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Bile reflux

Definition :
Most people are familiar with acid reflux — the backflow of caustic stomach acids into the esophagus, the tube that connects your throat and stomach. Less well known is bile reflux, which occurs when bile — a digestive fluid produced in the liver — flows upward (refluxes) from the small intestine into the stomach and esophagus.

Bile reflux often accompanies acid reflux, and together they're a formidable team, inflaming the lining of the esophagus and potentially increasing the risk of esophageal cancer. Bile reflux also affects the stomach, where it causes further inflammation.

Unlike acid reflux, bile reflux usually can't be controlled by changes in diet or lifestyle. Instead, bile reflex is most often managed with certain medications or, in severe cases, with surgery. Neither solution is uniformly effective, however, and some people continue to experience bile reflux even after treatment.

Bile is a greenish-yellow fluid that's essential for digesting and absorbing fats and for eliminating worn-out red blood cells and certain toxins from your body. It's produced in the liver and stored in the gallbladder in a highly concentrated form. Eating a meal that contains even a modest amount of fat signals the gallbladder to release bile, which flows through two small tubes (cystic duct

and common bile duct) into the upper part of the small intestine (duodenum).

At the same time, food enters the small intestine through the pyloric valve, a heavy ring of muscle that sits at the outlet of your stomach. Ordinarily, the pyloric valve opens just slightly — enough to release about an eighth of an ounce of liquefied food at a time, but not enough to allow digestive juices to flow back into the stomach. In many cases of bile reflux, the valve doesn't close properly, and bile backwashes into the stomach, where it causes irritation and inflammation (gastritis).

Most damage to the pyloric valve occurs as a complication of gastric surgery, including total removal of the stomach (gastrectomy) and gastric bypass operations for weight loss. Other causes of bile reflux include :

  • Peptic ulcer. Sometimes a peptic ulcer can obstruct the pyloric valve. Rather than not closing tightly, the valve doesn't open enough to allow the stomach to empty as quickly as it should. The stagnant food and liquid can lead to increased gastric pressure that causes bile and stomach acid to back up 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.

Reflux into the esophagus
Bile and stomach acid reflux into the esophagus when another muscular valve, the lower esophageal sphincter, malfunctions. The lower esophageal sphincter separates the esophagus and stomach. Normally, it opens only to allow food to pass into the stomach and then closes tightly. But if the valve relaxes abnormally or weakens, stomach acid and bile can wash back into the esophagus, causing heartburn and ongoing inflammation that may lead to serious complications.

Symptoms :
Bile reflux can be difficult to distinguish from acid reflux — the signs and symptoms are similar, and the two conditions frequently occur at the same time. But unlike acid reflux, bile reflux inflames the stomach, often causing a gnawing or burning pain in the upper abdomen. Other signs and symptoms include :

  • Frequent heartburn — a burning sensation in your chest that sometimes spreads to your throat along with a sour taste in your mouth
  • Nausea
  • Vomiting bile
  • Occasionally, a cough or hoarseness

Doctors often can diagnose a reflux problem from a description of symptoms. But distinguishing between acid reflux and bile reflux is notoriously 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.

  • Endoscopy. In this test, your doctor places a thin, flexible tube with a light and camera (endoscope) down your throat. The endoscope can show ulcerations or inflammation in your stomach or esophagus and can reveal a peptic ulcer. The test, technically called an esophagogastroduodenoscopy, also allows your doctor to take tissue samples to test for Barrett's esophagus — a condition in which cells in the esophagus undergo precancerous changes — or esophageal cancer, two potential complications of acid and bile reflux.
  • Ambulatory acid tests. These tests use an acid-measuring probe to identify when, and for how long, acid regurgitates into your esophagus. In the standard tube test, a thin, flexible tube (catheter) is threaded through your nose into your esophagus to insert the probe, which is placed just above the lower esophageal sphincter. A second probe may be placed over your upper esophagus. Attached to the other end of the catheter is a small computer that you wear around your waist or over your shoulder during the test. After the probe is in place, you go about your life, the device records pH levels every four seconds for 24 hours, and then you return to have the device removed.

    The test is somewhat uncomfortable, makes sleeping and showering difficult, and isn't always accurate; eating a highly acidic meal can skew the results. Tests are available that may be more comfortable, however. The Bravo test, for example, eliminates the need for a nose tube because the probe is attached to the lower portion of your esophagus during endoscopy. And rather than having to be removed, the probe detaches on its own and passes through your intestinal tract in a week or so.
  • sophageal impedance. Rather than measuring acid, this test can measure whether gas or liquids reflux into the esophagus. It's helpful for people who have regurgitation of substances that aren't acidic and therefore wouldn't be detected by a pH probe. As in a standard probe test, esophageal impedance uses a probe that's placed into the esophagus with a catheter.

Complications :
A sticky mucous coating protects your stomach from the corrosive effects of stomach acid, but the esophagus lacks this protection, which is why bile reflux and acid reflux can seriously damage esophageal tissue. And although bile reflux can injure the esophagus on its own — even when the pH of the reflux is neutral or alkaline — the combination of bile and acid reflux seems to be particularly harmful, increasing the risk of complications, such as :

  • Heartburn and gastroesophageal reflux disease (GERD). Millions of people experience heartburn, sometimes on a daily basis. Occasional heartburn usually isn't a concern, although a severe episode can mimic a heart attack. But frequent or constant heartburn is the most common symptom of gastroesophageal reflux disease (GERD), a potentially serious problem that causes irritation and inflammation of esophageal tissue (esophagitis).
  • Esophageal narrowing (stricture). Repeated exposure to stomach acid, bile or both can cause scar tissue to form in the lower esophagus. This narrows the tube, interfering with swallowing and increasing the risk of choking.
  • Barrett's esophagus. In this uncommon but serious condition, long term exposure to stomach acid or a combination of acid and bile cause a change in the color and composition of the tissue in the lower esophagus (metaplasia). The new cells resemble glandular tissue in the stomach — under a microscope, they look like shag carpeting — and although they're resistant to stomach acid, they have a high potential for malignancy. Only a small percentage of people with GERD have Barrett's esophagus, but those who do have a greatly increased risk of esophageal cancer.
  • Esophageal cancer. This serious form of cancer can occur almost anywhere along the length of the esophagus, but it frequently starts in the glandular cells closest to the stomach (adenocarcinoma).Because esophageal cancer may not be diagnosed until it's quite advanced, the outlook for people with the disease is often poor. The link between esophageal cancer and bile reflux and acid reflux remains controversial, but many experts think a direct connection exists. In animal models, bile reflux alone has been shown to cause cancer of the esophagus.
  • Gastritis. In addition to causing irritation and inflammation in the esophagus, bile reflux can cause stomach irritation (gastritis). Although not always serious, untreated gastritis can lead to stomach ulcers and to bleeding, a potentially life-threatening problem that requires immediate medical care. Chronic gastritis can also increase the risk of stomach cancer, especially when there is extensive thinning of the stomach lining or a change in the makeup of the stomach cells.

Drugs called proton pump inhibitors are considered the best treatment for GERD and Barrett's esophagus. Although the primary purpose of these medications, which include esomeprazole (Nexium), lansoprazole (Prevacid) and rabeprazole (AcipHex), is to block acid production, they may also help reduce bile reflux.

Still, the most commonly prescribed drug for bile reflux is ursodeoxycholic acid, which helps promote bile flow. If bile reflux results from delayed stomach emptying, doctors may prescribe drugs to increase the rate at which food moves through your stomach.

Surgical treatments
When medications fail to reduce severe symptoms or there are precancerous changes in the esophagus, doctors sometimes recommend surgery. Because some types of operations are often more successful than others, be sure to discuss the pros and cons carefully with your doctor.

Surgical options include :

  • Diversion surgery. This is usually the preferred procedure for treating bile reflux. In what is called a Roux-en-Y operation, surgeons make a new connection for bile drainage further down in the intestine, thereby diverting bile away from the stomach.
  • Anti-reflux surgery. Typically used to treat acid reflux, this operation — known medically as fundoplication — may be less successful in people who have bile reflux problems. During the procedure, the part of the stomach closest to the esophagus (fundus) is wrapped and then sewn around the lower esophageal sphincter. This increases the pressure at the lower end of the esophagus and reduces acid reflux. People with bile reflux may continue to have symptoms after fundoplication, however.
Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.
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