www.wjgnet.com BRIEF ARTICLES Prevalence of bile relux in gastroesophageal relux disease patients not responsive to proton pump inhibitors Luigi Monaco, Antonio Brillantino, Francesco Torelli, Michele Schettino, Giuseppe Izzo, Angelo Cosenza, Natale Di Martino Online Submissions: wjg.wjgnet.com World J Gastroenterol 2009 January 21; 15(3): 334-338 wjg@wjgnet.com World Journal of Gastroenterology ISSN 1007-9327 doi:10.3748/wjg.15.334 © 2009 The WJG Press and Baishideng. All rights reserved. Luigi Monaco, Antonio Brillantino, Francesco Torelli, Michele Schettino, Giuseppe Izzo, Angelo Cosenza, Natale Di Martino, Ⅷ Department of General and Gastrointestinal Surgery, School of Medicine, Second University of Naples, Piazza Miraglia 2, Naples 80138, Italy Author contributions: Di Martino N designed the research; Monaco L, Brillantino A, Torelli F, Schettino M, Izzo G and Cosenza A performed the research; Monaco L and Brillantino A wrote the paper. Correspondence to: Luigi Monaco, MD, Second University of Naples, School of Medicine-I Policlinico, Piazza Miraglia 2, Naples 80138, Italy. luigi.monaco@unina2.it Telephone: +39-328-2780316 Fax: + 39-081-5665055 Received: March 9, 2008 Revised: June 6, 2008 Accepted: June 13, 2008 Published online: January 21, 2009 Abstract AIM: To determine the prevalence and characteristics of bile relux in gastroesophageal relux disease (GERD) patients with persistent symptoms who are non- responsive to medical therapy. METHODS: Sixty-five patients (40 male, 25 female; mean age, 50 ± 7.8 years) who continued to report symptoms after 8 wk of high-dose proton pump inhibitor (PPI) therapy, as well as 18 patients with Barrett’s esophagus, were studied. All patients illed out symptom questionnaires and underwent endoscopy, manometry and combined pH-metry and bilimetry. RESULTS: There were 4 groups of patients: 22 (26.5%) without esophagitis, 24 (28.9%) grade A-B esophagitis, 19 (22.8%) grade C-D and 18 (21.6%) Barrett’s esophagus. Heartburn was present in 71 patients (85.5%) and regurgitation in 55 (66.2%), with 44 (53%) reporting simultaneous heartburn and regurgitation. The prevalence of pathologic acid relux in the groups without esophagitis and with grades A-B and C-D esophagitis was 45.4%, 66.6% and 73.6%, respectively. The prevalence of pathologic bilirubin exposure in these 3 groups was 53.3%, 75% and 78.9%, respectively. The overall prevalence of bile relux in non-responsive patients was 68.7%. Pathologic acid and bile reflux was observed in 22.7% and 58.1% of non-esophagitic patients and esophagitic patients, respectively. CONCLUSION: The high percentage of patients poorly responsive to PPI therapy may result from poor control of duodenogastroesophageal reflux. Many patients without esophagitis have simultaneous acid and bile reflux, which increases with increasing esophagitis grade. © 2009 The WJG Press and Baishideng. All rights reserved. Key words: Gastroesophageal reflux disease; Duodenogastric relux; Bile relux; Bilirubin; Barrett’s esophagus Peer reviewer: Tomohiko Shimatani, Assistant Professor, Department of General Medicine, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima 7348551, Japan Monaco L, Brillantino A, Torelli F, Schettino M, Izzo G, Cosenza A, Di Martino N. Prevalence of bile relux in gastroesophageal relux disease patients not responsive to proton pump inhibitors. World J Gastroenterol 2009; 15(3): 334-338 Available from: URL: http://www.wjgnet.com/1007-9327/15/334.asp DOI: http://dx.doi.org/10.3748/wjg.15.334 INTRODUCTION As a result of their strong acid suppression, proton pump inhibitors (PPIs) have been used to treat most patients with gastroesophageal relux disease (GERD) [1-5] . Acid relux is the main risk factor for GERD, with pH- metry being the standard method used in the diagnosis of GERD. Many patients with typical GERD symptoms, however, have been found to have a negative pH- metry [6] ; these patients have been found to differ in symptoms, response to medical therapy, and endoscopy results from patients with positive pH-metry. Although the role of acid relux in GERD has been established, and links between acid and bile relux have been found, less is known about the role of bile in the pathogenesis of esophageal mucosal damage. Thus, the incidence of GERD, its clinical impact, etiology, evolution and therapeutic implications cannot be determined directly. This limitation, however, was improved by the introduction of bilimetry in clinical practice [7] . This method uses spectrophotometric analysis to measure the