Therapeutic implications of duodeno-gastric reflux

Both medical and surgical treatment of gastroduodenal reflux have many inherent limitations. Some available drugs act on gastroduodenal reflux by enhancing gastric emptying. Other agents bind bile acids intragastrically or protect gastric epithelial cells from the cytotoxic effect of duodenal juice. Bioavailability of these latter substances is not fully investigated. One has to consider that in general treatment of gastroduodenal reflux must be administered over a considerable length of time. Greater importance has, therefore, to be attached to drug safety than to any impressive short-term pharmacological effect. Such considerations are to a certain degree rate limiting factors for long-term treatment with metoclopramide, high doses of antacid, cholesytramine and prostaglandins. Due to the poor correlation between the patient's symptoms and the noxious effect of duodenal juice considerable problems have to be expected with patient's compliance. This may be one of the main reasons for the absence of convincing controlled long-term trials documenting the value of treatment of gastroduodenal reflux in gastric ulcer disease, acute or chronic gastritis and reflux oesophagitis. Better evaluated, but not without considerable hazards is the surgical treatment of gastroduodenal reflux. Biliary diversion is doubtless effective in some patients suffering from postoperative alkaline gastritis. It is, however, impossible to correlate in the individual patient postgastrectomy or postvagotomy symptoms to bile reflux and this is the main reason for the many failures of the surgical procedures.