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Bile reflux

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Related Terms
  • Acid reflux, antroduodenal motility disorder, bile, bile reflux gastritis, biliary reflux, duodenogastric reflux (DGR), gastritis, gastroesophageal reflux disease (GERD), pyloric valve.

Background
  • Bile is a digestive fluid composed of bile salts, bile pigments, cholesterol, and fatty acids. Bile is produced by the liver, stored in the gallbladder, and released into the duodenum (the upper section of the small intestine) when needed to aid the digestion of fats. Bile is essential for digesting fats and for eliminating aged red blood cells and certain toxins from the body.
  • Bile reflux, also called duodenogastric reflux, occurs when bile flows upward from the small intestine into the stomach. Bile reflux is caused by damage to the pyloric valve, which is a ring of muscle that separates the stomach from the duodenum. When the pyloric valve fails to close properly, bile flows into the stomach, causing pain and inflammation.
  • Bile reflux and acid reflux (also called gastroesophageal reflux disease (GERD)) have similar signs and symptoms, and the two conditions may occur at the same time. When bile reflux and acid reflux occur together, the mixture of bile and stomach acids flows backwards further into the esophagus (the tube that connects the throat to the stomach), causing heartburn and damage to the esophagus. Unlike acid reflux, bile reflux often causes a burning or gnawing pain in the stomach.
  • Diagnosing bile reflux is often difficult, because bile reflux and acid reflux have similar signs, and it is not uncommon for symptoms of the two conditions to occur at the same time. Since acid reflux is more common, bile reflux is often overlooked or mistaken for acid reflux and improperly treated.
  • Unlike acid reflux management, changes in diet or lifestyle are usually ineffective in the prevention or treatment of bile reflux. Instead, bile reflux is most often managed with medications or, in severe cases, with surgery. Many of the therapies used to manage bile reflux will also reduce acid reflux. This distinction is important, because these two conditions often occur at the same time and together result in serious complications if not treated.
  • Bile reflux causes damage to the lining of the stomach (called gastritis), which may progress to sores in the stomach (known as ulcers), bleeding, and stomach cancer. In patients that have both bile reflux and acid reflux, the combination seems to be particularly harmful, increasing the risk of damage to the esophagus, including conditions such as Barrett's esophagus and esophageal cancer.

Signs and symptoms
  • General: Bile reflux and acid reflux have similar signs and symptoms, and the two conditions may occur at the same time. Unlike acid reflux, bile reflux often causes a burning or gnawing pain in the stomach.
  • Cough or hoarseness: Some, but not all, patients with bile reflux experience a cough or hoarseness that is caused by stomach acid and/or bile rising up into the throat and burning the lining.
  • Frequent heartburn: Heartburn is a burning sensation in the chest that may spread to the throat along with a sour taste in the mouth. In severe cases, it may be mistaken for a heart attack.
  • Nausea and vomiting: Nausea is feeling the need to vomit. Some patients with bile reflux may vomit bile.
  • Upper abdominal pain: Bile reflux often causes a burning or gnawing pain in the stomach.
  • Weight loss: In some patients with bile reflux, unintended weight loss may occur.

Diagnosis
  • General: Diagnosing bile reflux is often difficult, because bile reflux and acid reflux have similar signs and symptoms and may occur at the same time. Since acid reflux is more common, bile reflux is often overlooked or mistaken for acid reflux and improperly treated. Tests that may be used to differentiate bile reflux from acid reflux include an endoscopic examination of the esophagus and stomach to check for inflammation or ulceration, an acid test to check for acid in the esophagus (this would be negative if bile reflux is the only problem), and an esophageal impedance test to determine if gas or liquids reflux into the esophagus.
  • Ambulatory acid tests: During an ambulatory acid test, an acid-measuring probe is placed in the esophagus to identify when, and for how long, stomach acid backs up into the esophagus. The BilitecTM ambulatory bile reflux monitor may be used. Ambulatory acid tests are negative in patients with bile reflux unless they also have acid reflux.
  • Endoscopy: During an esophagogastroduodenoscopy (EGD), a thin, flexible tube with a light and camera (called an endoscope) is inserted down the throat to look for ulcerations or inflammation in the stomach or esophagus. During this test, complications of bile reflux (i.e., peptic ulcers, signs of Barrett's esophagus, or esophageal cancer) may also be identified.
  • Esophageal impedance: An esophageal impedance test uses a probe that is placed into the esophagus to measure whether gas or liquids back up into the esophagus.

Complications
  • General: Bile reflux causes damage to the lining of the stomach (called gastritis), which may progress to stomach ulcers, bleeding, and stomach cancer. Bile reflux often occurs in patients that also have acid reflux. The combination of bile and acid reflux seems to be particularly harmful, increasing the risk of damage to the esophagus, including conditions such as Barrett's esophagus and esophageal cancer.
  • Acid reflux: It is not uncommon for bile reflux and acid reflux to occur at the same time. In this case, both stomach acid and bile flow back into the esophagus, causing heartburn and persistent inflammation that damages the esophagus over time.
  • Barrett's esophagus: Barrett's esophagus is caused by long-term exposure to stomach acid or a combination of acid and bile. Over time, there is a change in the color and composition of the cells that line the lower part of the esophagus. These changed cells are at a higher risk of developing into esophageal cancer.
  • Esophageal cancer: Esophageal cancer is caused by tumor growth along the esophagus. Since it may not be diagnosed until it is in an advanced stage, esophageal cancer is nearly always fatal. There is some controversy over whether there is a link between bile and acid reflux and esophageal cancer. In animal studies, bile reflux alone has been shown to cause esophageal cancer.
  • Esophageal narrowing: Repeated exposure to stomach acid, bile or both can cause scar tissue to form in the lower esophagus. This scarring may cause the esophagus to narrow, interfering with swallowing and increasing the risk of choking.
  • Gastritis: When bile backs up into the stomach from the small intestine, the stomach becomes irritated and inflamed, a condition known as gastritis. Untreated gastritis may cause stomach ulcers, bleeding, and stomach cancer.

Treatment
  • General:
  • Unlike acid reflux, changes in diet or lifestyle are usually ineffective in the prevention or treatment of bile reflux. Instead, bile reflux is most often managed with medications or, in severe cases, with surgery. Many of the therapies used to manage bile reflux will also reduce acid reflux. This is important, because these two conditions often occur at the same time and together result in serious complications if not treated.
  • Lifestyle changes:
  • General: Unlike acid reflux, bile reflux appears to be unrelated to lifestyle choices, including diet, smoking, weight loss, and excess alcohol consumption. However, since acid reflux and bile reflux often occur at the same time, adopting a healthy lifestyle may help.
  • Dietary changes: Small, frequent meals are recommended to reduce pressure on the lower esophageal sphincter and the pyloric valve. After a meal, it is important to wait at least 2-3 hours before laying down to be sure that the stomach has had a chance to empty. Many foods have been found to worsen acid reflux and bile reflux, because they tend to increase stomach acid production and to relax the lower esophageal sphincter, allowing acid and bile to back up into the esophagus. Such foods include high-fat foods, caffeine, vinegar, onions, chocolate, citrus, carbonated drinks, tomatoes, spicy foods, and mint.
  • Limit or avoid alcohol: Drinking alcohol irritates the esophagus and relaxes the lower esophageal sphincter, predisposing the body to acid reflux.
  • Quit smoking: Smoking increases the production of stomach acid and dries up saliva, which cause the esophagus to be more vulnerable to damage by refluxed bile and stomach acid.
  • Relaxation: Patients under stress experience slower digestion, which may worsen reflux symptoms.
  • Tilted bed: Raising the head of the bed by about 4-6 inches may prevent reflux symptoms. This may be effective, because with the upper body elevated, gravity assists in preventing bile from flowing backwards through the digestive tract. Using a wedge or blocks is more effective than using pillows.
  • Weight loss: Overweight patients with bile reflux may lessen the backflow of bile when less body fat is pressing down on the stomach and small intestine.
  • Medications:
  • General: Many medications used to manage bile reflux are also used to treat acid reflux, as these conditions often occur together. Other medications specifically limit the amount of bile released during digestion.
  • Cholesterol-lowering medications: Drugs such as Questran® and Colestid® assist the body in removing bile.
  • Cisapride: Cisapride (Propulsid®) has been demonstrated to eliminate or greatly reduce bile reflux in children. This product has been removed from the market in the United States due to side effects.
  • Promotility agents: Promotility agents may be used to improve stomach emptying, therefore reducing the amount of bile that may leak back into the stomach.
  • Proton pump inhibitors: Proton pump inhibitors (Protonix®, Prilosec®, Prevacid®, AcipHex®, and Nexium®) are prescription drugs that are used to treat acid reflux, because they reduce stomach acid production. There is some controversy over whether proton pump inhibitors help to reduce bile reflux or make bile reflux worse. They may be prescribed because bile reflux and acid reflux often occur together.
  • Ursodeoxycholic acid: Ursodeoxycholic acid is a prescription drug that aids in bile flow and may lessen the frequency of symptoms and the severity of stomach pain associated with bile reflux. However, this medication does not cure bile reflux.
  • Surgical treatments:
  • General: Surgery is a treatment of last resort, if nothing else reduces severe symptoms of bile reflux or when there are signs of esophageal cancer.
  • Diversion surgery (Roux-en-Y procedure): During the Roux-en-Y procedure, a new connection for bile drainage farther down in the intestine is made, resulting in the diversion of bile away from the stomach. The Roux-en-Y surgery reportedly has a 50-90% success rate. This is the same type of procedure as weight loss bypass surgery.
  • Fundoplication (antireflux surgery): During fundoplication, the fundus (the portion of the stomach closest to the esophagus) is wrapped and then sewn around the lower esophageal sphincter. This procedure strengthens the lower esophageal sphincter, which prevents the backflow of acid and bile into the esophagus. This procedure is used more often in patients with acid reflux. It is not clear how effective it is in patients with bile reflux.

Integrative therapies
  • Note: Although integrative therapies have not been clinically proven to effectively treat bile reflux, therapies that are commonly used to treat gastritis may be beneficial.
  • Unclear or conflicting scientific evidence:
  • Dimethyl sulfoxide (DMSO): DMSO is naturally found in vegetables, fruits, grains, and animal products. DMSO is available for both nonmedicinal and medicinal uses. The major clinical use of DMSO is to relieve symptoms of interstitial cystitis (chronic bladder infection). When used with acid-blocking drugs (e.g., ranitidine), DMSO may help treat gastritis. More research is needed.
  • Avoid if allergic or hypersensitive to DMSO. Use caution with urinary tract cancer or liver or kidney dysfunction. Avoid if pregnant or breastfeeding.
  • Gamma-oryzanol: Gamma-oryzanol occurs in rice bran oil and has been extracted from corn and barley oils as well. Gamma-oryzanol is frequently sold as a body-building aid, specifically to increase testosterone levels, stimulate the release of endorphins (pain-relieving substances made in the body), and promote the growth of lean muscle tissue. However, currently, scientific support in humans for these claims is lacking. Little research has been done on the effects of gamma-oryzanol on gastritis.
  • Avoid if allergic or hypersensitive to gamma-oryzanol, its components, or rice bran oil. Use cautiously if taking anticoagulants (blood thinners); central nervous system (CNS) suppressants; cholesterol-lowering or thyroid drugs, herbs, or supplements; drugs or herbs that alter blood sugar levels; growth hormone; immunomodulators; luteinizing hormone or luteinizing hormone-releasing hormone; or prolactin. Use cautiously with diabetes, hypothyroidism, hypoglycemia, hyperglycemia, or high cholesterol. Avoid if pregnant or breastfeeding.
  • Garlic: The garlic bulb is made of many cloves wrapped with a paper-thin, white skin, and it is used both medicinally and as a spice in food (fresh or dehydrated). Garlic is widely used for the treatment and prevention of cardiovascular disease and cancer. Bleeding has been reported with garlic use. Patients should speak with a healthcare professional before taking garlic in amounts more than those normally found in foods. Preliminary evidence suggests that a combination product containing garlic (Karinat®) may be beneficial in the management of chronic atrophic gastritis, a precursor of stomach cancer. Additional evidence is needed before a conclusion can be made.
  • Avoid if allergic or hypersensitive to garlic or other members of the Liliaceae(lily) family (e.g., hyacinth, tulip, onion, leek, chive). Avoid with history of bleeding problems, asthma, diabetes, low blood pressure, or thyroid disorders. Stop using supplemental garlic two weeks before dental, surgical, or diagnostic procedures, and avoid using immediately after such procedures to avoid bleeding problems. Use cautiously with history of peptic ulcer disease. Avoid supplemental doses if pregnant or breastfeeding.
  • Qi gong: Qi gong, an ancient type of traditional Chinese medicine (TCM) consisting of choreographed movements, postures, and meditation, has been used for thousands of years. It is traditionally used for spiritual enlightenment, medical care, and self-defense. Qi gong is meant to be in balance with the environment and has been described as "a way of working with life energy." In TCM, Qi gong is used to treat conditions such as cancer, chronic fatigue syndrome, osteoporosis (bone loss), high blood pressure, stomach ulcers, and asthma. Some evidence suggests that internal Qi gong may be useful in the treatment of gastritis. Further research is needed.
  • Qi gong is generally considered to be safe when learned from a qualified instructor and practiced in moderation. In cases of potentially serious medical conditions, Qi gong should not be used in place of more proven therapies, and use of Qi gong should not cause delay in seeing an appropriate healthcare provider. Caution is advised in patients with diabetes, hypoglycemia, bleeding disorders, or low blood pressure, or in patients taking drugs, herbs, or supplements for these disorders. Caution is advised in immune-compromised individuals, pregnant or breastfeeding women, patients with preexisting psychoses, or vulnerable individuals without a psychiatric history.
  • Thymus extract: Thymus extracts for nutritional supplements are usually bovine (derived from young calves). Thymus extract is commonly used to stimulate the immune system and to treat bone marrow failure, autoimmune disorders, chronic skin diseases, recurrent viral and bacterial infections, hepatitis, allergies, chemotherapy side effects, and cancer. Most basic and clinical research involving oral and injectable thymus extract has been conducted in Europe. Studies in humans suggest promising results in terms of allergies, asthma, cancer, chemotherapeutic side effects, cardiomyopathy (weakening of the heart muscle), chronic obstructive pulmonary disease (COPD), HIV/AIDS, immune system stimulation, liver disease, respiratory tract infections, systemic lupus erythematosus, and tuberculosis. However, not all study results agree, and well-conducted studies are still needed in many fields. Preliminary evidence suggests that thymus extract speeds healing of gastric lesions. More studies are needed before a conclusion can be made involving thymus extract for this use.
  • Avoid if allergic or hypersensitive to thymus extracts. Use bovine thymus extract supplements cautiously, due to the potential for exposure to the prion that causes "mad cow disease." Avoid use with an organ transplant or other forms of allografts or xenografts. Avoid if receiving immunosuppressive therapy or hormonal therapy, or with thymic tumors, myasthenia gravis (a neuromuscular disorder), or untreated hypothyroidism. Avoid if pregnant or breastfeeding.

Prevention
  • General: Unlike acid reflux, changes in diet or lifestyle are usually ineffective in the prevention or treatment of bile reflux.
  • Limit or avoid alcohol: Drinking alcohol irritates the esophagus and relaxes the lower esophageal sphincter, predisposing the body to acid reflux.
  • Quit smoking: Smoking increases the production of stomach acid and dries up saliva, which cause the esophagus to be more vulnerable to damage by refluxed bile and stomach acid.
  • Relaxation: Patients under stress experience slower digestion, which may worsen reflux symptoms.
  • Tilted bed: Raising the head of the bed by about 4-6 inches may prevent reflux symptoms. Using a wedge or blocks is more effective than using pillows.
  • Weight loss: Overweight patients with bile reflux may lessen the backflow of bile when less body fat is pressing down on the stomach and small intestine.

Author information
  • This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

Bibliography
  1. Chen H, Li X, Ge Z, et al. Rabeprazole combined with hydrotalcite is effective for patients with bile reflux gastritis after cholecystectomy. Can J Gastroenterol. 2010 Mar;24(3):197-201.
  2. Kauer WK, Stein HJ. Bile reflux in the constellation of gastroesophageal reflux disease. Thorac Surg Clin. 2005 Aug;15(3):335-40.
  3. Madura JA. Primary bile reflux gastritis: which treatment is better, Roux-en-Y or biliary diversion? Am Surg. 2000 May;66(5):417-23; discussion 423-4.
  4. National Institutes of Health.
  5. Natural Standard: The Authority on Integrative Medicine.
  6. Netzer P, Gut A, Brundler R, et al. Influence of pantoprazole on oesophageal motility, and bile and acid reflux in patients with oesophagitis. Aliment Pharmacol Ther. 2001 Sep;15(9):1375-84.
  7. Okholm M, Sørensen H, Wallin L, et al. Bile reflux into the esophagus. Bilitec 2000 measurements in normal subjects and in patients after Nissen fundoplication. Scand J Gastroenterol. 1999 Jul;34(7):653-7.
  8. Pace F, Sangaletti O, Pallotta S, et al. Biliary reflux and non-acid reflux are two distinct phenomena: a comparison between 24-hour multichannel intraesophageal impedance and bilirubin monitoring. Scand J Gastroenterol. 2007 Sep;42(9):1031-9.
  9. Richter JE. Importance of bile reflux in Barrett's esophagus. Dig Dis. 2000-2001;18(4):208-16.
  10. Souza RF. The role of acid and bile reflux in oesophagitis and Barrett's metaplasia. Biochem Soc Trans. 2010 Apr;38(2):348-52.
  11. Szarszewski A, Korzon M, Kamiñska B, et al. Duodenogastric reflux: clinical and therapeutic aspects. Arch Dis Child. 1999 Jul;81(1):16-20.
  12. Triadafilopoulos G. Acid and bile reflux in Barrett's esophagus: a tale of two evils. Gastroenterology. 2001 Dec;121(6):1502-6.

Causes
  • General: Bile reflux occurs when bile flows upward from the small intestine into the stomach. Bile reflux is caused by damage to the pyloric valve, which is a ring of muscle that separates the stomach from the duodenum (the upper section of the small intestine). The pyloric valve opens briefly to let partially digested food pass into the small intestine. It then closes to prevent the mixture from flowing backwards into the stomach. Bile reflux occurs when the pyloric valve fails to close properly, causing bile to flow back into the stomach, resulting in pain and inflammation. When bile reflux and acid reflux occur together, the mixture of bile and stomach acids flows backwards further into the esophagus (the tube that connects the throat to the stomach), causing heartburn and damage to the esophagus. In the absence of acid reflux, bile may flow back into the esophagus if there is too much pressure in the stomach.
  • Acid reflux: Acid reflux is caused by the failure of a valve called the lower esophageal sphincter. This valve prevents stomach acids and partially digested food from the stomach from flowing back into the esophagus. Bile reflux often accompanies acid reflux. In this case, both the esophageal sphincter and the pyloric valve malfunction at the same time. This allows stomach acid and bile to flow back into the esophagus, causing heartburn and persistent inflammation that may lead to damage to the esophagus.
  • Constipation: In rare instances, persistent constipation may cause bile reflux.
  • Peptic ulcer: A peptic ulcer that obstructs the pyloric valve and prevents it from opening or closing properly may cause bile reflux.
  • Proton pump inhibitors: Proton-pump inhibitors (PPIs) are often used to treat acid reflux. It is controversial whether PPIs are a cause of bile reflux.
  • Scar tissue: Scar tissue near the pyloric valve may prevent the valve from opening enough to allow partially digested food to flow from the stomach to the small intestine. In this case, pressure may build up in the stomach, pushing both acid and bile into the esophagus.
  • Surgery: The pyloric valve may be damaged due to gallbladder removal surgery or gastric surgery, including gastrectomy (total removal of the stomach) and gastric bypass operations for weight loss.

Risk factors
  • Acid reflux: Bile reflux may occur at the same time as acid reflux. Acid reflux is also known as gastroesophageal reflux disease (GERD).
  • Cholecystectomy (gall bladder removal): Patients who have undergone cholecystectomy (gallbladder removal) are at a higher risk of developing bile reflux.
  • Helicobacter pylori infection of the stomach: It has been reported that patients with esophageal bile reflux had a higher likelihood of also having Helicobacter pylori infection of the stomach than patients without bile reflux.

Types of the disease
  • Primary bile reflux: Primary bile reflux is caused by improper formation of the pyloric valve, which separates the stomach from the small intestine.
  • Secondary bile reflux: Secondary bile reflux is caused by pyloric valve damage, which may occur due to gallbladder removal, gastric surgery, a peptic ulcer, or the use of certain medications.

Copyright © 2011 Natural Standard (www.naturalstandard.com)


The information in this monograph is intended for informational purposes only, and is meant to help users better understand health concerns. Information is based on review of scientific research data, historical practice patterns, and clinical experience. This information should not be interpreted as specific medical advice. Users should consult with a qualified healthcare provider for specific questions regarding therapies, diagnosis and/or health conditions, prior to making therapeutic decisions.

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