Bile Reflux and Bilitec System MEDTRONIC GASTROENTEROLOGY What

Bile Reflux and Bilitec System MEDTRONIC GASTROENTEROLOGY

What is DG- or DGE- Reflux? n Acid reflux Bile reflux Retrograde movement of duodenal content such as bile, pancreatic and enteric juices to the stomach and esophagus: Esophagus Duodeno-Gastric Reflux (DGR) n Duodeno-Gastro-Esophageal Reflux (DGER) LES Gallblader Duodenum Stomach Sphincter of Oddi n Pancreas MEDTRONIC GASTROENTEROLOGY

Indications n n n Patients with symptoms of gastroesophageal reflux (GER) Evaluation in patients with complications of GER such as: n Barrett’s esophagus n Strictures n Ulceration of the esophagus Patients that have failed medical therapy for acid reflux Patients with poor response to medical treatment of reflux esophagitis Postgastrectomized patients with reflux symptoms Pre- and postoperative evaluation of anti-reflux surgery MEDTRONIC GASTROENTEROLOGY

How to Measure DG- and DGE- Reflux n The Bilitec System has been recognized as being the best method for detecting duodenogastric/bile reflux n 4 studies has validated that: n Bilirubin is a suitable marker to measure the presence of bile acids – i. e. demonstrate that there is a correlation between Bilitec readout (presence of bilirubin) and presence of biliary salts n In-vivo spectrophotometric reading of Bilitec is reliable - i. e. compare Bilitec reading with spectrophotometric measurements carried out on samples drawn from the stomach and/or esophagus; this could be defined as optical validation MEDTRONIC GASTROENTEROLOGY

Why is Bile Reflux Important? n The main reason to measure bile-reflux is based on the indications that in GERD, duodenal juice is an important component in the refluxed gastric juice that causes damage to the esophageal mucosa. MEDTRONIC GASTROENTEROLOGY

Composition of Refluxed Juice in GERD* *From De. Meester et al: Biology of Gastroesophageal Reflux Disease, 1999 MEDTRONIC GASTROENTEROLOGY

Is measurement of DGR/DGER relevant? Bile Reflux Increased Risk for Mucosal Damage The clinical benefit of the Bilitec system is to identify patients at risk for: n. Mucosal injury n. Barret’s esophagus n. High grade dysplasia. Select patients for further examination of esophageal damage (e. g. biopsy) and for whom anti-reflux surgery should be considered MEDTRONIC GASTROENTEROLOGY

Examples of Bile reflux studies n n n “Patients with erosive esophagitis and Barrett’s metaplasia have increased esophageal exposure to duodenal juice compared to normal subjects”, Kauer et al, 1995 “The combined reflux of gastric and duodenal juices causes severe esophageal mucosal damage. The vast majority of duodenal reflux occurs at a p. H range of 4 to 7, at which bile acids, the major component of duodenal juice, are capable of damaging the esophageal mucos”, Kauer et al, 1995 “Duodenal juice adds a noxious component to the refluxed gastric juice and potentiates the injurious effects of gastric juice on the esophageal mucosa” Fein et al, 1997 “The prolonged simultaneous attack of bile and acid may play a key role in the development of Barrett's metaplasia”, Menges et al, 2001. . . MEDTRONIC GASTROENTEROLOGY

Detection of Bile/Bilirubin n n Bilitec uses two wavelengths for detection of bilirubin: 470 nm and 565 nm The absorbance is calculated from Beer’s law based on light intensities transmitted in absence and presence of absorbing substance (bilirubin) The absorbance is proportional to the concentration of bilirubin however, Bilirubin is only a marker and the knowledge of its concentration is not important from a clinical point of view Bilitec measures the exposure time of bilecontaining reflux to the gastric-/esophageal mucosa Absorption spectrum of a gastric sample containing bile MEDTRONIC GASTROENTEROLOGY

Normal values MEDTRONIC GASTROENTEROLOGY

Selection of Absorbance Threshold n n A default threshold of 0. 14 in absorbance values is considered in all the validations. This is the threshold introduced by P. Bechi: “it is the lowest value where the absorbance can be considered as an actual measurement of bilirubin and not as noise due to mucus in the stomach” There are different opinions on the threshold level, and in other studies higher absorbance values are used as threshold (e. g. 0. 2 and 2. 5). From presentation by T. De. Meester, DDW, 2001 MEDTRONIC GASTROENTEROLOGY

Correction of absorbance values rel. p. H Is Bile reflux underestimated in an acidic environment? This is a controversial subject discussed in a few papers: n J. Richter: 30% underestimation of Bilitec reading for p. H<3. 5 n P. Bechi: 18% underestimation of Bilitec reading for p. H<3. 5 n J. Janssens: such underestimation has only minor effect on the results of Bile reflux testing and thereby, have no clinical impact. n Only few centers consider this in their analysis of Bile reflux MEDTRONIC GASTROENTEROLOGY

Bilitec System Components n n n Bilitec 2000 n Carrying case n Cable for serial interface n Optical calibration chambers n Manuals Fiber Optic Bile Catheter n Single-use catheter, n length 175 cm, diam. 3. 0 mm Bile Upload analysis option for P 98 p. H n Fiber Optic Catheter Note: Available in US when 510(k) cleared MEDTRONIC GASTROENTEROLOGY

The Bilitec Procedure n Set-up Bilitec 2000 device n n n Intubate patient with single-use fiber optic probe n n w/wo p. H recording Start the measurement n n n Set average time and 1 or 2 channels Calibrate Bilitec system in water Standard Diet: abs. < 0. 05 at 470 nm Patient Keeps Diary: symptoms & events Extubate patient, upload analyze data MEDTRONIC GASTROENTEROLOGY

Features and Benefits MEDTRONIC GASTROENTEROLOGY

Polygram Bile Analysis Software Technical Review of the Software MEDTRONIC GASTROENTEROLOGY

Protocol Settings n 0 -4 channels p. H and 1 -2 channels Bile n Adjustment of Bile values MEDTRONIC GASTROENTEROLOGY

Protocol Settings n Analysis of Bile Reflux: MEDTRONIC GASTROENTEROLOGY

Bile Analysis MEDTRONIC GASTROENTEROLOGY

Upload Procedure for Combined Studies n Upload p. H data first n …awaiting data from the Bilitec 2000 device n n connect Bilitec to the serial port go to data transfer mode and press “Enter” NB: Uses Digitrapper time for Combined Studies - the Bilitec 2000 has no Clock MEDTRONIC GASTROENTEROLOGY

Capture View MEDTRONIC GASTROENTEROLOGY

Review MEDTRONIC GASTROENTEROLOGY

Combined p. H and Bile Report MEDTRONIC GASTROENTEROLOGY

Pitfalls n n Variety of substances in food may result in false-positive readings. - Therefore, it is important to use a modified diet. If long periods of bile reflux are recorded, this may be simply a “contaminated” detector or other artifact. Presence of blood may distort the readings obtained from the device Underestimation of bile reflux in an acid environment (p. H < 3. 5) MEDTRONIC GASTROENTEROLOGY