which is an intermediate station.
WHERE DOES Bile FLOW IN THE INTESTINE?
Bile flows through the bile ducts to the region called the duodenum 2nd continent (12 finger intestines), 10-12 cm ahead of the stomach exit.
WHAT IS THE VOLUME OF THE GALLBLADDER?
The volume of the gallbladder varies between 35-65 cc.
WHAT IS THE USE OF GALLBLADDER?
The gallbladder is the preliminary storage and concentration area of the bile produced in the liver, approximately 1500-2000 cc per day, before flowing into the intestine. bile, bile produced by the liverIt is stored by concentrating approximately 10 times (5-20 times) in its sac. In proportion to the fat content of the foods we eat, bile, concentrated enough for fats to be digested, flows into the second continent of the duodenum with the contraction of the gallbladder.
WHAT HAPPENS AFTER THE GALLBLADDER IS SURGICALLY REMOVED?
In cases where the gallbladder is surgically removed due to any reason (gallbladder stone, gallbladder polyp, gallbladder tumor, etc.), bile flows into the intestine (duodenum) continuously in proportion to the rate of production in the liver. While 150-200 cc of concentrated bile flows into the duodenum when it is needed, in the amount needed, when the gallbladder is present, 150-2000 cc of concentrated bile flows into the duodenum continuously, regardless of need, and at the same density as it is produced in the liver, unconcentrated, after the gallbladder is removed. Due to the flow of bile at a volume ten times normal into the duodenum, in cases where the PILOR, which is located at the exit of the stomach and acts as a kind of valve, is poorly functional or dysfunctional, some of the bile leaks into the stomach (BILE REFLUX). As a result, stomach disorders may develop. Due to surgical removal of the gallbladder, problems occur in the digestion and absorption of fats and fat-soluble vitamins.
WHAT IS BILE REFLUX?
Bile Reflux means bile leaking into the stomach. In every person, some bile may leak into the stomach at certain periods and this situation is called Physiological Bile Reflux. However, as the amount of reflux increases, a condition called Alkaline Reflux Gastritis occurs, which is considered a disease.
WHO HAS BILE REFLUX MORE?
Bile Reflux is seen in people whose valve system called PILOR, located at the exit of the stomach, is weak. Normally, the direction of flow of contents in the digestive system is always forward, and backward movement is a pathological process. In cases where the gallbladder is removed or the internal volume of the gallbladder is occupied by a stone or mass, since the gallbladder cannot fulfill its adequate storage function, the bile produced by the liver flows into the duodenum in high volume without being concentrated or less concentrated, and some of the bile is produced by a mechanism that can be called the overflow effect. Stomach leakage occurs in these people with PYLORIC DYSFUNCTION. Complaints occur depending on the amount of bile escaping and the duration.
WHAT IS PYLOOR?
PYLOOR is a muscle bundle located at the exit of the stomach. The pylorus works like a VALVE at the exit of the stomach, thus performing the functions of storing the food we eat in the stomach, controlling the flow of pre-digested food in the stomach to the duodenum, and preventing the duodenal content from flowing back into the stomach.
WHAT IS PYLORIC INSUFFICIENCY (DYSFUNCTION)?
PYLORIC INSUFFICIENCY is the condition in which the pylorus cannot perform its VALVE function at all or partially. If the pylorus is in normal function, it is called NORMOTONIC PYLOR, if there is partial leakage, it is called HYPOTONIC PYLOOR, and if it is completely dysfunctional, it is called ATONIC PYLOR.
WHAT CAUSES BILE REFLUX?
Bile Reflux, Alkaline Reflux can cause gastritis, heartburn, intestinal infections, frequent diarrhea, digestive system flora disorder, flora dysbiosis, Helicobacter Pylori infection in the stomach, intestinal discomfort, excessive gas, belching, abdominal pain, bad breath, sleep disorder, malnutrition, etc. . why could it be.
WHAT ARE THE SYMPTOMS OF BILE REFLUX?
Bile Reflux Symptoms; Abdominal pain, constant burning sensation in the stomach, decreased complaints after meals, increased complaints during hunger, weight loss, bad breath, excessive gas, burping, intestinal discomfort, malnutrition, frequent diarrhea, etc.
HOW IS Bile Reflux Diagnosed?
Bile Reflux is diagnosed by endoscopic examination. During endoscopy, bilious green content is observed in the stomach. Alkaline Reflux Gastritis is observed due to the effect of bile entering the stomach (redness, edema, sometimes bleeding areas, ulcers, etc. on the inner surface of the stomach). In the endoscopic examination, when light mechanical stimulation is applied to the stomach outlet with the tip of the endoscopy device, the PILOR normally closes, this is called the normal pyloric structure (NORMOTONIC PYLORO). However, in patients with bile reflux, in endoscopic examination, the pylorus is observed either not closing completely (HYPOTONIC PYLOOR) or not closing at all (ATONIC PYLOOR).
BY WHICH MECHANISM DOES BILE REFLUX DAMAGE THE STOMACH?
The stomach is an acidic environment and the pH is 1.5-2. Bile is basic and its pH is 8-8.5. Bile escaping into the stomach erodes the structure called MUCUS, which protects the inner surface of the stomach from external influences, and creates a CHEMICAL BASIC BURN on the inner surface of the stomach. Due to this basic burn, ALKALINE REFLUX GASTRITIS occurs.
HOW IS BILE REFLUX TREATED?
In Bile Reflux, the stomach surface is tried to be protected by giving surface coating drugs to prevent bile from coming into contact with the stomach surface. However, bile reflux cannot be treated permanently without eliminating the main problem. To treat bile reflux, it is necessary to either restore the function of the pylorus or perform surgeries that change the anatomical structure that will prevent bile from flowing back into the stomach. We clinically apply the technique we call PYLOOR REVISION, which restores function to the pylorus by endoscopically injecting filler around the pylorus without disturbing the existing anatomy. If the pylorus cannot be restored to function, the other treatment to be performed is Duodenal Switch surgery.
WHAT IS PYLORIC REVISION?
PYLORA REVISION is an endoscopic interventional procedure performed to prevent pyloric leakage in patients whose pylorus does not close completely or at all.
HOW IS PYLORIC REVISION DONE?
Pyloric Revision is the process of closing the opening causing leakage in the pylorus by performing filler injections around the pylorus of patients with HYPOTONIC and ATONIC pylorus by entering endoscopically under sedation anesthesia. In this way, bile content is prevented from flowing back into the stomach. The process is completed in 15 minutes in total. The patient can return to daily life on the same day. No hospitalization is required. He is discharged from the hospital 2 hours after the procedure.
IS PYLORIC REVISION PERMANENT AND HOW LONG IS THE EFFECT DURATION?
In our clinical study, the effectiveness of the “Pyloric Revision” performed in the control endoscopy of the patients to whom we performed “Pyloric Revision” during an average follow-up period of 32 months still continues in 92% of the patients.
BY WHOM WAS PYLORIC REVISION FIRST DEFINED AND APPLIED?
PYLOric REVISION was defined and applied for the first time by “Assoc. Prof. Murat KANLIÖZ”. It has been proven by scientific academic publications that bile reflux can be prevented with Pyloric Revision. Clinical study results and description of the technique were published in 2023 in the peer-reviewed American Medical journal CUREUS. The name PYLOric REVISION was given to the procedure by Associate Professor Murat KANLIÖZ, who discovered and defined the technique.
HOW IS DUODENAL SWITCH SURGERY PERFORMED IN BILE REFLUX?
In Duodenal Switch surgery, the passage between the stomach and small intestine is closed from the immediate exit of the stomach. 150 cm from the stomach exit, the small intestine is cut in full thickness and divided into two ends, one incoming and one outgoing. The separated end of the outgoing intestinal segment is brought into the stomach (anastomosis is performed). The other end of the intestine, which is reserved for the 75th cm of the intestinal segment that is mouthed to the stomach, is mouthed to ensure the flow of both bile and stomach contents. In this way, bile flow is removed from the stomach, preventing bile from flowing back into the stomach.
WHAT ARE THE POSSIBLE COMPLICATIONS OF DUODENAL SWITCH SURGERY?
Depending on the surgery performed, anastomotic leakage and bleeding may occur at a rate of 1-2%. Depending on the surgery performed, the first point of contact of the stomach contents with the intestine will be at the 150th cm of the intestine, so severe pain, bloating and excessive gas may occur in the abdomen after meals. This table is called DUMPING SYNDROME. Dumping Syndrome occurs at a rate of 10-15% after DUODENAL SWITCH surgery, and these complaints may continue for life. Digestion and absorption of carbohydrates occurs in the first 100 cm after the stomach exit. Carbohydrate absorption disorders are observed after Duodenal Switch. The most important factor accused in the formation of dumping syndrome is expressed as the contact of dense carbohydrate content with the intestine after the 150th cm.
WHEN SHOULD DUODENAL SWITCH SURGERY BE PERFORMED IN BILE REFLUX?
Duodenal Switch surgery should be performed when the quality of life is severely impaired due to bile reflux and cannot be treated with any other method. Duodenal Switch is a surgery that should be considered as the last option in Alkaline Reflux Gastritis.
WHAT ARE THE ADVANTAGES OF PYLORIC REVISION OVER DUODENAL SWITCH SURGERY?
- There are no surgical risks in Duodenal Switch surgery
- Anatomical structure is not damaged
- Does not require hospitalization
- No loss of workforce
- Does not cause malnutrition
- Dumping syndrome is not observed
- It is cheap
- It is not an invasive procedure
- Does not cause loss of labor
- It is extremely effective
WHAT ARE THE DISADVANTAGES OF PYLORIC REVISION COMPARED TO DUODENAL SWITCH SURGERY?
Pyloric Revision does NOT have any disadvantages compared to Duodenal Switch surgery.
Assoc. Prof. Murat KANLIÖZ
General surgery specialist