Bile Reflux

What is it?

Bile reflux occurs when bile — a digestive fluid produced in the liver — flows upward from your small intestine into your stomach and esophagus. Bile reflux often accompanies acid reflux — the backflow of stomach acids into your esophagus, the tube that connects your throat and stomach.

Together bile and acid reflux can have serious consequences, inflaming the lining of your esophagus and potentially increasing your risk of esophageal cancer. Bile reflux also affects your stomach, where it can cause further inflammation.

Unlike acid reflux, bile reflux usually can’t be completely controlled by changes in diet or lifestyle. Instead, bile reflux is most often managed with medications or, in severe cases, with surgery.

Symptoms

Bile reflux can be difficult to distinguish from acid reflux — the signs and symptoms are similar, and the two conditions may occur at the same time. But unlike acid reflux, bile reflux inflames the stomach, often causing a gnawing or burning pain in the upper abdomen.

Bile reflux 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 bile
Occasionally, a cough or hoarseness
Unintended weight loss

Causes

Bile is a greenish-yellow fluid that’s essential for digesting fats and for eliminating worn-out red blood cells and certain toxins from your body. It’s produced in your liver and stored in your gallbladder in a highly concentrated form.

Eating a meal that contains even a modest amount of fat signals your gallbladder to release bile, which flows through two small tubes (cystic duct and common bile duct) into the upper part of your small intestine (duodenum).

Bile reflux into the stomach

At the same time that bile is entering the duodenum, food enters your small intestine through the pyloric valve, a heavy ring of muscle located at the outlet of your stomach. Ordinarily, the pyloric valve opens just slightly — enough to release about an eighth of an ounce (about 3.5 milliliters) of liquefied food at a time, but not enough to allow digestive juices to backup (reflux) into the stomach. In many cases of bile reflux, the valve doesn’t close properly, and bile backwashes into the stomach, where it causes irritation and inflammation (gastritis).

Bile reflux into the esophagus

Bile and stomach acid reflux into the esophagus when another muscular valve, the lower esophageal sphincter, malfunctions. The lower esophageal sphincter separates the esophagus and stomach. Normally, it opens only to allow food to pass into the stomach and then closes tightly. But if the valve relaxes abnormally or weakens, stomach acid and bile can wash back into the esophagus, causing heartburn and ongoing inflammation that may lead to serious complications.

Bile reflux may be caused by:

Gastric surgery complications. Most damage to the pyloric valve occurs as a complication of gastric surgery, including total removal of the stomach (gastrectomy) and gastric bypass operations for weight loss.
Peptic ulcers. Sometimes a peptic ulcer can block the pyloric valve. Rather than not closing tightly, the valve doesn’t open enough to allow the stomach to empty as quickly as it should. The stagnant food and liquid in the stomach can lead to increased gastric pressure that causes refluxed bile and stomach acid to back up into the esophagus.
Gallbladder surgery (cholecystectomy). People who have had their gallbladders removed have significantly more bile reflux than do people who haven’t had this surgery.

Complications

A sticky mucous coating protects the lining of your stomach from the corrosive effects of stomach acid, but the esophagus doesn’t have this protection. This lack of protection is why bile reflux and acid reflux can seriously damage esophageal tissue. And although bile reflux can injure the esophagus on its own, the combination of bile and acid reflux seems to be particularly harmful, increasing the risk of complications, such as:

Heartburn and gastroesophageal reflux disease (GERD). Occasional heartburn usually isn’t a concern, although a severe episode can mimic a heart attack. But frequent or constant heartburn is the most common symptom of gastroesophageal reflux disease (GERD), a potentially serious problem that causes irritation and inflammation of esophageal tissue (esophagitis).
Esophageal narrowing (stricture). Repeated exposure to stomach acid, bile or both can cause scar tissue to form in the lower esophagus. This narrows the tube, interfering with swallowing and increasing the risk of choking.
Barrett’s esophagus. In this serious condition, long-term exposure to stomach acid or a combination of acid and bile causes a change in the color and composition of the tissue in the lower esophagus (metaplasia). The cells resemble glandular tissue in the small intestine — under a microscope, they look like shag carpeting — and although they’re resistant to stomach acid, they have increased potential for malignancy.
Esophageal cancer. This serious form of cancer can occur almost anywhere along the length of the esophagus, and it may not be diagnosed until it’s quite advanced. The possible link between bile and acid reflux and esophageal cancer remains controversial, but many experts think a direct connection exists. In animal studies, bile reflux alone has been shown to cause cancer of the esophagus.
Gastritis. In addition to causing irritation and inflammation in the esophagus, bile reflux can cause stomach irritation (gastritis). Although not always serious, untreated gastritis can lead to stomach ulcers and to bleeding, a potentially life-threatening problem that requires immediate medical care. Chronic gastritis can also increase the risk of stomach cancer.

Diagnosis

Doctors often can diagnose a reflux problem from a description of symptoms. 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.

Endoscopy. In this test, your doctor passes a thin, flexible tube with a light and camera (endoscope) down your throat. The endoscope can show ulcerations or inflammation in your stomach or esophagus and can reveal a peptic ulcer. The test, technically called an esophagogastroduodenoscopy (EGD), also allows your doctor to take tissue samples to test for Barrett’s esophagus — a condition in which cells in the esophagus undergo precancerous changes — or esophageal cancer, two potential complications of acid and bile reflux.
Ambulatory acid tests. These tests use an acid-measuring probe to identify when, and for how long, acid refluxes into your esophagus. Because these tests look for the presence of acid, they’re useful for diagnosing acid reflux. Ambulatory acid tests are negative in people with bile reflux.
In the standard tube test, a thin, flexible tube (catheter) with a probe at the end is threaded through your nose into your esophagus. The probe is placed just above the lower esophageal sphincter. A second probe may be placed in your upper esophagus. Attached to the other end of the catheter is a small computer that you wear around your waist or over your shoulder during the test. After the probe is in place, you go about your daily routine, the device records acid (pH) levels for 24 hours, and then you return to have the device removed.
The test is somewhat uncomfortable, makes sleeping and showering difficult, and eating a highly acidic meal can skew the results. Tests are available that may be more comfortable, however. The Bravo test, for example, eliminates the need for a nose tube because the probe is attached to the lower portion of your esophagus during endoscopy. And rather than having to be removed, the probe detaches in a timely manner on its own and passes through your intestinal tract.
Esophageal impedance. Rather than measuring acid, this test can measure whether gas or liquids reflux into the esophagus. It’s helpful for people who have regurgitation of substances that aren’t acidic and therefore wouldn’t be detected by a pH probe. As in a standard probe test, esophageal impedance uses a probe that’s placed into the esophagus with a catheter.

Treatments and drugs

Ursodeoxycholic acid

One prescription medication for bile reflux treatment is ursodeoxycholic acid, which helps promote bile flow. This medication may lessen the frequency of symptoms and the severity of pain associated with bile reflux. If bile reflux results from delayed stomach emptying, your doctor may prescribe drugs to increase the rate at which food moves through your stomach.

Proton pump inhibitors

Drugs called proton pump inhibitors are often prescribed for the treatment of GORD and Barrett’s esophagus. Although the primary purpose of these medications, which include esomeprazole (Nexium) and lansoprazole (Zoton), is to block acid production, they may also help reduce bile reflux.

Surgical treatments

When medications fail to reduce severe symptoms or there are precancerous changes in the esophagus, doctors sometimes recommend surgery. Because some types of operations are often more successful than others, be sure to discuss the pros and cons carefully with your doctor.

Surgical options include:

Diversion surgery. Surgeons have successfully used a procedure called a Roux-en-Y (roo-en-wi) operation to treat bile reflux in people who have had previous gastric surgery with pylorus removal (Billroth I or Billroth II). In this procedure, surgeons make a new connection for bile drainage farther down in the intestine, thereby diverting bile away from the stomach.
Anti-reflux surgery. Typically used to treat acid reflux, this operation — known medically as fundoplication — may be less successful in people who have bile reflux problems, though there is little data about its effectiveness. During the procedure, the part of the stomach closest to the esophagus (fundus) is wrapped and then sewn around the lower esophageal sphincter. This increases the pressure at the lower end of the esophagus and reduces acid reflux. People with bile reflux may continue to have symptoms after fundoplication, however.

Lifestyle Remedies

Unlike acid reflux, which can be caused or aggravated by eating certain foods and by smoking, obesity and excess alcohol consumption, bile reflux seems unrelated to lifestyle factors. But because many people experience both acid reflux and bile reflux, making some lifestyle changes may help relieve your symptoms:

Stop smoking. When it comes to acid reflux, smoking is a double threat: It increases the production of stomach acid, and it dries up saliva, which normally 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 at least two to three hours before taking a nap or going to bed 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. Although the same foods don’t trouble everyone, the worst offenders for most people include caffeinated and carbonated drinks, chocolate, citrus foods and juices, vinegar-based dressings, onions, spicy foods, and mint because they increase the production of stomach acid and may relax the lower esophageal sphincter.
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. Raise the head of your bed by about four to six inches. The incline may help prevent reflux symptoms. You can either sleep on a foam wedge or elevate the head of your bed with blocks. Pillows usually aren’t an effective way to elevate your upper body while sleeping.
Relax. When you’re under stress, digestion slows, which may worsen reflux symptoms. Relaxation techniques such as deep breathing, meditation or yoga may help.

Alternative medicine

Many people with frequent 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.

Although no alternative therapies have been found to specifically relieve bile reflux, some have been proven to help protect against and relieve esophageal inflammation. These include:

Chamomile, which has anti-inflammatory properties. Chamomile teas are readily available and have a low risk of side effects.
Licorice, which is commonly used to soothe inflammation associated with GERD, gastritis, ulcers and other digestive problems. However, licorice contains a phytochemical called glycyrrhizin that’s associated with serious health risks — such as high blood pressure and tissue swelling — if used long term. Talk with your doctor before trying this therapy. Prescription preparations are available that don’t contain glycyrrhizin.
Slippery elm, which encourages a protective mucous lining. Available as a root bark powder, slippery elm can be mixed with water and taken after meals and before bed. It may, however, decrease the absorption of prescription medications.
Marshmallow (Althea officinalis), which has been used for GERD symptom relief. Like slippery elm, marshmallow may cause problems with the absorption of medications. Note that this is the herb, not the puffy white confection.

Prevention

Lose excess weight. Heartburn and acid reflux are more likely to occur when excess weight puts added pressure on your stomach.
Raise your bed. Raise the head of your bed by about four to six inches. The incline may help prevent reflux symptoms. You can either sleep on a wedge or elevate the head of your bed with blocks. Pillows usually aren’t an effective way to elevate your upper body while sleeping.
Relax. When you’re under stress, digestion slows, which may worsen reflux symptoms. Relaxation techniques such as deep breathing, meditation or yoga may help.