Bile Reflux

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Published: February 14, 2017
Last reviewed: April 28, 2017

What is bile reflux?

Bile reflux or duodenal gastroesophageal reflux refers to back-flow of the bile from the duodenum into the stomach and further into the esophagus [1].

Causes

Causes and risk factors for bile reflux may include [1,2,3]:

  • Gastroesophageal reflux disease (GERD)
  • Hiatus hernia
  • Peptic ulcer that affects the pyloric sphincter (the muscular valve between the stomach and duodenum)
  • H. pylori infection of the stomach [5]
  • Gallbladder removal (cholecystectomy) [10]
  • Scars (strictures) within the duodenum
  • Partial surgical stomach removal
  • Bypass surgery for weight loss
  • Smoking [8]

Often the cause of bile reflux cannot be identified.

Symptoms

Symptoms of bile reflux are similar to those in acid reflux [3,14]:

  • Stomach or lower chest pain after the meals, which is not relieved by acid-lowering drugs
  • Fat intolerance
  • Heartburn
  • A cough or hoarseness
  • Nausea and vomiting green or yellow fluid (bile)
  • Metallic or bitter taste in mouth
  • Unintended weight loss

Complications

Possible complications of bile reflux:

  • Barrett’s esophagus (damage of the mucosal lining at the bottom of the esophagus), which is a risk factor for esophageal cancer [1,3]
  • Gastritis and peptic ulcer [6,7]
  • Gastric polyps [15]

Diagnosis

Bile reflux can be confirmed by detecting the bile in the esophagus during an upper endoscopy [1].

Treatment

Drugs

There is some evidence that the following drugs MAY BE EFFECTIVE in the prevention or decrease of the symptoms of bile reflux:

  • Omeprazole [3] or rabeprazole with hydrotalcite [11] (proton pump inhibitors, which decrease the acidity of the stomach)
  • Baclofen (prevents excessive relaxation of the lower esophageal sphincter) [1]
  • Domperidone (a prokinetic drug, which stimulates gastric emptying) [2]
  • Sucralfate (protects the gastric mucosal lining) [3]
  • Ursodeoxycholic acid (promotes the bile flow) [3,13]

Structural abnormalities, such as a hiatus hernia and duodenal strictures, that cause biliary reflux can be surgically corrected.

The following drugs seem to be LESS EFFECTIVE in the treatment of bile reflux: antacids [12], H2 antagonists [12], bile salt binders (cholestyramine, colestipol and colesevelam) [3,9,12] and metoclopramide [12].

Natural Remedies

There seems to be NO EVIDENCE about the effectiveness of the following herbs and remedies in the prevention or treatment of bile reflux: chamomile, licorice, marshmallow and slippery elm [3].

Prevention

If you have bile reflux, you almost certainly also have acid reflux. To prevent the reflux of acid and bile from the stomach into the esophagus [1,3,4]:

  • Lose weight if you are overweight.
  • Have frequent small meals.
  • Limit foods that relax lower esophageal sphincter: fatty foods (oils, chocolate, cheese, butter, fatty fish), citrus fruits, vinegar and other acidic foods, tomatoes, onions, carbonated, caffeinated and alcoholic beverages, mint, spicy and hot foods.
  • Do not lie down after the meals and do not eat before sleeping.
  • Raise your bed at the head side.
  • Do not smoke.
  • Avoid unnecessary stress.
  • References

      1. Sifrim D, 2013, Bile reflux management  PubMed Central
      2. Cheifetz AS et al, Biliary reflux,  Oxford American Handbook of Gastroenterology and Hepatology, p. 239
      3. Bile reflux  Drugs.com
      4. Reflux – Acid or Bile? Know the difference  Gastrointestinal Associates
      5. Ladas SD et al, 1996, Helicobacter pylori may induce bile reflux: link between H pylori and bile induced injury to gastric epithelium  PubMed Central
      6. Vere CC et al, 2005, Endoscopical and histological features in bile reflux gastritis  PubMed
      7. Black RB et al, 1971, The effect of healing on bile reflux in gastric ulcer  PubMed Central
      8. Müller-Lissner SA, 1986, Bile reflux is increased in cigarette smokers  PubMed
      9. Fass R, 2016, Approach to refractory gastroesophageal reflux disease in adults  UpToDate
      10. Kalima T et al, 1981, Bile reflux after cholecystectomy  PubMed
      11. Chen H et al, 2010, Rabeprazole combined with hydrotalcite is effective for patients with bile reflux gastritis after cholecystectomy  PubMed Central
      12. Nath BJ et al, 1984, Alkaline reflux gastritis and esophagitis  PubMed
      13. Stefaniwsky AB et al, 1985, Ursodeoxycholic acid treatment of bile reflux gastritis  PubMed
      14. Kleba T, 1998, Gastroscopic criteria and most frequent pain in bile reflux gastritis  PubMed
      15. Wang Zi-Kay et al, 2013, Upper gastrointestinal microbiota and digestive diseases  PubMed Central

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