Intragastric Alkali Infusion

Abstract

Alkaline reflex gastritis is a disabling clinical syndrome, occurring most often after gastric surgery. It is characterized by abdominal pain and bilious vomiting, and, presumably, is due to gastric irritation by regurgitated duodenal contents. The only known effective treatment is by surgical diversion to prevent the duodenal reflux. Unfortunately, the clinical diagnosis is difficult to prove, and the results of surgery are too often disappointing because of inaccurate patient selection. This is a report of a new test for distinguishing patients with symptomatic bile reflux gastritis. The test consists of blind sequential infusion into the stomach, via nasogastric tube, of 20 ml of 0.1 N HCl, normal saline, 0.1 N NaOH, and the patient's own gastric contents. Each solution is given twice. A positive test is defined as reproduction of the patient's usual pain by NaOH, and/or gastric contents, but not by acid or saline. Fifteen of 21 patients with clinical symptoms and endoscopic findings suggesting bile gastritis had a positive alkali infusion test, while only one of 18 normal controls and none of 17 controls with other causes of abdominal pain had a positive test (p less than 0.001). Of the 21 patients with clinical-endoscopic bile gastritis, 15 have had surgical treatment by Roux-en-Y gastrojejunostomy. Nine of ten patients with positive test had excellent symptomatic relief after surgery. Zero of five patients with a negative test were relieved of pain after the operation. Tis simple test appears to be a sensitive, specific, and accurate means for selecting patients for surgical treatment of alkaline reflux gastritis.

Invited commentary

“…Finally, and most importantly, objective and discriminate diagnostic maneuvers must be developed that will reliably distinguish those postgastrectomy patients who are afflicted with the syndrome from those who are not. Promising current approaches include the use of provocative testing with either concentrated NaOH [13] or autologous upper intestinal content [9], the measurement of intragastric bile acid concentration [5,7], the estimation of net bile acid reflux per unit time [5,7], or the direct assessment of reflux volume by gamma scintography following the injection of 99Tc-labeled HIDA [14]. Until such time as one of these approaches (or some other, yet to be devised, approach) proves so specific and so sensitive that a successful therapeutic outcome becomes predictable and reproducible rather than random and haphazard, the syndrome of alkaline reflux gastritis cannot be considered a proven clinical entity and the prudent surgeon should approach its remedial operative therapy with considerable circumspection.…”