Original Paper: Motility Digestion 2002;66:42–48 DOI: 10.1159/000064420 Presence of Bile in the Oesophagus Is Associated with Less Effective Oesophageal Motility Jacob Freedman a Madeleine Lindqvist b Per M. Hellström c Lars Granström a Erik Näslund a Divisions of a Surgery and b Clinical Physiology, Karolinska Institutet Danderyd Hospital, Danderyd and c Department of Gastroenterology and Hepatology, Karolinska Hospital, Karolinska Institutet, Stockholm, Sweden Received: January 29, 2002 Accepted: April 11, 2002 Dr. Jacob Freedman Department of Surgery Danderyd Hospital SE–182 88 Danderyd (Sweden) Tel. +46 8 655 6670, Fax +46 8 655 7766, E-Mail Jacob.Freedman@kir.ds.sll.se ABC Fax + 41 61 306 12 34 E-Mail karger@karger.ch www.karger.com © 2002 S. Karger AG, Basel 0012–2823/02/0661–0042$18.50/0 Accessible online at: www.karger.com/journals/dig Key Words Oesophagitis W Bile reflux W Reflux, gastro-oesophageal W Motility disorder, oesophageal W Disease, oesophageal W Ambulatory monitoring W Fundoplication Abstract Background/Aims: Reflux of bile to the oesophagus has been shown to be of importance in the development of gastro-oesophageal reflux disease. This study aims to assess oesophageal motility patterns in relation to acid and bile reflux to the oesophagus. Methods: Forty-nine subjects with and without reflux disease underwent 24- hour ambulatory recordings of oesophageal pH, bile and 3-channel manometry. Gastroscopy was performed to assess severity of oesophagitis. The percentage of effec- tive peristaltic contractions (oesophageal contractions with a peristaltic pattern and a pressure 1 30 mm Hg) were correlated to the degree of acid and bile reflux. Ten subjects were re-evaluated within 2 years post-fundopli- cation. Results: Acid and bile reflux were associated with fewer effective contractions (R 2 = 0.07, p = 0.06 and R 2 = 0.21, p = 0.008, respectively). However, in a multivariate model including acid, bile, age and gender dependency, only bile could show a systematic effect on the variation in percentage of effective peristaltic contractions (R 2 = 0.22, p = 0.001). One year after laparoscopic fundoplica- tion, 24-hour oesophageal motility was unchanged. Con- clusion: Reflux of duodenal juice to the oesophagus is associated with less effective oesophageal motility, which in turn can perpetuate the disease by less effective oesophageal clearance of bile and acid. The reduced oesophageal motility is not reversed by fundoplication. Copyright © 2002 S. Karger AG, Basel Introduction Gastro-oesophageal reflux disease (GORD) is mainly caused by reflux of acid and pepsin to the oesophagus. Reflux of duodenal contents has also been found to have an important role in the development of GORD. Circa- dian monitoring of bilirubin in the oesophagus has shown that patients with more severe disease, like Barrett’s oesophagus, have bile in the oesophagus during approxi- mately 20% of the day [1–5]. Oesophageal clearance of acid and bile is dependent on gravity, oesophageal peri- stalsis and swallowing of saliva to neutralize residual acid [6, 7]. A defect in any of these mechanisms can prolong oesophageal exposure to refluxed gastric and duodenal