What is the treatment for biliary gastritis?

Treatment of Biliary Gastritis

The most effective treatment for symptomatic biliary gastritis is surgical diversion of bile away from the gastric mucosa using a Roux-en-Y reconstruction, as medical therapy has consistently proven ineffective for this condition. 1, 2, 3

Medical Management Limitations

Medical therapy for biliary gastritis has been disappointing and largely ineffective:

• Bile acid chelating agents (cholestyramine) and prokinetic drugs fail to provide meaningful symptom relief in most patients 1, 2
• Antacids and dietary modifications frequently aggravate rather than improve symptoms 1
• While cholestyramine can bind 97-100% of bile acids in vitro at various pH levels, this does not translate to clinical efficacy in vivo 4
• Conservative management should be attempted initially, but surgery should be considered when symptoms persist for at least 2 years despite medical treatment and significantly affect quality of life 3

Surgical Treatment Approach

Primary Biliary Gastritis (Without Prior Gastric Surgery)

For patients with primary biliary gastritis (often associated with prior cholecystectomy), Roux-en-Y choledochojejunostomy without gastric resection or vagotomy is the procedure of choice:

• This approach achieves complete symptom relief in 87% of patients 2
• No operative mortality and minimal long-term complications (no anastomotic strictures) 2
• Gastric emptying remains normal or improves in the majority of patients (63% improvement in those with preoperative abnormalities) 2
• Self-limited bile leaks occur rarely but resolve without intervention 2

Post-Gastrectomy Biliary Gastritis

For patients with biliary reflux gastritis following gastric surgery (Billroth II, vagotomy with gastrojejunostomy, or pyloroplasty):

• Roux-en-Y reconstruction is the standard surgical diversion procedure 1, 3, 5
• The Tanner 19 modification (Roux-19 procedure) may reduce the incidence of delayed gastric emptying complications 1, 3
• Early results show excellent pain relief (84%) and resolution of bilious vomiting (96%) 3
• Long-term results demonstrate excellent or good outcomes in 87% of patients 3

Common Pitfalls and Complications

Roux stasis syndrome is the most frequent complication following Roux-en-Y reconstruction:

• Occurs in approximately 35-40% of patients 3
• Despite this complication, quality of life is significantly improved in most patients 3
• The Tanner 19 modification may help reduce this complication rate 1

Other surgical considerations:

• Operative mortality is low (approximately 3.8%) 3
• Overall morbidity is approximately 57%, but most complications are manageable 3
• Careful patient selection is essential to achieve satisfactory results 3

Diagnostic Confirmation Before Surgery

Diagnosis should be confirmed by:

• Typical symptoms: epigastric pain, bilious vomiting, weight loss, and nausea 1, 2, 3
• Endoscopic visualization of bile reflux and gastritis 1, 3
• Histological documentation of gastritis severity (mild, moderate, or severe) 3
• Note that endoscopic and histological findings support but are not specific for the diagnosis 1

Treatment Algorithm

1. Initial conservative management with medical therapy (cholestyramine, prokinetics) for symptomatic patients 1, 3
2. If symptoms persist for ≥2 years and significantly impair quality of life despite medical treatment, proceed to surgical evaluation 3
3. For primary biliary gastritis: Roux-en-Y choledochojejunostomy without gastric resection 2
4. For post-gastrectomy biliary gastritis: Roux-en-Y reconstruction or Tanner 19 modification 1, 3

Histological changes may persist after surgery despite symptom improvement, so clinical response rather than histological resolution should guide assessment of surgical success 3