Effect of baclofen therapy for duodenogastroesophageal reflux in a patient with distal subtotal gastrectomy with preservation of the lower esophageal sphincter and the vagal nerve

A 63-year-old male patient presented with a 2-year history of typical retrosternal heartburn solely during nightime, causing the patient to wake up between 3 and 4 o’clock in the morning. Magaldrate quickly relieved the symptoms, however the prophylactic use showed no benefit. The past medical history revealed distal subtotal gastrectomy with Roux-en-Y reconstruction for Stage 0 gastric cancer in the year 1997. A gastroscopy in June 2003 showed no esophagitis. He was started on several drugs, including PPIs, H2-antagonists, antacids and prokinetics, all with no benefit.

In october 2004, the patient was sent to our outpatient department, his complaints still unchanged. Physical examination, routine laboratory parameters, upper GI endoscopy and abdominal ultrasound were normal. Bilitec monitoring using the Bilitec2000 system showed duodenogastroesophageal reflux solely during nighttime.

We decided to start the patient on a trial with baclofen 10mg before nighttime (around 10 o’clock pm). With the first dose the patient reported complete relief of his symptoms. Since then, he is on 5mg baclofen maintenance and remains asymptomatic. 4 weeks following therapy initiation, a repeat bilitec monitoring showed complete normalisation of the reflux episodes.

Medical treatment of duodenogastroesophageal reflux in postgastrectomy patients has been disappointing. Transient lower esophageal sphincter relaxations (TLESRs) are rapid and prolonged relaxations of the lower esophageal sphincter (LES) that are not associated with swallowing. They are the mechanism by which most gastroesophageal reflux episodes occur in normal people and in patients with gastroesophageal reflux disease. Transient LES relaxations appear to be mediated by a vagovagal reflex. Gamma-Aminobutyric acid (GABA) is an important inhibitory neurotransmitter within the central nervous system. Baclofen is a gamma-aminobutyric acid (GABA) derivative, that inhibits the production of TLESRs by acting as a GABA-B receptor agonist. Animal and human studies suggest, that baclofen decreases the number of reflux events and amount of esophageal acid exposure. Due to its pharmacological action, it is necessary, that the LES and vagal nerves are preserved, in particular in patients following abdominal surgery.