Bile Reflux

1 What is Bile Reflux?

 Bile reflux, also called duodenogastric reflux, occurs when bile — a digestive fluid made by your liver — flows upward from the small intestine into your stomach and esophagus. A damage to the pyloric valve, a muscular ring that separates the stomach from the duodenum is the cause for bile reflux. When this valve does not close properly, bile flows upwards into the stomach.

Bile reflux may occur along with acid reflux, the medical term for the backwash of stomach acids into your esophagus. When bile reflux and acid reflux occur at the same time, a mixture of bile and stomach acids flows upwards further into the esophagus causing heartburn and esophageal damage. Bile reflux results in a burning or gnawing pain in the upper abdomen. As acid reflux is more common, bile is often suspected as a cause of reflux only when people respond incompletely or not at all to powerful acid-suppressant medications.

Unlike acid reflux, bile reflux usually cannot be completely treated with changes in diet or lifestyle. Bile reflux is managed using medications or surgery, in severe cases.

2 Symptoms

As bile reflux has similar signs and symptoms as acid reflux, its often difficult to distinguish. Bile reflux often causes a burning, gnawing pain in the stomach. Other symptoms include:

  • Frequent heartburn — a burning sensation in your chest that may also spread into your throat leaving a sour taste in your mouth 
  • Nausea 
  • Vomiting a greenish-yellow fluid (bile) 
  • Cough or hoarseness due to burning of the lining of the throat from the stomach acid and bile reflux
  • Unexpected weight loss 

 When to see a doctor 

  Consult your doctor if you experience symptoms of reflux very often, or if you are losing weight without trying. If you have been diagnosed with gastroesophageal reflux disease (GERD), and you are not able to get adequate relief from your medications, call your doctor. You may require additional treatment for bile reflux.

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3 Causes

Bile reflux may be caused by bile flowing in the upward direction from the small intestine into the stomach. It is caused by a damage to the pyloric valve, a ring of muscle, which separates your stomach from the duodenum (the upper section of the small intestine). The pyloric valve normally opens for a short time to let the partially digested food to pass into the small intestine. It then remains closed so that the mixture does not flow backwards into the stomach.

Bile reflux results when this pyloric valve does not close properly. The bile flows back into the stomach, resulting in pain and inflammation. If bile reflux and acid reflux occur in combination, the mixture of bile and stomach acids flows further upwards into the esophagus causing heartburn and damage to the esophagus. If acid reflux is absent, bile alone may flow upwards into the esophagus if there is excessive pressure in the stomach.

Bile reflux into the stomach 

Bile and food that get mixed in the duodenum enters your small intestine through the pyloric valve, which usually opens only slightly to release about an eighth of an ounce (about 3.5 milliliters) of liquefied food at a time, but not to allow digestive juices to reflux into the stomach. In most cases of bile reflux, this valve fails to close properly, and bile goes back into the stomach. 

Bile reflux into the esophagus 

Bile and stomach acid can reflux into the esophagus when another muscular valve, the lower esophageal sphincter does not close properly. The lower esophageal sphincter separates the esophagus and stomach. The valve normally opens just to allow food to pass into the stomach. If the valve becomes weak or relaxes abnormally, bile can wash back into the esophagus. 

What leads to bile reflux? 

  Bile reflux may be caused by:

  • Complications of surgery: Gastric surgery, including total removal of the stomach (gastrectomy), gallbladder removal surgery, and gastric bypass surgery for weight loss may cause damage to pyloric valve, which is responsible for most bile reflux.
  • Peptic ulcers:  A peptic ulcer may obstruct the pyloric valve, and prevents it from opening enough to allow the stomach to empty as fast as it should. Stagnant food in the stomach causes increased gastric pressure and allows bile and stomach acid to back up into the esophagus. 
  • Constipation: In rare cases, chronic constipation may cause bile reflux.
  • Scar tissue: Scar tissue formation near the pyloric valve may not allow the valve to open properly to allow partially digested food to empty from the stomach into the small intestine. As a result, pressure builds up in the stomach, and pushes both acid and bile back into the esophagus.

4 Making a Diagnosis

Make an appointment with your doctor to make a diagnosis of bile reflux if you believe that you have signs or symptoms of it. After your doctor's initial evaluation, you may be referred to a specialist in digestive disorders (gastroenterologist). Here is some information that helps you prepare for your appointment.

 What you can do 

   Write down your symptoms and their duration. Make a list of your key medical information, including the conditions for which you are being treated and the medications, vitamins or supplements you are taking. Ask a family member or your friend to accompany you to the appointment, if possible. Someone who is with you during the appointment can help you remember what the doctor says. 

Write down questions to ask your doctor

 Preapring a list of questions in advance help you remember the questions you want to ask your doctor during your appointment. Some questions you may ask your doctor include:

  • Do I have acid reflux, bile reflux or both?
  • What treatment do you recommend? 
  • Are there any side effects associated with these treatments? 
  • Are there any lifestyle or dietary changes that can help me reduce or manage my symptoms? 
  • How can I best manage my other health conditions together? 

What to expect from your doctor 

  Your doctor may ask you a number of questions such as:

  • What are your symptoms, and for how long have you had these symptoms?
  • Are your symptoms transient or stay about the same?
  • If you have pain, where exactly is your pain located? 
  • Do you have vomiting?
  • Does anything trigger your symptoms, including certain foods or beverages? 
  • Have you lost your weight unintentionally? 
  • Have you consulted your doctor for these symptoms before? 
  • Have you been treated for this condition before? Has anything helped? 
  • Do you have any other medical conditions?
  • Have you had stomach surgery or had your gallbladder removed in the past? 
  • What is your typical daily diet? 
  • Do you drink alcohol? How much? 
  • Do you smoke?

Usually, symptoms are often sufficient to diagnose a reflux problem. Further testing is required to diffrentiate between acid reflux and bile reflux. Tests to check for damage to your esophagus and stomach as well as for precancerous changes may be done. Tests may include: 

   Endoscopy: A thin, flexible tube with a light and camera (endoscope) is passed down your throat to check for peptic ulcers or inflammation in your stomach and esophagus. During endoscopy procedure, your doctor may take tissue samples to test for Barrett's esophagus or esophageal cancer.

  Ambulatory acid tests: These tests involve placement of an acid-measuring probe in the esophagus to identify when, and for how long the stomach acid refluxes into your esophagus. In one test, a thin, flexible tube (catheter) with a probe at the end is threaded through your nose into your esophagus. In another (the Bravo test), the probe is attached to the lower portion of your esophagus during endoscopy. The results of ambulatory acid tests are negative in bile reflux unless it is associated with acid reflux. The BilitecTM ambulatory bile reflux monitor is commonly used.

   Esophageal impedance: This test detects whether it is gas or liquid that refluxes into the esophagus. It is helpful for people who regurgitate substances that are not acidic (such as bile) and cannot be detected by an acid probe. Similar to a standard probe test, esophageal impedance make use of a probe that is placed into the esophagus using a catheter.

5 Treatment

Bile reflux is difficult to treat with medications, and there is very little evidence that assesses the efficacy of bile reflux treatments.

   Medications 

    Ursodeoxycholic acid: This is a prescription medication that helps promote bile flow. It may lessen the frequency and severity of your symptoms such as stomach pain

    Bile acid sequestrants: Doctors prescribe bile acid sequestrants to disrupt the circulation of bile, but studies have show that these drugs are less effective than other treatments. 

    Proton pump inhibitors: These are prescription medications that are often prescribed to reduce stomach acid production, but it is not clear whether proton pump inhibitors help in reducing bile reflux. These are often prescribed as bile reflux and acid reflux occur together.

   Cholesterol-lowering medications: These drugs help in removing bile.

   Promotility agents: These agents can improve stomach emptying, and thereby reduce the amount of bile that may leak back into the stomach.

   Surgical treatments

Surgery is recommended if medications are ineffective in reducing your symptoms or when precancerous changes have occurred in your esophagus. Discuss with your doctor the pros and cons of each procedure as some procedures may be more successful than others. The options include: 

      Diversion surgery (Roux-en-Y procedure): This procedure, which is also a type of weight-loss bypass surgery, is often recommended in people who have had previous gastric surgery with pylorus removal. During this procedure, your surgeon will make a new connection for bile drainage farther down in the small intestine, thus diverting bile away from the stomach.

      Anti-reflux surgery (fundoplication): In this procedure, the part of the stomach that is closest to the esophagus called fundus is wrapped and then sewn around the lower esophageal sphincter. This procedure strengthens the valve and can reduce acid and bile reflux into the esophagus. However, it is unclear how well it works in patients with bile reflux.

6 Alternative and Homeopathic Remedies

Several alternative and homeopathic remedies are used for bile reflux.

Most of the times, people take over-the-counter or alternative medications to obtain relief from frequent heartburn. It is important to remember that natural treatments also have risks and adverse reactions, which include potentially serious drug interactions with prescription medications. Hence, always do careful research and discuss with your doctor before choosing an alternative treatment. There are no alternative therapies that have been proven to relieve bile reflux. 

Some herbal supplements may be helpful, but there is no evidence about thier effectiveness, and some may even be harmful. If you want to take any of these therapies, discuss with your doctor. The herbal remedies include:

    Chamomile, which has anti-inflammatory properties: Chamomile teas are readily available and have lesser side effects. 

    Licorice, which is commonly used to soothe inflammation associated with GERD, gastritis, ulcers, and other digestive problems. However, licorice contains a chemical called glycyrrhizin (glis-uh-RIE-zin) that is found to be associated with serious health risks such as high blood pressure and tissue swelling, if used for long periods. Prescription products without glycyrrhizin are also available.

    Slippery elm, which is obtained from a tree bark and root helps in soothing the digestive tract. Slippery elm should be mixed with water and consumed after meals before going to bed. Slippery elm may interfere with the absorption of prescription medications. 

    Marshmallow (Althaea officinalis) is an herb that has been used to get relief from GERD symptoms. This also causes problems with the absorption of other prescription medications.

7 Lifestyle and Coping

Lifestyle changes are unlikely to provide relief from bile reflux. But as most patients have acid reflux and bile reflux together, some of your symptoms may be relieved by making few lifestyle modifications: 

   Quit smoking: Smoking can increase the secretion of stomach acid and also reduces salivary flow. Stop smoking to protect your esophagus from getting damaged by refluxed bile.

   Eat small meals: Eating smaller and more-frequent meals decreases the pressure on your lower esophageal sphincter, and thereby avoids the opening of valve during wrong time.

   Stay upright after eating: After a meal, wait for about two to three hours before lying down. This allows time for your stomach to empty. 

   Limit the intake of fatty foods: High-fat meals relax your lower esophageal sphincter and also slows down the rate at which the food leaves your stomach. 

  Avoid intake of problematic foods and beverages: Certain foods are known to increase the production of stomach acid and relax your lower esophageal sphincter. Among the foods causing this effect are caffeinated and carbonated drinks, chocolate, citrus foods and juices, vinegar-based dressings, onions, tomato-based foods, spicy foods, and mint. 

  Limit or completely avoid drinking alcohol: Alcohol causes irritation in the esophagus and also causes relaxation of the lower esophageal sphincter, predisposing to acid reflux.

  Lose excess weight: Reducing the body fat that puts added pressure on your stomach and small intestine can help in decreasing the reflux of bile.

  Raise your bed: Sleep with your upper body raised 4 to 6 inches (10 to 15 centimeters) to prevent reflux symptoms. Raising the head side of your bed with the use of blocks or sleeping on a foam wedge is more effective than using extra pillows.

  Relax: Stress slows down your digestion process, further worsening your symptoms of reflux. Relaxation techniques, such as deep breathing, meditation or Yoga can be helpful to manage your stress.

8 Risks and Complications

Risk Factors

The following factors may be associated with an increased risk of developing bile reflux:

   Acid reflux: Patients with acid reflux may also have bile reflux at the same time.

  Cholecystectomy (surgical removal of gall bladder): Patients who have undergone cholecystectomy are at an increased risk of developing bile reflux.

  Helicobacter pylori infection of the stomach: It is seen that patients with esophageal bile reflux have greater chances of having Helicobacter pylori infection.

The esophageal tissue can get easily damaged by bile reflux as it lacks the sticky mucus coat on its lining. 

Complications

  Bile reflux irritates the stomach lining (gastritis), which if left untreated may lead to conditions such as stomach ulcers, bleeding, and stomach cancer. Bile reflux commonly occurs along with acid reflux, and the combination of these is very harmful. It increases the risk of complications such as esophageal cancer and Barrett's esophagus.

   GERD: Frequent or continual heartburn is the most common symptom of GERD. It is a potentially serious problem that causes irritation and persistent inflammation of esophageal tissue (esophagitis). 

   Barrett's esophagus: This is a serious condition, which occurs from long-term exposure to stomach acid, or combination of acid and bile. It damages tissue in the lower esophagus. The damaged esophageal cells have an increased risk of turning into malignant cells. Animal studies have also linked bile reflux to the occurrence of Barrett's esophagus.

   Esophageal cancer: This form of cancer may not be diagnosed until it is in a quite advanced stage, and it is nearly fatal. The link between bile and acid reflux and esophageal cancer remains controversial, but experts believe there is a direct connection. In animal studies, bile reflux alone is the cause cancer of the esophagus.

   Esophageal narrowing: Continuous exposure to stomach acid, bile or both results in scar tissue formation in the lower esophagus. This scarring causes narrowing of the esophagus, which interferes with swallowing and increases the risk of choking.

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