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Bile reflux occurs when bile Empty
PostSubject: Bile reflux occurs when bile   Bile reflux occurs when bile EmptyTue Jan 04, 2011 5:44 am

Bile reflux occurs when bile — a
digestive fluid produced in the liver — flows upward from your small
intestine into your stomach and esophagus. Bile reflux often accompanies
acid reflux — the backflow of stomach acids into your esophagus, the
tube that connects your throat and stomach.

Together bile and acid reflux can have serious consequences, inflaming
the lining of your esophagus and potentially increasing your risk of
esophageal cancer. Bile reflux also affects your stomach, where it can
cause further inflammation.

Unlike acid reflux, bile reflux usually can't be completely controlled
by changes in diet or lifestyle. Instead, bile reflux is most often
managed with medications or, in severe cases, with surgery.


Bile reflux can be difficult to distinguish from acid reflux — the signs
and symptoms are similar, and the two conditions may 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.

Bile reflux symptoms include:

* Upper abdominal pain that may be severe
* 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
* Unintended weight loss

When to see a doctor
Make an appointment with your doctor if you frequently experience
symptoms of bile reflux, or if you're losing weight without trying.

If you've been diagnosed with gastroesophageal reflux disease (GERD) but
aren't getting adequate relief from your medications, call your doctor.
You may need additional treatment for bile reflux.


Bile is a greenish-yellow fluid that's essential for digesting fats and
for eliminating worn-out red blood cells and certain toxins from your
body. It's produced in your liver and stored in your gallbladder in a
highly concentrated form.

Eating a meal that contains even a modest amount of fat signals your
gallbladder to release bile, which flows through two small tubes (cystic
duct and common bile duct) into the upper part of your small intestine

Bile reflux into the stomach
At the same time that bile is entering the duodenum, food enters your
small intestine through the pyloric valve, a heavy ring of muscle
located at the outlet of your stomach. Ordinarily, the pyloric valve
opens just slightly — enough to release about an eighth of an ounce
(about 3.5 milliliters) of liquefied food at a time, but not enough to
allow digestive juices to backup (reflux) 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

Bile 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.

What leads to bile reflux?
Bile reflux may be caused by:

* Gastric surgery complications. 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.
* Peptic ulcers. Sometimes a peptic ulcer can block 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 in the stomach can lead to increased gastric pressure that
causes refluxed 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.


A sticky mucous coating protects the lining of your stomach from the
corrosive effects of stomach acid, but the esophagus doesn't have this
protection. This lack of protection is why bile reflux and acid reflux
can seriously damage esophageal tissue. And although bile reflux can
injure the esophagus on its own, 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). 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
* 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 serious condition, long-term exposure
to stomach acid or a combination of acid and bile causes a change in
the color and composition of the tissue in the lower esophagus
(metaplasia). The cells resemble glandular tissue in the small intestine
— under a microscope, they look like shag carpeting — and although
they're resistant to stomach acid, they have increased potential for
* Esophageal cancer. This serious form of cancer can occur almost
anywhere along the length of the esophagus, and it may not be diagnosed
until it's quite advanced. The possible link between bile and acid
reflux and esophageal cancer remains controversial, but many experts
think a direct connection exists. In animal studies, 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.

Preparing for your appointment

Make an appointment with your doctor if you have signs or symptoms
common to bile reflux. After your doctor's initial evaluation, you may
be referred to a specialist in digestive disorders (gastroenterologist).

Here's some information to help you prepare for your appointment and what to expect from your doctor.

What you can do

* Write down any symptoms you're experiencing, and for how long.
* Make a list of your key medical information, including any other
conditions for which you're being treated and the names of any
medications, vitamins or supplements you're taking.
* Find a family member or friend who can come with you to the
appointment, if possible. Someone who accompanies you can help remember
what the doctor says.
* Write down questions to ask your doctor. Creating your list of
questions in advance can help you make the most of your time with your

For bile reflux, some basic questions to ask your doctor include:

* Do I have bile reflux?
* Are there any other possible causes for my symptoms?
* What diagnostic tests do I need?
* What treatment approach do you recommend trying first?
* If the first treatment doesn't work, what will we try next?
* Are there any side effects associated with these treatments?
* What dietary changes are most likely to reduce my symptoms?
* Are there any lifestyle changes I can make to help reduce or manage my symptoms?
* I have these other health conditions. How can I best manage them together?

In addition, don't hesitate to ask questions during your appointment at any time that you don't understand something.

What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to
answer them may reserve time to go over points you want to spend more
time on. You may be asked:

* What are your symptoms?
* How long have you had these symptoms?
* Do your symptoms come and go, or stay about the same?
* If your symptoms include pain, where is your pain located?
* Have your signs and symptoms included vomiting?
* Does anything seem to trigger your symptoms, including certain foods or beverages?
* Have you lost weight without trying?
* Have you seen a doctor for these symptoms before?
* What treatments have you tried so far? Has anything helped?
* Have you been diagnosed with any other medical conditions?
* Have you had surgery of your stomach or had your gallbladder removed?
* What medications are you taking, including prescription and over-the-counter medications, vitamins, herbs and supplements?
* What is your typical daily diet?
* Do you drink alcohol? How much?
* Do you smoke?

Tests and diagnosis

Doctors often can diagnose a reflux problem from a description of
symptoms. But distinguishing between acid reflux and bile reflux is
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 passes 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 (EGD), 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 refluxes into your esophagus.
Because these tests look for the presence of acid, they're useful for
diagnosing acid reflux. Ambulatory acid tests are negative in people
with bile reflux.

In the standard tube test, a thin, flexible tube (catheter) with a
probe at the end is threaded through your nose into your esophagus. The
probe is placed just above the lower esophageal sphincter. A second
probe may be placed in 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 daily routine, the device records acid (pH) levels for 24
hours, and then you return to have the device removed.

The test is somewhat uncomfortable, makes sleeping and showering
difficult, and 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 in a timely manner
on its own and passes through your intestinal tract.
* Esophageal 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.

Treatments and drugs

Ursodeoxycholic acid
One prescription medication for bile reflux treatment is ursodeoxycholic
acid, which helps promote bile flow. This medication may lessen the
frequency of symptoms and the severity of pain associated with bile
reflux. If bile reflux results from delayed stomach emptying, your
doctor may prescribe drugs to increase the rate at which food moves
through your stomach.

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

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

Surgical options include:

* Diversion surgery. Surgeons have successfully used a procedure
called a Roux-en-Y (roo-en-wi) operation to treat bile reflux in people
who have had previous gastric surgery with pylorus removal (Billroth I
or Billroth II). In this procedure, surgeons make a new connection for
bile drainage farther 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, though there is little data
about its effectiveness. 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.

Lifestyle and home remedies

Unlike acid reflux, which can be caused or aggravated by eating certain
foods and by smoking, obesity and excess alcohol consumption, bile
reflux seems unrelated to lifestyle factors. But because many people
experience both acid reflux and bile reflux, making some lifestyle
changes may help relieve your symptoms:

* Stop smoking. When it comes to acid reflux, smoking is a double
threat: It increases the production of stomach acid, and it dries up
saliva, which normally helps protect the esophagus.
* Eat smaller meals. Eating smaller, more frequent meals reduces
pressure on the lower esophageal sphincter, helping to prevent the valve
from opening at the wrong time.
* Stay upright after eating. After a meal, waiting at least two to
three hours before taking a nap or going to bed allows time for your
stomach to empty.
* Limit fatty foods. High-fat meals relax the lower esophageal
sphincter and slow the rate at which food leaves your stomach.
* Avoid problem foods and beverages. Although the same foods don't
trouble everyone, the worst offenders for most people include
caffeinated and carbonated drinks, chocolate, citrus foods and juices,
vinegar-based dressings, onions, spicy foods, and mint because they
increase the production of stomach acid and may relax the lower
esophageal sphincter.
* Limit or avoid alcohol. Drinking alcohol relaxes the lower esophageal sphincter and irritates the esophagus.
* Lose excess weight. Heartburn and acid reflux are more likely to
occur when excess weight puts added pressure on your stomach.
* Raise your bed. Raise the head of your bed by about four to six
inches. The incline may help prevent reflux symptoms. You can either
sleep on a foam wedge or elevate the head of your bed with blocks.
Pillows usually aren't an effective way to elevate your upper body while
* Relax. When you're under stress, digestion slows, which may worsen
reflux symptoms. Relaxation techniques such as deep breathing,
meditation or yoga may help.

Alternative medicine

Many people with frequent heartburn use over-the-counter or alternative
therapies for symptom relief. Remember that even natural remedies can
have risks and side effects, including potentially serious interactions
with prescription medications. Always do careful research and talk with
your doctor before trying an alternative therapy.

Although no alternative therapies have been found to specifically
relieve bile reflux, some have been proven to help protect against and
relieve esophageal inflammation. These include:

* Chamomile, which has anti-inflammatory properties. Chamomile teas
are readily available and have a low risk of side effects.
* Licorice, which is commonly used to soothe inflammation associated
with GERD, gastritis, ulcers and other digestive problems. However,
licorice contains a phytochemical called glycyrrhizin that's associated
with serious health risks — such as high blood pressure and tissue
swelling — if used long term. Talk with your doctor before trying this
therapy. Prescription preparations are available that don't contain
* Slippery elm, which encourages a protective mucous lining.
Available as a root bark powder, slippery elm can be mixed with water
and taken after meals and before bed. It may, however, decrease the
absorption of prescription medications.
* Marshmallow (Althea officinalis), which has been used for GERD
symptom relief. Like slippery elm, marshmallow may cause problems with
the absorption of medications. Note that this is the herb, not the puffy
white confection.


* Lose excess weight. Heartburn and acid reflux are more likely to
occur when excess weight puts added pressure on your stomach.
* Raise your bed. Raise the head of your bed by about four to six
inches. The incline may help prevent reflux symptoms. You can either
sleep on a wedge or elevate the head of your bed with blocks. Pillows
usually aren't an effective way to elevate your upper body while
* Relax. When you're under stress, digestion slows, which may worsen
reflux symptoms. Relaxation techniques such as deep breathing,
meditation or yoga may help.
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