Bile reflux

Overview

Bile reflux occurs when bile — a digestive liquid produced in your liver — backs up (refluxes) into your stomach and, in some cases, into the tube that connects your mouth and stomach (esophagus).

Bile reflux may accompany the reflux of stomach acid (gastric acid) into your esophagus. Gastric reflux may lead to gastroesophageal reflux disease (GERD), a potentially serious problem that causes irritation and inflammation of esophageal tissue.

Unlike gastric acid reflux, bile reflux can't be completely controlled by changes in diet or lifestyle. Treatment involves medications or, in severe cases, surgery.

Symptoms

Bile reflux can be difficult to distinguish from gastric acid reflux. The signs and symptoms are similar, and the two conditions may occur at the same time.

Bile reflux signs and symptoms include:

• Upper abdominal pain that may be severe
• Frequent heartburn — a burning sensation in your chest that sometimes spreads to your throat, along with a sour taste in your mouth
• Nausea
• Vomiting a greenish-yellow fluid (bile)
• Occasionally, a cough or hoarseness
• Unintended weight loss

When to see a doctor

Make an appointment with your doctor if you frequently experience symptoms of reflux, or if you're losing weight without trying.

If you've been diagnosed with GERD but aren't getting enough relief from your medications, call your doctor. You may need additional treatment for bile reflux.

Causes

Bile is essential for digesting fats and for eliminating worn-out red blood cells and certain toxins from your body. Bile is produced in your liver and stored in your gallbladder.

Eating a meal that contains even a small amount of fat signals your gallbladder to release bile, which flows through a small tube into the upper part of your small intestine (duodenum).

Bile reflux into the stomach

Bile and food mix in the duodenum and enter your small intestine. The pyloric valve, a heavy ring of muscle located at the outlet of your stomach, usually opens only slightly — enough to release about an eighth of an ounce (about 3.75 milliliters) or less of liquefied food at a time, but not enough to allow digestive juices to reflux into the stomach.

In cases of bile reflux, the valve doesn't close properly, and bile washes back into the stomach. This can lead to inflammation of the stomach lining (bile reflux gastritis).

Bile reflux into the esophagus

Bile and stomach acid can reflux into the esophagus when another muscular valve, the lower esophageal sphincter, doesn't work properly. The lower esophageal sphincter separates the esophagus and stomach. The valve normally opens just long enough to allow food to pass into the stomach. But if the valve weakens or relaxes abnormally, bile can wash back into the esophagus.

What leads to bile reflux?

Bile reflux may be caused by:

• Surgery complications. Stomach surgery, including total or partial removal of the stomach and gastric bypass surgery for weight loss, is responsible for most bile reflux.
• Peptic ulcers. A peptic ulcer can block the pyloric valve so that it doesn't open or close properly. Stagnant food in the stomach can lead to increased gastric pressure and allow bile and stomach acid to back up into the esophagus.
• Gallbladder surgery. People who have had their gallbladders removed have significantly more bile reflux than do people who haven't had this surgery.

Complications

Bile reflux gastritis has been linked to stomach cancer. The combination of bile reflux and acid reflux also increases the risk of the following complications:

• GERD. This condition, which causes irritation and inflammation of the esophagus, is most often due to excess acid, but bile may be mixed with the acid.

  Bile is often suspected of contributing to GERD when people respond incompletely or not at all to powerful acid-suppressant medications.

• Barrett's esophagus. This serious condition can occur when long-term exposure to stomach acid, or to acid and bile, damages tissue in the lower esophagus. The damaged esophageal cells have an increased risk of becoming cancerous. Animal studies have also linked bile reflux to Barrett's esophagus.
• Esophageal cancer. There's a link between acid reflux and bile reflux and esophageal cancer, which may not be diagnosed until it's quite advanced. In animal studies, bile reflux alone has been shown to cause cancer of the esophagus.

Diagnosis

A description of your symptoms and knowledge of your medical history is usually enough for your doctor to diagnose a reflux problem. But distinguishing between acid reflux and bile reflux is difficult and requires further testing.

You're also likely to have tests to check for damage to your esophagus and stomach, as well as for precancerous changes.

Tests may include:

• Endoscopy. A thin, flexible tube with a camera (endoscope) is passed down your throat. The endoscope can show bile, peptic ulcers or inflammation in your stomach and esophagus. Your doctor may also take tissue samples to test for Barrett's esophagus or esophageal cancer.

• Ambulatory acid tests. These tests use an acid-measuring probe to identify when, and for how long, acid refluxes into your esophagus. Ambulatory acid tests can help your doctor rule out acid reflux but not bile reflux.

  In one test, a thin, flexible tube (catheter) with a probe at the end is threaded through your nose into your esophagus. The probe measures the acid in your esophagus over a period of 24 hours.

  In another test called the Bravo test, the probe is attached to the lower portion of your esophagus during endoscopy and the catheter is removed.

• Esophageal impedance. This test measures whether gas or liquids reflux into the esophagus. It's helpful for people who regurgitate substances that aren't acidic (such as bile) and can't be detected by an acid probe. As in a standard probe test, esophageal impedance uses a probe that's placed into the esophagus with a catheter.

Treatment

Lifestyle adjustments and medications can be very effective for acid reflux into the esophagus, but bile reflux is harder to treat. There is little evidence assessing the effectiveness of bile reflux treatments, in part because of the difficulty of establishing bile reflux as the cause of symptoms.

Medications

• Ursodeoxycholic acid. This medication may lessen the frequency and severity of your symptoms.
• Sucralfate. This medication can form a protective coating that protects the lining of the stomach and esophagus against bile reflux.
• Bile acid sequestrants. Doctors often prescribe bile acid sequestrants, which disrupt the circulation of bile, but studies show that these drugs are less effective than other treatments. Side effects, such as bloating, may be severe.

Surgical treatments

Doctors may recommend surgery if medications fail to reduce severe symptoms or there are precancerous changes in your stomach or esophagus.

Some types of surgery can be more successful than others, so be sure to discuss the pros and cons carefully with your doctor.

The options include:

• Diversion surgery. During this type of surgery, a doctor creates a new connection for bile drainage farther down in the small intestine, diverting bile away from the stomach.
• Anti-reflux surgery. The part of the stomach closest to the esophagus is wrapped and then sewn around the lower esophageal sphincter. This procedure strengthens the valve and can reduce acid reflux. However, there's little evidence about the surgery's effectiveness for bile reflux.

Self care

Unlike acid reflux, bile reflux seems unrelated to lifestyle factors. But because many people experience both acid reflux and bile reflux, your symptoms may be eased by lifestyle changes:

• Stop smoking. Smoking increases the production of stomach acid and dries up saliva, which helps protect the esophagus.
• Eat smaller meals. Eating smaller, more-frequent meals reduces pressure on the lower esophageal sphincter, helping to prevent the valve from opening at the wrong time.
• Stay upright after eating. After a meal, waiting two to three hours before lying down allows time for your stomach to empty.
• Limit fatty foods. High-fat meals relax the lower esophageal sphincter and slow the rate at which food leaves your stomach.
• Avoid problem foods and beverages. Some foods increase the production of stomach acid and may relax the lower esophageal sphincter. Foods to avoid include caffeinated and carbonated drinks, chocolate, citrus foods and juices, vinegar-based dressings, onions, tomato-based foods, spicy foods, and mint.
• Limit or avoid alcohol. Drinking alcohol relaxes the lower esophageal sphincter and irritates the esophagus.
• Lose excess weight. Heartburn and acid reflux are more likely to occur when excess weight puts added pressure on your stomach.
• Raise your bed. Sleeping with your upper body raised 4 to 6 inches (10 to 15 centimeters) may help prevent reflux symptoms. Raising the head of your bed with blocks or sleeping on a foam wedge is more effective than is using extra pillows.
• Relax. When you're under stress, digestion slows, possibly worsening reflux symptoms. Relaxation techniques, such as deep breathing, meditation or yoga, may help.

Alternative medicine

Many people with frequent stomach problems, including heartburn, use over-the-counter or alternative therapies for symptom relief. Remember that even natural remedies can have risks and side effects, including potentially serious interactions with prescription medications. Always do careful research and talk with your doctor before trying an alternative therapy.

Preparing for your appointment

Make an appointment with your doctor if you have signs or symptoms common to bile reflux. After your doctor's initial evaluation, you may be referred to a specialist in digestive disorders (gastroenterologist).

Here's some information to help you prepare for your appointment and what to expect from your doctor.

What you can do

• Write down any symptoms you've been experiencing and for how long.
• Make a list of your key medical information, including any other conditions for which you're being treated and the names of any medications, vitamins or supplements you're taking.
• Find a family member or friend who can come with you to the appointment, if possible. Someone who accompanies you can help remember what the doctor says.
• Write down questions to ask your doctor. Creating your list of questions in advance can help you make the most of your time with your doctor.

Don't hesitate to ask questions during your appointment. Some questions to ask your doctor include:

• Do I have bile reflux?
• What treatment approach do you recommend?
• Are there any side effects associated with these treatments?
• Are there any lifestyle or dietary changes I can make to help reduce or manage my symptoms?
• I have other health conditions. How can I best manage them together?

What to expect from your doctor

Your doctor is likely to ask you a number of questions. Being ready to answer them may give you time to go over points you want to spend more time on. You may be asked:

• What are your symptoms?
• How long have you had these symptoms?
• Do your symptoms come and go or stay about the same?
• If your symptoms include pain, where is your pain located?
• Have your signs and symptoms included vomiting?
• Does anything seem to trigger your symptoms, including certain foods or beverages?
• Have you lost weight without trying?
• Have you seen a doctor for these symptoms before?
• What treatments have you tried so far? Has anything helped?
• Have you been diagnosed with any other medical conditions?
• Have you had stomach surgery or had your gallbladder removed?
• What medications are you taking, including prescription and over-the-counter medications, vitamins, herbs and supplements?
• What is your typical daily diet?
• Do you drink alcohol? How much?
• Do you smoke?