What is bile reflux?
Biliary reflux is the backward flow of bile, the emulsifying agent produced by the liver and stored in the gallbladder, up into the stomach and/or esophagus. The reflux of bile is commonly associated with acid reflux and even with the treatment of gastroesophageal reflux disease (GERD) with PPIs (proton pump inhibitors), bile reflux may continue in many cases.
Although bile is not as strong an irritant as acid, it can still cause ongoing inflammation of both the stomach and esophageal lining. Changes of pH and the presence of the Helicobacter pylori (H.pylori) bacterium can alter the composition of the bile rendering it into different forms, all of which can cause irritation of the mucosal lining of the stomach and esophagus.
Bile reflux should not be confused with vomiting bile, as the vomiting process causes the sudden and forceful expulsion originating from as low down as the middle parts of the small intestine. Bile vomitus may however be seen with persistent bile reflux leading to severe gastritis.
Causes of Bile Reflux
Bile is secreted in the duodenum and passes down the gut with the rest of the intestinal chyme. If the integrity of the pyloric valve (part of the stomach that controls the outflow of gastric contents into the duodenum) is compromised then the retrograde flow of bile may occur leading to irritation of the stomach lining. This can cause persistent gastritis despite the appropriate gastritis treatment.
If the lower esophageal sphincter is also impaired, then the bile along with the acidic stomach contents can flow up into the esophagus. Irritation of the mucosal lining by the bile, even if the stomach acid is neutralized by one or more agents discussed under stomach acid medication, will cause the typical symptoms associated with acid reflux.
Most cases of bile reflux are associated with chronic conditions affecting the pyloric sphincter and lower esophageal sphincter (LES).
Symptoms of Bile Reflux
The symptoms associated with bile reflux is often a combination of gastritis and acid reflux symptoms.
- Chronic heartburn (persistent or recurrent burning chest pan)
- Regurgitation (vomiting less frequent)
- Abdominal pain (gnawing or burning pain, discomfort, stomach ache)
- Lack of appetite
- Unintentional weight loss
- Chronic cough and chronic sore throat, particularly a morning sore throat, often associated with LPR reflux (laryngopharyngeal reflux disease)
Bile reflux may lead to the same complications associated with GERD and chronic gastritis.
Treatment and Surgery
Medical treatment involves many of the same drugs used for chronic acid reflux. This includes :
- Proton pump inhibitors to reduce gastric acid production.
- Prokinetic drugs to speed up gastric emptying.
These drugs however, will not neutralize the bile although it may help to some extent with the reflux.
Ursodeoxycholic acid is an oral biliary agent often used for the treatment of gallstones. It promotes bile flow and reduces the extent and severity of bile reflux.
Surgical treatment may involve :
- Anti-reflux surgery (fundoplication) which is usually done laparoscopically to strengthen the lower esophageal sphincter (LES).
- Diversion surgery (Roux-en-Y) redirects the drainage of bile lower down the small intestine and should not be confused with similar procedures for weight loss as the clinical goal differs.