What is bile reflux?
Bile reflux or duodenal gastroesophageal reflux refers to back-flow of the bile from the duodenum into the stomach and further into the esophagus [1].
Causes
Causes and risk factors for bile reflux may include [1,2,3]:
- Gastroesophageal reflux disease (GERD)
- Hiatus hernia
- Peptic ulcer that affects the pyloric sphincter (the muscular valve between the stomach and duodenum)
- H. pylori infection of the stomach [5]
- Gallbladder removal (cholecystectomy) [10]
- Scars (strictures) within the duodenum
- Partial surgical stomach removal
- Bypass surgery for weight loss
- Smoking [8]
Often the cause of bile reflux cannot be identified.
Symptoms
Symptoms of bile reflux are similar to those in acid reflux [3,14]:
- Lower chest or stomach pain after the meals, which is not relieved by acid-lowering drugs
- Fat intolerance
- Heartburn
- A cough or hoarseness
- Throat pain
- Difficulty swallowing
- Nausea and vomiting green or yellow bile
- Metallic or bitter taste in mouth
- Unintended weight loss
Complications
Possible complications of bile reflux:
- Barrett’s esophagus (damage of the mucosal lining at the bottom of the esophagus), which is a risk factor for esophageal cancer [1,3]
- Gastritis and peptic ulcer [6,7]
- Gastric polyps [15]
Diagnosis
Bile reflux can be confirmed by detecting the bile in the esophagus during an upper endoscopy [1].
Treatment
Drugs
There is some evidence that the following drugs MAY BE EFFECTIVE in the prevention or decrease of the symptoms of bile reflux:
- Omeprazole [3] or rabeprazole with hydrotalcite [11] (proton pump inhibitors, which decrease the acidity of the stomach)
- Baclofen (prevents excessive relaxation of the lower esophageal sphincter) [1]
- Cisapride (promotes stomach emptying) [16]
- Domperidone (a prokinetic drug, which stimulates gastric emptying) [2]
- Sucralfate (protects the gastric mucosal lining) [3]
- Ursodeoxycholic acid (promotes the bile flow) [3,13]
Structural abnormalities, such as a hiatus hernia and duodenal strictures, that cause biliary reflux can be surgically corrected.
The following drugs seem to be LESS EFFECTIVE in the treatment of bile reflux: antacids [12], H2 antagonists [12], bile salt binders (cholestyramine, colestipol and colesevelam) [3,9,12] and metoclopramide [12].
Natural Remedies
There seems to be NO EVIDENCE about the effectiveness of the following herbs and remedies in the prevention or treatment of bile reflux: chamomile, licorice, marshmallow and slippery elm [3].
Prevention
If you have bile reflux, you almost certainly also have acid reflux. To prevent the reflux of acid and bile from the stomach into the esophagus [1,3,4]:
- Lose weight if you are overweight.
- Have frequent small meals.
- Limit foods that relax lower esophageal sphincter: fatty foods (oils, chocolate, cheese, butter, fatty fish), citrus fruits, vinegar and other acidic foods, tomatoes, onions, carbonated, caffeinated and alcoholic beverages, mint, spicy and hot foods.
- Do not lie down after the meals and do not eat before sleeping.
- Raise your bed at the head side.
- Do not smoke.
- Avoid unnecessary stress.
- References
- Sifrim D, 2013, Bile reflux management PubMed Central
- Cheifetz AS et al, Biliary reflux, Oxford American Handbook of Gastroenterology and Hepatology, p. 239
- Bile reflux Drugs.com
- Reflux – Acid or Bile? Know the difference Gastrointestinal Associates
- Ladas SD et al, 1996, Helicobacter pylori may induce bile reflux: link between H pylori and bile induced injury to gastric epithelium PubMed Central
- Vere CC et al, 2005, Endoscopical and histological features in bile reflux gastritis PubMed
- Black RB et al, 1971, The effect of healing on bile reflux in gastric ulcer PubMed Central
- Müller-Lissner SA, 1986, Bile reflux is increased in cigarette smokers PubMed
- Fass R, 2016, Approach to refractory gastroesophageal reflux disease in adults UpToDate
- Kalima T et al, 1981, Bile reflux after cholecystectomy PubMed
- Chen H et al, 2010, Rabeprazole combined with hydrotalcite is effective for patients with bile reflux gastritis after cholecystectomy PubMed Central
- Nath BJ et al, 1984, Alkaline reflux gastritis and esophagitis PubMed
- Stefaniwsky AB et al, 1985, Ursodeoxycholic acid treatment of bile reflux gastritis PubMed
- Kleba T, 1998, Gastroscopic criteria and most frequent pain in bile reflux gastritis PubMed
- Wang Zi-Kay et al, 2013, Upper gastrointestinal microbiota and digestive diseases PubMed Central
- Szarszewski A et al, 1999, Duodenogastric reflux: clinical and therapeutic aspects Archives of Disease in Childhood
I get a feeling of being pinched at the top of my clavicles with inspiration more so after eating something. I’ve had a cough for about 9 months with a hoarse voice for 18 months and was just diagnosed with reactive airway( no smoking, no asthma previous). Upper GI showed hiatal hernia, multiple esophageal ulcers, esophageal spasms and questions barrette’s esophagus. And EGD was negative for that but showed large amount of bile in my stomach.. I have good doctors and I’m a nurse and have been researching, but I have so many other symptoms going with this and it’s scary. Is it ever linked to cancer?
I take nexium twice daily and I still get heartburn. Sometimes lasts up to 3 days. Seems to gradually move to the right side and then into my back below the shoulder blade. Gall bladder removed 10 yrs ago Have rhuematoid and take Celebrex and oxy for pain sometimes pressure so bad throw up. I’m not overweight don’t smoke or drink. Eat small meals only 2 to 3 cups coffee a day.
Bile reflux is relatively common after gallbladder removal. But you can have bile reflux only if your lower esophageal sphincter (LES) does not close properly. I strongly suggest you to ask a doctor about investigations to see what can be done. In meantime, you can check for a diet for prevention of acid reflux: limiting fatty foods and such, not lying down after meals, sleeping with raised upper body, etc.
Is it possible to have this occasionally? The symptoms fit but I only get an attack every few months.
Yes, it would be possible to have bile reflux only occasionally. Triggers could be similar as in acid reflux, for example some foods: fatty foods, alcohol, etc.
Your advice on diets are helpful. I have tried limiting the culprit foods but in bile reflux the effect of this is uncertain. I have had meals which are bland and I have had the reflux, I have had meals that I thought would harm me and I have been ok. My hiatus hernia at the pyloric junction recently diagnosed seems to be the root of it. It is small. PPIs are of limited effectiveness although they do stop the after-eating cough. I cough up a lot of green yellow stuff bile reflux after sleeping. I think I need tests on PH levels not just an endoscopic result, which showed bile reflux and hernia but otherwise seemed ok. Doctors are completely ignorant on bile reflex. They prescribe Omaprezole as a universal panacea for reflux. Too much of PPIs is likely to result in other problems. Our stomachs need acid after all to help with bacteria. Also malabsorption of necessary minerals as a a side effect is a worry. There is a key somewhere to treating bile reflux but doctors have not yet found it. My weakened sphincter has not been helped by continuous hard coughing from a chest problem which probably caused the hernia. Bile reflux is very hard to live with as can be seen by the many posts on the subject.
The main cause of both acid and bile reflux is the lower esophageal sphincter that does not close properly, usually due to hiatal hernia. There are fatty and other foods that keep this sphincter too relaxed (as you can read above in the article). For bile reflux to occur, the pyloric sphincter at the end of the stomach also needs to be too relaxed or affected by an ulcer or structural abnormality. I’m not sure if I understood which sphincter you said is affected.