Have you been diagnosed with acid reflux and the medications are not working well?
Then you may have bile reflux, a condition with similar symptoms, but requiring very different medications and treatments to obtain the relief you need. Bile reflux can be initially diagnosed as acid reflux.
The odds of having bile reflux are much higher when acid reflux medications do not work, your gallbladder has been removed, or you have had stomach surgery.
This bile reflux guide is user friendly, clickable to get more medically verifiable information on any subject and will help you:
- Understand bile reflux and why it is extremely important to actively address this condition
- What tests and treatments are successful
- Identify other conditions that may be a cause
- Help you locate and have a helpful conversation with a medical provider
This guide was developed using a review of over seventy-five research articles and 1,200 comments from current bile reflux sufferers in the Bile Reflux Support Group.
Understanding Bile Reflux
Symptoms of bile reflux may include abdominal pain, nausea, regurgitation, inflammation of stomach and esophageal linings, indigestion, a burning sensation, yellow vomit or stools, weight loss and other related problems. Other additional symptoms may occur in the throat, voice and ears in a related condition.
To explain bile reflux, your digestive track is designed to move what you eat and drink downward. The pathway moves down through your throat, esophagus, then through a valve called the lower esophageal sphincter (LES), into the stomach, through another valve under your stomach called the pyloric sphincter and into the colon and intestines.
Bile is essential to digestion and is released into the intestines by the liver and gall bladder (if it has not been removed). Normally, the pyloric sphincter will release about 1/8 of an ounce of bile and liquified food into the stomach in short spurts as needed.
In bile reflux, the pyloric sphincter does not close quickly or tightly enough and additional bile flows upwards into the stomach, where it does not belong, and from this upward flow a wide variety of bile reflux symptoms may occur.
Additionally, if the stomach pressure is too high or the esophageal sphincter above the stomach is too weak, then these fluids can also travel up the esophagus and into the throat area, potentially causing biliary laryngopharyngeal reflux (LPR) that requires a specialized treatment.
Physicians typically assume that your reflux is acid reflux and prescribe acid reducing medications using PPIs and acid reducers. A problem comes in when those fail and even more acid reducing medications are prescribed.
If you have bile reflux, acid reducing medications fail about 68% of the time because acid reflux is acidic and bile reflux is alkaline. Therefore acid reducers such as Nexium and Pepcid will not control alkaline based bile. At times bile reflux can trigger acid reflux since the bile backflow mixes with acids in the stomach. So, it is possible to have both, confusing the treatment.
The picture below shows the critical difference between acid reflux and bile reflux:
Common Causes of Bile Reflux
Gall Bladder Removal
A significant cause of bile reflux comes as a result of the surgery to remove the gall bladder, known as a cholecystectomy. Estimates are that there are 300,000 gall bladder removals in the US every year. There is evidence that in 58% of cases gall bladder removal can lead to bile reflux even after many years. Also an additional condition called post cholecystectomy syndrome can occur even many years later. Gall bladder removal is also known to cause duodenogastric reflux, alkaline reflux gastritis intestinal metaplasia, and a reduction in H. pylori colonization.
Pyloric Sphincter Issues
Problems can occur if the pyloric sphincter, which sits between the stomach and intestines, is not opening and closing in a timely and correct manner and therefore bile can travel upward into the stomach. This condition can also result in a buildup of pressure in the stomach where contents are forced upward and into the esophagus through the LES.
Impaired Gastric Motility
Gastric motility issues relate to the speed at which materials flow through the digestive system and into the intestines and is estimated to cause 40% of all reflux. This frequently involves the miscoordination of the pyloric sphincter opening and closing and the speed at which stomach contents flow.
Motility issues can be related to gastroparesis, a difficult condition which causes many digestive flow problems and involves food remaining in the stomach for too long.
Other Conditions to Rule Out
At times other conditions may contribute to bile reflux symptoms. Ruling these conditions out as a cause during the bile reflux diagnostic process is important to fully examine causes and symptoms.
- SIBO or small intestine bacterial overgrowth, is a serious condition. At times SIBO may be a side effect of PPIs that are used to treat reflux.
- Sphincter of ODDI When this sphincter does not function correctly gastric juices can back up and cause pain and may require surgery.
- Hiatal Hernia A hiatal hernia occurs when the upper part of the stomach pushes through an opening in the diaphragm and into the chest cavity causing pain.
- H pylori is a bacteria that damages the stomach, causing inflammation, and weakening the stomach lining and may also cause ulcers.
- Bile acid diarrhea can cause abdominal cramping and urgency.
- Gastritis involves redness and inflammation of the stomach lining. Gastritis is confusing as it can have multiple causes, one of which is bile reflux.
- Gastroparesis is a very important issue to evaluate in bile reflux as it involves the delayed movement of materials from your stomach into your intestines. This condition occur in 40-45% of bile reflux cases. This condition may involve damage of the vagus nerve which plays a role in stomach contractions.
Medications and Supplements That Are Commonly Used to Treat Bile Reflux
The medications and supplements listed here have been scientifically researched as valid methods in the treatment of bile reflux:
- Ursodeoxycholic acid thins the content of bile in the stomach so that it can flow more easily. This can be especially useful in cases where the gall bladder has been removed.
- Bile acid sequestrants chemically binds bile.
- Sucralfate (carafate) coats and protects the lining of the stomach and esophagus.
- Prokinetic agents enhance the motility between the stomach and small intestine.
- Baclofen decreases the relaxation of the lower esophageal sphincter.
- Alginates protect bile from refluxing upward into the esophagus by creating a foamy gel that essentially forms a chemical “raft” that floats on the surface of the gastric content in the stomach.
- Psyllium Husks have been shown to be superior to PPIs in the treatment of gastroesophageal reflux disease and other conditions. Psyllium acts as a bile binder for bile salts and a laxative which can help with the gastric motility flow through the pyloric valve.
- Proton pump inhibitors, generally known as PPIs, and acid reducers such as Pepcid are frequently the first medications prescribed as medical providers assume acid reflux as the primary cause of most reflux. PPIs are ineffective in bile reflux 68% of the time. They also do not perform better than a placebo treatment. If PPIs are partially effective it is quite often the case that the patient has both bile and acid reflux at the same time. PPIs were initially designed for use in acid reflux. Bile reflux is alkaline, the opposite of acidic. Users typically report that PPIs make bile reflux systems worse.
- Some popular PPI names are Omeprazole (Prilosec), Esomeprazole (Nexium), Lansoprazole (Prevacid), and many other name and brand names. H2 blockers that are prescribed to block acid formation such as Pepcid (famotidine).
- Hydroxyzine and amitriptyline are prescribed to reduce stress, anxiety, pain and depression.
- Supplements are on the market that treat bile reflux symptoms. The psyllium husks and alginates listed above are well researched. Many of these supplements not well researched. They do have user comments on amazon. It is not generally known if they are safe, have long term health effects, are effective, are specific to bile as opposed to acid reflux, or may interact to other supplements or medications. Therefore, it is important to look these treatments up and see lots of comments about them at Amazon. A few of the more popular supplements include DGL, marshmallow root, slippery elm, mastic gum, aloe vera L-glutamine, Collagen, zinc carnosine, bentonite clay, iberogast, ginger root, gentian root, digestive bitters, digestive enzymes, and others.
Common Tests For Bile Reflux
- Upper endoscopy exam. This is also known as an EGD. The procedure involves inserting a tube through the throat, stomach, and intestine, utilizing a small camera and a device that allows the physician to snip out samples for later laboratory study. The procedure requires about twenty minutes under light anesthesia. The amount of bile refluxing into the stomach varies daily. Therefore, a brief look at stomach contents showing no bile to be present cannot always be relied upon to diagnosis bile reflux.
- Esophageal impedance test. This procedure identifies if reflux moving into your esophagus is acidic or biliary (bile). This test involves the insertion of a small catheter into your esophagus through the nose for a period of 24 hours to measure and record reflux events.
- HIDA scan. This radiology procedure takes a live image that tracks the flow of the bile from the liver and small intestine. It can require one to even four hours.
- Esophageal Manometry tests stomach contractions in digestion.
- Bravo test is sometimes used but tests acid and not bile
- Bilitec monitoring system. This form of monitoring involves the use of a capsule to aid monitoring in esophageal reflux to detect bile and other contents.
- Electrogastrogram measures the electrical activity around the stomach that may cause nausea, vomiting or pain.
Surgical Options For Bile Reflux
Many of the surgeries for bile reflux were originally intended to treat acid reflux or weight loss. Their usefulness and potential side effects and risks for treating bile reflux can be different than for acid reflux and are not always well established. In fact, bile reflux can be caused by stomach surgery.
Therefore, it is important that bile reflux sufferers be proactive in identifying and asking questions, evaluating risks and outcomes related to these surgeries that are specific to bile reflux (and not simply acid reflux). It may also be helpful to review a Facebook support group called Surgical Options for Chronic Bile Reflux
- Diversion surgery is utilized toredirect bile. Many of these types of surgeries are a variation of weight loss surgeries. The issue with diversion surgery regarding success and short and long term after effects are complex.
- Anti-reflux surgery The most frequently used surgery for reflux is the Nissen Fundoplication which reinforces the lower esophageal sphincter by surgically wrapping a section of the stomach around it. There are many variations of the Nissen. Success rates can be positive, and years later at times another surgery is needed. One reason for this failure rate is that the pyloric sphincter may be slow or blocked and is forcing pressure upwards. Therefore, the issue of pyloric sphincter blockage can be thoroughly examined and ruled out prior to determining if the surgery is necessary.
- The stretta procedure strengthens the LES over time.
- Endoscopic Balloon Dilation (EBD) This is simple procedure that uses a surgical balloon to stretch the pyloric sphincter that is too closed or obstructed.
Biliary Laryngopharyngeal Reflux (LPR)
Biliary laryngopharyngeal reflux can accompany bile reflux. Many people with bile reflux complain of issues in the throat, voice, and ears and assume these are symptoms of the bile reflux. This condition requires an additional diagnosis, understanding and treatment as an enzyme called pepsin is primarily involved that is not involved.
It is important to understand the causes and treatments for LPR as they are different than reflux. This guide can be helpful Guide to LPR Causes and Treatments.
About Stress, Emotions and Bile Reflux
As we all know, stress and emotions affect literally every part of our body, and different people in different ways. In bile reflux there may be several connections to both stress and emotions. Digestion is controlled through the vagus nerve which is connected to nearly every organ in the body, including the digestive system.
It is thought that issues with the pyloric sphincter, which controls bile reflux, occur because of injury to the vagus nerve. Hydroxyzine is sometimes used successfully to treat stress related discomfort at the top of the stomach. Histamines are also involved in the process. Amitriptyline is often used to treat anxiety and depression. It is instructive to research that PPIs, hydroxyzine, amitriptyline and Pepcid are all antihistamines!
Lifestyle and Diet Changes
There is a lot of discussion among members of public sites about dietary changes to help reduce bile reflux. In many cases, looking at the bile reflux facebook page, many report that the same low acid or gastritis diet used to reduce acid reflux may help bile reflux. This diet includes reducing or eliminating coffee, chocolate, alcohol, types of foods, and other potential offenders. Additionally, as the bile system is built to digest fat, lowering fat in the diet may help to keep the sphincters operating as they should.
In general, someone with bile reflux will usually experiment with different foods and drinks and learn from experience what tends to make their symptoms better or worse.
Other changes that can also help reduce bile reflux include stress reduction, smoking cessation, avoiding alcohol, eating smaller meals, losing weight, wearing lose fitting clothes around the middle, raising the back of the bed to help prevent the upward flow of bile at night, and staying upright after meals.
How to Do Further Research
Once you have reviewed the information in this guide you may want to research specific questions and ask your physician about these. It is important to exercise great care as there is so much information “out there” on the internet from questionable resources. This is a guide to that issue to help you evaluate those.
However, there are credible resources if you look in the right places.
It is helpful when doing an inquiry to be as specific as possible.
Places to look include:
- google scholar for research
- google from credible resources with fairly recent dates such as Cleveland Clinic, Mayo Clinic and Johns Hopkins, and articles with NCBI research. These resources have thorough medical reviews before they are shared to the public.
- UpToDate is used by physicians for science based treatment. It requires a subscription but allows the public to see some of the information.
How To Locate An Experienced Specialist
Once you have located a specialist it is important that you use the materials in this guide to help ask questions!
Finding a physician with experience who follows current research in bile reflux can be difficult. Many medical providers are more focused and experienced with acid reflux and not bile reflux.
To locate a specialist/gastroenterologist that is up to date, one method is to look for large, digestive focused practices where the physician may have more exposure to complex cases and multiple points of view.Physicians or researcher attached to universities where there is a teaching hospital may be more up to date. Many physicians are listed in “health grades” via web searches se you can see their patient experiences.
In your discussion with your primary physician, it is important to let them know of your concern about finding someone with specific bile reflux knowledge so you can be directed to the right medical expert. At times it can be useful to ask your physician where they would they might refer a family member.
Some Promising Bile Reflux Investigations
Thoroughly understanding the issue of bile reflux, its root causes and cures have largely been evasive. Therefore, currently the field has been reliant on medications and surgery to simply treat symptoms. Several new approaches are being investigated.
One very promising research around stimulation of the vagus nerve. This is the nerve that affects digestion. Another area is investigating the role of histamines, as, interestingly, medications used to treat reflux, such as Pepcid and PPIs, are antihistamines. Several projects are underway to try and block parts of the complex chemical chain in the reflux process.[GS1]
It is extremely important that you as the patient understand and be actively involved in the treatment of bile reflux as this condition does not get better on its own, is frequently misdiagnosed and requires very different medications and treatments than acid reflux, may involve or be caused by several other medical conditions, and is related to cancer increases.