Bile Reflux: Signs, Symptoms and Complications

Bile Reflux Overview

Bile reflux occurs when bile a digestive liquid produced in your liver backs up (refluxes) into your stomach and esophagus (the tube that connects your mouth and stomach). Bile reflux may accompany acid reflux, the medical term for the backwash of stomach acids into your esophagus.

Whether bile is important in reflux is controversial. Bile is often implicated as a cause of reflux when people respond incompletely or not at all to powerful acid-suppressant medications. But there is little evidence pinpointing the effects of bile reflux in people. Studies in lab animals indicate that over time, bile reflux may have serious consequences, potentially increasing your risk of esophageal cancer.

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.

Signs and symptoms of Bile Reflux

• 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.

Causes of Bile Reflux

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

Eating a meal that contains even a small 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 (duodenum).

Bile Reflux into the stomach

At the same time that bile flows into the duodenum, food enters your small intestine through the pyloric valve, a heavy ring of muscle located at the outlet of your stomach. The pyloric valve usually opens only 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 reflux into the stomach. In many cases of bile reflux, the valve doesn’t close properly, and bile washes back into the stomach.

Bile Reflux into the esophagus

Bile and stomach acid can reflux into the esophagus when another muscular valve, the lower esophageal sphincter, malfunctions. The lower esophageal sphincter separates the esophagus and stomach. The valve normally opens just long enough to allow food to pass into the stomach. But if the valve weakens or relaxes abnormally, bile can wash back into the esophagus.

What leads to Bile Reflux?

Bile reflux may be caused by:

• 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 surgery for weight loss.
• Peptic ulcers. A peptic ulcer can block the pyloric valve so that it doesn’t open enough to allow the stomach to empty as quickly as it should. Stagnant food in the stomach can lead to increased gastric pressure that refluxes bile and stomach acid 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.

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 of Bile Reflux

Sticky mucous coats and protects the lining of your stomach from the corrosive effects of stomach acid. The esophagus lacks this protection, so acid and bile reflux can seriously damage esophageal tissue. The combination of bile and acid reflux increases the risk of complications, including:

• GERD. Occasional heartburn usually isn’t a concern. But frequent or continual heartburn is the most common symptom of GERD, a potentially serious problem that causes irritation and inflammation of esophageal tissue (esophagitis). GERD is most often due to excess acid. Although bile has been implicated, its importance in reflux is controversial.
• Barrett’s esophagus. This serious condition can occur when long-term exposure to stomach acid, or to acid and bile, damages tissue in the lower esophagus. The damaged esophageal cells (metaplasia) have an increased risk of becoming cancerous. Animal studies have also linked bile reflux to the occurrence of Barrett’s esophagus.
• Esophageal cancer. This serious form of cancer 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

Treatment of Bile Reflux

Although treatments for acid reflux can be very effective, medications for bile reflux may not be helpful for many people. There is little evidence assessing the effectiveness of bile reflux treatments, in part because of the difficulty of establishing bile reflux as the cause of symptoms.

Medications

• Bile acid sequestrants. These medications, which disrupt the circulation of bile, may be helpful for some people with bile reflux. Side effects, such as bloating, may be severe.
• Ursodeoxycholic acid. This medication helps promote bile flow. It may lessen the frequency and severity of your symptoms.
• Prokinetic agents. These medications can help your stomach empty more rapidly and help tighten the lower esophageal sphincter. These medications have several side effects, including fatigue, depression, anxiety and other neurological problems.
• Proton pump inhibitors. These medications are often prescribed to block acid production, but they don’t have a clear role in treating bile reflux.

Surgical treatments

Doctors may recommend surgery if medications fail to reduce severe symptoms, or there are precancerous changes in your esophagus. Some types of surgery can be more successful than others, so be sure to discuss the pros and cons carefully with your doctor.

The options include:

• Diversion surgery (Roux-en-Y). This procedure may be recommended for people who have had previous gastric surgery with pylorus removal (Billroth I or Billroth II). In Roux-en-Y, surgeons make a new connection for bile drainage farther down in the small intestine, diverting bile away from the stomach.
• Anti-reflux surgery (fundoplication). The part of the stomach closest to the esophagus (fundus) is wrapped and then sewn around the lower esophageal sphincter. This procedure strengthens the valve and can reduce acid reflux. There is little evidence about the surgery’s effectiveness for bile reflux.