Bile secretion is at the greatest 20 to 40 minutes after eating, particularly following the ingestion of a fatty meal. If vomiting occurs a short while after eating or if a person has severe acid reflux then bile along with food, acid and enzymes may enter the esophagus and even reach the mouth. Depending on the force, these fluids may be pushed out of the mouth rapidly.
Bile Reflux vs Bile Vomit
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.
What is bile vomiting?
Vomiting bile often presents as a bright yellow to dark green color in the vomitus. While the color may be due to the breakdown of food, the presence of bile should not be ignored as it could be related to serious causes that require immediate medical attention, especially if it is of a sudden onset. In most cases, the vomiting is accompanied by nausea and small bowel obstruction has to always be excluded, especially in infants. If the vomiting occurs with no nausea, raised intracranial pressure needs to be excluded.
Bile is often present in the vomit but goes unnoticed in small quantities. It becomes more evident as the ingested contents are passed out and only water and mucus are remaining. Therefore many of the same causes of vomiting, especially recurrent vomiting, will lead to bile vomitus. Persistent vomiting, especially a short while after eating a meal, may lead to bile vomitus.
Causes of Bile Vomit
Yellow to green vomit should not be immediately considered as bile vomitus. Foods and drinks that can color the gastric contents in this manner need to be excluded. The causes below are not a complete list of conditions resulting in bile vomitus.
The presence of bile in the vomit should always raise the concern of bowel obstruction. Any obstruction of the small intestine, even as far as the the jejunum and ileum of the small intestine, will usually cause the expulsion of intestinal contents which have already mixed with bile in the duodenum. As mentioned under vomiting control, antiperistaltic contractions which move contents up the gut can begin as low as the ileum of the small intestine.
However, bile vomiting will not be present in a case of gastric outlet obstruction or any blockage lying proximal to the duodenum. The most common symptoms are constipation (also referred to as obstipation in intestinal obstruction) and abdominal distention. Abdominal pain is typically present but in infants this may only be evident as constant crying. The causes of small bowel obstruction include :
- Newborns and Infants
- Hirschsprung’s disease
- Congenital duodenal atresia – distal to the ampulla of Vater
- Pyloric stenosis
- Foreign bodies
- Adhesions (post-operative)
- Malignant tumor
- Inflammatory bowel disease
- Gallstone ileus, foreign bodies
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.
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 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).
Bile reflux may be a result of :
- Bile may enter the stomach following a cholescystectomy (surgical removal of the gallbladder). This is known as postcholecystectomy syndrome and often results in gastritis and esophagitis. The irritation of the stomach lining may lead to vomiting of the bile and other gastric contents.
- Any gastric surgery that may affect the pyloric sphincter of the stomach may allow bile to enter the stomach during intestinal peristalsis. This is sometimes seen in a gastrectomy and gastric bypass surgery and is often associated with rapid gastric emptying.
- Peptic ulcer
Drugs and Alcohol
Certain drugs and alcohol, especially in large quantities, are known irritants of the gastrointestinal tract.
If the irritation is ongoing as seen with alcohol abuse and poisoning, bile vomiting may occur. With the consumption of certain drinks, particularly cocktails, the dyes used to color these drinks may at times be mistaken for bile.
Drugs like morphine and digitalis derivatives may stimulate the chemoreceptor trigger zone and lead to prolonged bouts of vomiting with bile vomitus.
Cyclic Vomiting Syndrome
This is a chronic functional disorder and the exact cause is unknown. In CVS, there may be bouts of nausea and vomiting that may last for a few hours to day and then spontaneously resolve. It can recur anywhere between a few days to weeks or months later. Bouts of vomiting of this nature with no known cause with at least 3 episodes in a 6 month period are usually considered as CVS.
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 of Bile Reflux
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.
Last updated on September 30, 2018.