Leslie from Houston sent us this question: “Hello there. I had a cholecystectomy in 2018 and a sphincterotomy a few months ago. Since then, I have been having severe Bile reflux with Bile vomiting, gastritis, and GERD. I did not have this beforehand. I have a very small hernia that did not cause me any problems until sphincterotomy – only when taking motility-reducing medication. The pH in my stomach has been above 6 without PPI. One can clearly see Bile and the gastritis. I am managing with prokinetics, bile binders and sucralfate, but I am still extremely nauseous and losing weight. (I went from a BMI of a healthy 21 to now 18.7) PPIs are not effective. I can taste the Bile in my mouth and my asthma has gotten progressively worse. I have been diagnosed with small fiber neuropathy (as part of my autoimmune connective tissue disease) which is probably connected to the gastroparesis and the autonomic dysfunction I experience. Because of the low QoL and the gastritis that does not heal my doctors are thinking about surgery. I have been offered a choledochojejunostomy, but I am a bit worried about the high rates of strictures and reflux cholangitis. I have also seen that the Duodenal Switch seems to be a very good option for bile reflux, but it is rarely used in my country of origin. (The original DS from DeMeester for Bile Reflux and not weight loss). I am wondering if fixing the gastric emptying can reduce Bile reflux and severe type C gastritis? The prokinetics only help shortly and it seems in some studies that the Gastric emptying improves after surgery for Bile reflux. I also have the feeling that since gastritis I have much more problems with gastric emptying than beforehand. Luckily, I could manage very well beforehand without medication. I would really like your feedback and discuss my options, what you think might be best in my situation. I am not sure if treating gastric motility would normalize bile reflux, but I am intrigued by the thought… Best wishes”.
In general, there are two kinds of treatment in medicine: palliative and curative. Curative treatment is always preferred as it eradicates the root cause of the problem and eliminates symptoms. In your case, the root cause of all your symptoms and problems is gastroparesis. Gastroparesis results in GERD including bile and acid reflux. GERD exacerbates asthma and result in heartburn, sore throat… and poor quality of life. Gastroparesis also results in bile and food stasis in stomach causing gastritis and discomfort. Furthermore, gastroparesis is associated with impaired gastro-duodenal motility. Impaired gastro-duodenal motility exacerbates duodenogastric bile reflux. Indeed, you may be suffering from gastroduodenoparesis, a condition characterized by absent duodenal motility in addition to impaired gastric motility. Duodenum is typically dilated in these cases. Gastroparesis is a heterogeneous disorder with different subtypes that we still don’t fully understand.
I am not sure why you underwent a laparoscopic cholecystectomy followed by sphincterotomy. My guess is that you have had gastroparesis from the start and your gastroparesis symptoms were mistaken for biliary colic symptoms. Few studies in the literature show increased duodenogastric bile reflux following laparoscopic cholecystectomy. In the setting of duodenogastroparesis and following a sphincterotomy, duodenogastric bile reflux is expected to dramatically increase resulting in the symptoms you describe.
The root cause of your problem is impaired gastric, possible duodenal, motility. There are no effective medications for gastroparesis treatment. Surgical options are not standardized and most adopted surgical options for medically refractory gastroparesis are not effective.
An antrum preserving longitudinal gastrectomy along the Magenstrasse line is a procedure I have developed to promote gastric emptying. I have had great success with this surgical approach in all 50 gastroparesis patients I have treated so far. This approach would be my first line treatment recommendation for you. It is much less invasive than a duodenal switch and choledochojejunostomy. It does not burn any bridges for potential future interventions. It is very safe and minimally invasive with fast recovery. Most importantly, an antrum preserving longitudinal gastrectomy is a curative and not palliative procedure that addresses the root cause of your problem. By normalizing gastric emptying, GERD and bile stasis are expected to resolve without the need to divert bile from duodenum.