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 .
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 
- Gallbladder removal (cholecystectomy) 
- Scars (strictures) within the duodenum
- Partial surgical stomach removal
- Bypass surgery for weight loss
- Smoking 
Often the cause of bile reflux cannot be identified.
Symptoms of bile reflux are similar to those in acid reflux [3,14]:
- Lower chest or stomach pain after the meals, which is not relieved by acid-lowering drugs
- Fat intolerance
- A cough or hoarseness
- Throat pain
- Difficulty swallowing
- Nausea and vomiting green or yellow fluid (bile)
- Metallic or bitter taste in mouth
- Unintended weight loss
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 
Bile reflux can be confirmed by detecting the bile in the esophagus during an upper endoscopy .
There is some evidence that the following drugs MAY BE EFFECTIVE in the prevention or decrease of the symptoms of bile reflux:
- Omeprazole  or rabeprazole with hydrotalcite  (proton pump inhibitors, which decrease the acidity of the stomach)
- Baclofen (prevents excessive relaxation of the lower esophageal sphincter) 
- Domperidone (a prokinetic drug, which stimulates gastric emptying) 
- Sucralfate (protects the gastric mucosal lining) 
- 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 , H2 antagonists , bile salt binders (cholestyramine, colestipol and colesevelam) [3,9,12] and metoclopramide .
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 .
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.
- Sifrim D, 2013, Bile reflux management PubMed Central
- Cheifetz AS et al, Biliary reflux, Oxford American Handbook of Gastroenterology and Hepatology, p. 239
- Bile reflux Drugs.com
- Reflux – Acid or Bile? Know the difference Gastrointestinal Associates
- Ladas SD et al, 1996, Helicobacter pylori may induce bile reflux: link between H pylori and bile induced injury to gastric epithelium PubMed Central
- Vere CC et al, 2005, Endoscopical and histological features in bile reflux gastritis PubMed
- Black RB et al, 1971, The effect of healing on bile reflux in gastric ulcer PubMed Central
- Müller-Lissner SA, 1986, Bile reflux is increased in cigarette smokers PubMed
- Fass R, 2016, Approach to refractory gastroesophageal reflux disease in adults UpToDate
- Kalima T et al, 1981, Bile reflux after cholecystectomy PubMed
- Chen H et al, 2010, Rabeprazole combined with hydrotalcite is effective for patients with bile reflux gastritis after cholecystectomy PubMed Central
- Nath BJ et al, 1984, Alkaline reflux gastritis and esophagitis PubMed
- Stefaniwsky AB et al, 1985, Ursodeoxycholic acid treatment of bile reflux gastritis PubMed
- Kleba T, 1998, Gastroscopic criteria and most frequent pain in bile reflux gastritis PubMed
- Wang Zi-Kay et al, 2013, Upper gastrointestinal microbiota and digestive diseases PubMed Central