Bile reflux occurs when bile — a digestive liquid produced in your liver — backs up (refluxes) into your stomach and esophagus (the tube that connects your mouth and stomach). Bile reflux may accompany acid reflux, the medical term for the backwash of stomach acids into your esophagus.
Whether bile is important in reflux is controversial. Bile is often implicated as a cause of reflux when people respond incompletely or not at all to powerful acid-suppressant medications. But there is little evidence pinpointing the effects of bile reflux in people. Studies in lab animals indicate that over time, bile reflux may have serious consequences, potentially increasing your risk of esophageal cancer.
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. It isn't clear what role bile plays in reflux conditions.
Bile reflux signs and symptoms include:
Upper abdominal pain that may be severeFrequent heartburn — a burning sensation in your chest that sometimes spreads to your throat, along with a sour taste in your mouthNauseaVomiting a greenish-yellow fluid (bile)Occasionally, a cough or hoarsenessUnintended weight loss
CAUSES
Bile is a greenish-yellow fluid that 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 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 flows into the duodenum, food enters your small intestine through the pyloric valve, a heavy ring of muscle located at the outlet of your stomach. The pyloric valve usually opens only 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 reflux into the stomach. In many cases of bile reflux, the valve doesn't close properly, and bile washes 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, malfunctions. 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. Most damage to the pyloric valve occurs as a complication of gastric surgery, including total removal of the stomach (gastrectomy) and gastric bypass surgery for weight loss.Peptic ulcers. A peptic ulcer can block the pyloric valve so that it doesn't open enough to allow the stomach to empty as quickly as it should. Stagnant food in the stomach can lead to increased gastric pressure that refluxes bile and stomach acid 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
Sticky mucous coats and protects the lining of your stomach from the corrosive effects of stomach acid. The esophagus lacks this protection, so acid and bile reflux can seriously damage esophageal tissue. The combination of bile and acid reflux increases the risk of complications, including:
GERD. Occasional heartburn usually isn't a concern. But frequent or continual heartburn is the most common symptom of GERD, a potentially serious problem that causes irritation and inflammation of esophageal tissue (esophagitis). GERD is most often due to excess acid. Although bile has been implicated, its importance in reflux is controversial.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 (metaplasia) have an increased risk of becoming cancerous. Animal studies have also linked bile reflux to the occurrence of Barrett's esophagus. Esophageal cancer. This serious form of cancer 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.
DIAGNOSIS
A description of your symptoms is often 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 peptic ulcers or inflammation in your stomach and esophagus. Your doctor also may 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. 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. Ambulatory acid tests can help your doctor rule out acid reflux but not bile reflux.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
Although treatments for acid reflux can be very effective, medications for bile reflux may not be helpful for many people. 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
Bile acid sequestrants. These medications, which disrupt the circulation of bile, may be helpful for some people with bile reflux. Side effects, such as bloating, may be severe.Ursodeoxycholic acid. This medication helps promote bile flow. It may lessen the frequency and severity of your symptoms.Prokinetic agents. These medications can help your stomach empty more rapidly and help tighten the lower esophageal sphincter. These medications have several side effects, including fatigue, depression, anxiety and other neurological problems.Proton pump inhibitors. These medications are often prescribed to block acid production, but they don't have a clear role in treating bile reflux.
Surgical treatments
Doctors may recommend surgery if medications fail to reduce severe symptoms, or there are precancerous changes in your 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 (Roux-en-Y). This procedure may be recommended for people who have had previous gastric surgery with pylorus removal (Billroth I or Billroth II). In Roux-en-Y, surgeons make a new connection for bile drainage farther down in the small intestine, diverting bile away from the stomach.Anti-reflux surgery (fundoplication). The part of the stomach closest to the esophagus (fundus) is wrapped and then sewn around the lower esophageal sphincter. This procedure strengthens the valve and can reduce acid reflux. There is little evidence about the surgery's effectiveness for bile reflux.
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| Bile Reflux |
Whether bile is important in reflux is controversial. Bile is often implicated as a cause of reflux when people respond incompletely or not at all to powerful acid-suppressant medications. But there is little evidence pinpointing the effects of bile reflux in people. Studies in lab animals indicate that over time, bile reflux may have serious consequences, potentially increasing your risk of esophageal cancer.
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. It isn't clear what role bile plays in reflux conditions.
Bile reflux signs and symptoms include:
Upper abdominal pain that may be severeFrequent heartburn — a burning sensation in your chest that sometimes spreads to your throat, along with a sour taste in your mouthNauseaVomiting a greenish-yellow fluid (bile)Occasionally, a cough or hoarsenessUnintended weight loss
CAUSES
Bile is a greenish-yellow fluid that 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 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 flows into the duodenum, food enters your small intestine through the pyloric valve, a heavy ring of muscle located at the outlet of your stomach. The pyloric valve usually opens only 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 reflux into the stomach. In many cases of bile reflux, the valve doesn't close properly, and bile washes 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, malfunctions. 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. Most damage to the pyloric valve occurs as a complication of gastric surgery, including total removal of the stomach (gastrectomy) and gastric bypass surgery for weight loss.Peptic ulcers. A peptic ulcer can block the pyloric valve so that it doesn't open enough to allow the stomach to empty as quickly as it should. Stagnant food in the stomach can lead to increased gastric pressure that refluxes bile and stomach acid 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
Sticky mucous coats and protects the lining of your stomach from the corrosive effects of stomach acid. The esophagus lacks this protection, so acid and bile reflux can seriously damage esophageal tissue. The combination of bile and acid reflux increases the risk of complications, including:
GERD. Occasional heartburn usually isn't a concern. But frequent or continual heartburn is the most common symptom of GERD, a potentially serious problem that causes irritation and inflammation of esophageal tissue (esophagitis). GERD is most often due to excess acid. Although bile has been implicated, its importance in reflux is controversial.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 (metaplasia) have an increased risk of becoming cancerous. Animal studies have also linked bile reflux to the occurrence of Barrett's esophagus. Esophageal cancer. This serious form of cancer 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.
DIAGNOSIS
A description of your symptoms is often 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 peptic ulcers or inflammation in your stomach and esophagus. Your doctor also may 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. 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. Ambulatory acid tests can help your doctor rule out acid reflux but not bile reflux.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
Although treatments for acid reflux can be very effective, medications for bile reflux may not be helpful for many people. 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
Bile acid sequestrants. These medications, which disrupt the circulation of bile, may be helpful for some people with bile reflux. Side effects, such as bloating, may be severe.Ursodeoxycholic acid. This medication helps promote bile flow. It may lessen the frequency and severity of your symptoms.Prokinetic agents. These medications can help your stomach empty more rapidly and help tighten the lower esophageal sphincter. These medications have several side effects, including fatigue, depression, anxiety and other neurological problems.Proton pump inhibitors. These medications are often prescribed to block acid production, but they don't have a clear role in treating bile reflux.
Surgical treatments
Doctors may recommend surgery if medications fail to reduce severe symptoms, or there are precancerous changes in your 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 (Roux-en-Y). This procedure may be recommended for people who have had previous gastric surgery with pylorus removal (Billroth I or Billroth II). In Roux-en-Y, surgeons make a new connection for bile drainage farther down in the small intestine, diverting bile away from the stomach.Anti-reflux surgery (fundoplication). The part of the stomach closest to the esophagus (fundus) is wrapped and then sewn around the lower esophageal sphincter. This procedure strengthens the valve and can reduce acid reflux. There is little evidence about the surgery's effectiveness for bile reflux.
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