Chapter 27 (page 129)

The Pyloric Sphincteric Cylinder in Health and Disease

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Chapter 27 (page 129)

Subsequent Tests

Shortly after the above radiographic test for duodenogastric reflux was described (Keet l982), a similar procedure was mentioned by Hughes et al. (l982). Minimal reflux was considered to be a slight trickle through the pylorus, moderate reflux that which extended to the "antral" region of the stomach, and gross reflux that which extended to the body of the stomach. Duodenogastric reflux was found to be present in 6 (27 percent) of 22 normal subjects and in 128 (32 percent) of 396 patients with non-ulcer dyspepsia. Statistically there was no significant difference in incidence between the normal controls and dyspeptic patients.

Using a ^99mTc-EHIDA test, Niemela et al (l984) found reflux in 14 of 33 normal controls. With a similar test Wolverson et al (l984) noted duodenogastric reflux in 6 of 13 normal controls. With a nasogastric aspiration technique Wolverson et al (l984) found that 8 of 15 normal controls had reflux. By measuring the intragastric bile acid concentration by means of a nasogastric suction technique, Gotthard et al. (l985) showed that large fluctuations in reflux might occur during a 24 hour measuring period. Of 12 normal control subjects 10 showed reflux, with low daytime values and frequent high peaks in bile acid concentration during the night.

Discussion

Normal subjects

Du Plessis (l965) stated that slight duodenogastric reflux was a normal occurrence. Capper et al. (l966) found no reflux in 15 normal controls, while it occurred in one out of 12 normal subjects in Flint and Grech's (l970) series. Nevertheless Flint and Grech were of the opinion that the pylorus was normally competent, i.e. it did not allow reflux. Rovelstad (l976) stated that it was debatable whether duodenogastric reflux was a normal phenomenon, while Donovan et al (l977) found no reflux in normal controls. Nicolai et al. (l980) on the other hand, demonstrated a median reflux of 4.3 percent of an intravenously injected dose of radioactive technetium-labelled IDA.

In 5 of 14 normal subjects, and in l8 of 48 non-ulcer dyspeptic patients, Keet (l982) found minimal to moderate duodenogastric reflux. Hughes et al. (l982) found reflux in 6 of 22 normal subjects and in 128 of 396 patients with non-ulcer dyspepsia, the incidence in the two groups being more or less the same. Similar results were obtained by Niemela et al. (l984), who noted reflux in 14 of 33 normal control subjects, and by Wolverson et al. (l984) who found reflux in 6 of 13 controls. The findings of Gotthard et al. (l985) pointed to large fluctuations in reflux, with higher peaks occurring nocturnally.

It is concluded that mild to moderate duodenogastric reflux occurs in approximately one third of normal subjects, and in one third of patients with non-ulcer dyspepsia, as shown (inter alia) by the radiological tests of Keet (l982) and Hughes et al. (l982). In other words, the pylorus is normally not competent in a significant percentage of normal subjects and approximately the same percentage of patients with non-ulcer dyspepsia.

Duodenal Ulceration

Du Plessis (l965) stated that in some cases of duodenal ulceration, reflux was excessive. Capper et al. (l966) found moderate or gross reflux in 33 percent or duodenal ulcer cases, Donovan et al (l977) in 24 percent, while Valenzuela and Defilippi (l976) stated that the incidence of reflux in patients with duodenal ulceration was not significantly different from that in controls. Of 7 cases Nicolai et al. (l980) found increased reflux in 2 only; in both, pyloric deformity was also present.

In our series there were 25 cases of active duodenal ulceration or duodenal deformity typical of ulceration, l8 (approximately 72 percent) showing moderate duodenogastric reflux. Hughes et al. (l982) found reflux in 53 percent of one group of patients with duodenal ulcer, and in 32 percent of patients in another group. Of 60 patients with duodenal ulceration Wolverson et al. (l984) found 32 (53 percent) to be reflux positive.

It is concluded that duodenogastric reflux occurs in a significant percentage of cases with duodenal ulceration; the incidence, as reported by different authors, varies from approximately 24 percent to approximately 72 percent. As cyclical activity of the pyloric sphincteric cylinder is normal in the vast majority of cases of duodenal ulceration (Chap. 30), the reflux is difficult to explain on the basis of pyloric dysfunction.