Bile Reflux

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Published: February 14, 2017
Last reviewed: July 31, 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]:

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

2 Responses to Bile Reflux

  1. Jean Robinson says:

    Your advice on diets are helpful. I have tried limiting the culprit foods but in bile reflux the effect of this is uncertain. I have had meals which are bland and I have had the reflux, I have had meals that I thought would harm me and I have been ok. My hiatus hernia at the pyloric junction recently diagnosed seems to be the root of it. It is small. PPIs are of limited effectiveness although they do stop the after-eating cough. I cough up a lot of green yellow stuff bile reflux after sleeping. I think I need tests on PH levels not just an endoscopic result, which showed bile reflux and hernia but otherwise seemed ok. Doctors are completely ignorant on bile reflex. They prescribe Omaprezole as a universal panacea for reflux. Too much of PPIs is likely to result in other problems. Our stomachs need acid after all to help with bacteria. Also malabsorption of necessary minerals as a a side effect is a worry. There is a key somewhere to treating bile reflux but doctors have not yet found it. My weakened sphincter has not been helped by continuous hard coughing from a chest problem which probably caused the hernia. Bile reflux is very hard to live with as can be seen by the many posts on the subject.

    • Jan Modric says:

      The main cause of both acid and bile reflux is the lower esophageal sphincter that does not close properly, usually due to hiatal hernia. There are fatty and other foods that keep this sphincter too relaxed (as you can read above in the article). For bile reflux to occur, the pyloric sphincter at the end of the stomach also needs to be too relaxed or affected by an ulcer or structural abnormality. I’m not sure if I understood which sphincter you said is affected.

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