An Overview of Bile Reflux

Have you ever heard of bile reflux? For many people, the word “reflux” is almost synonymous with a condition known as “acid reflux,” which occurs when stomach acid backs up (refluxes) towards the esophagus and causes unpleasant sensations, including what is commonly referred to as heartburn. While occasional heartburn is common, chronic acid reflux flare-ups can be painful, draining, and frightening, especially if they occur during the nighttime.

Burning sensations in the throat and chest, coughing or choking, and feelings of panic or distress during sleep are commonly associated with chronic acid reflux; however, what many do not know is that they can also be associated with bile reflux.

Bile reflux is a condition in which bile from the liver, a naturally-produced substance that generally catalyzes the digestion of fats, backs up (refluxes) into the stomach and even into the esophagus. When this occurs, it can produce symptoms that are highly similar to those of acid reflux. However, one of the most important distinctions is that bile reflux symptoms do not usually alleviate with dietary or lifestyle changes

The similarities between acid reflux and bile reflux, which we will explore in more detail below, are why it is incredibly important for you to talk to your physician if you’re experiencing acid reflux symptoms that aren’t lessening with traditional acid treatment.

Understanding the Causes of Bile Reflux

Created by the liver, Bile is a green to dark yellow mixture of digestive salts that passes from the liver into the gallbladder and then, later, into the upper small intestine. Bile is uniquely equipped to help the body digest fats, as the digestive acids within separate and isolate fats to break them down apart from other components of food. Bile is less acidic than stomach acid, which helps it fulfill its second purpose: Nullifying stomach acid before it reaches the lower intestine.

When you consume a meal with fat in it, your gallbladder receives signals from your stomach to release bile into the small intestine in preparation for the digestion of fat. The bile accumulates in the upper small intestine and, normally, remains there as food and stomach acid pass from the stomach.
In the occurrence of bile reflux, the section of the stomach that connects with the small intestine known as the Pyloric Valve does not close quickly enough or tightly enough, which causes bile to flow back into the stomach. From there, it can then come in contact with the lower esophageal sphincter, the opening that connects the esophagus to the stomach.

If the esophageal sphincter is also weak or overly-relaxed, bile can then flow up (reflux) into the esophagus causing a number of unpleasant symptoms.
Sometimes, bile reflux and acid reflux can occur at the same time, since bile backflow often mixes with stomach acid in the stomach.

The Symptoms of Bile Reflux

The following symptoms are most commonly associated with bile reflux:

• Burning pain in the upper part of your abdomen, often in the chest and sometimes in the throat
• Acrid taste in back of mouth
• Coughing or sore throat
• Vomiting, especially if green or yellow fluid is present
• The feeling of nausea
• Unexpected weight loss that is not tied to any significant lifestyle changes

It’s important to pay special attention to any occurrence of vomiting in which bile is clearly present. While rare occurrences of intense vomiting can lead to expelling bile, regularly occurring vomiting with bile present should be taken as a potential signifier of bile reflux.

Many of the symptoms of bile reflux are shared with acid reflux, which is part of what makes bile reflux more difficult to pinpoint than acid reflux. If you are experiencing frequent heartburn, choking while sleeping, and bad taste in the back of your throat, you should talk with your doctor about looking into treatments for acid reflux.

If acid reflux treatments do not prove effective, it may be related to bile instead of stomach acid. Because of the difference in chemical makeup between bile and stomach acid, many of the treatments that relieve the overproduction and/or backup of stomach acid do not eliminate or nullify bile. This fact means that a process of elimination may be necessary to identify bile reflux.

Diagnosing and Treating Bile Reflux Effectively,

Diagnosing Bile Reflux

The initial diagnosis of bile reflux is difficult, and, unfortunately, physicians are rarely able to diagnose bile reflux separate from acid reflux from immediate symptoms alone. Because of this, it is common to attempt the treatment of acid reflux first, and then to investigate bile reflux should acid reflux treatment prove ineffective.

If acid reflux treatments are not working, it is likely that your physician will recommend an endoscopy. Endoscopies can reveal ulcers, swelling, and other irregularities that could point towards bile reflux as the cause of discomfort. Another diagnostic test that is sometimes done is known as “esophageal impedance,” which involves using a probe to determine what substances are flowing back into the esophagus. This test is often used for patients who are experiencing vomiting that is not accompanied by stomach acid or visibly contains bile.

Treating Bile Reflux

Lifestyle Changes.
As mentioned earlier, unlike acid reflux, bile reflux symptoms do not usually alleviate with dietary or lifestyle changes. Because people often experience both acid reflux and bile reflux at the same time, your symptoms may be eased by the following lifestyle changes recommended for acid reflux sufferers:

• Quit Smoking
• Change Eating Habits:
  • Eat Smaller Meals: Avoiding overly large meals is a great first step.
  • Timing of Meals: Wait before going to bed after eating meals.
  • Food Choice: Limit fatty, problem foods & beverages, and avoid alcohol.
• Lose Weight
• Sleeping Habits: Raise the head of your bed and avoid sleeping in clothing that can constrict your waist or stomach.
• Regular Relaxation and Stress Relief

Medications
Once bile reflux has been identified, treatment generally involves taking a medication like Ursodiol, which helps your body more easily move bile through the intestines, reducing the risk of backflow (refluxing).

Surgery
If medication is ineffective, surgery may be the next step. Three procedures are commonly used to treat bile reflux: Roux-en-Y diversion surgery, fundoplication, and Linx implant.

Roux-en-Y diversion surgery involves relocating the tubes that assist in draining bile into the small intestine so that bile will not accumulate near the opening to the stomach. The Roux-en-Y procedure is also commonly used as a form of weight loss treatment, meaning that it is not ideal for all patients, especially those who do not want to or should not lose weight. It tends to be best for patients who have already had other types of gastric surgery with pylorus removal.

Both fundoplication (Anti-reflux surgery) and Linx implant are commonly used to treat acid reflux because they both act to strengthen the lower esophageal sphincter. Fundoplication involves wrapping a portion of the upper stomach around the esophageal sphincter to reinforce it, while Linx implant involves placing a specially-designed titanium ring around the sphincter. Both of these procedures reinforce and strengthen the esophageal sphincter; the Linx surgery, though much newer, is considerably less invasive than fundoplication.

Unfortunately, there is limited research available on the effectiveness of both fundoplication and Linx implant for the purposes of treating bile reflux specifically, largely because both surgeries also can remove the symptoms of acid reflux simultaneously.

Conclusion – Bile Reflux and You

If you’re having any of the symptoms explored above, especially if you are currently undergoing treatment for acid reflux that is not proving effective, it is important to contact your doctor right away.

Bile reflux can be just as dangerous as long-term acid reflux since they both put undue stress on the lower esophagus.
Untreated bile reflux can lead to esophageal damage, the development of GERD, the development of Barrett’s esophagus, and increased risk of esophageal cancer. While occasional heartburn should not be a reason to suspect bile reflux, chronic episodes of the symptoms listed above should prompt a visit to your doctor.

Resources:
Bile reflux Symptoms, Causes, Diagnosis and Treatment (MayoClinic)
Management of Bile Reflux (US National Library of Medicine)
What You Need to Know About Throwing Up Bile (healthline)
Reflux – Acid or Bile? Know the difference (Gastrointestinal Associates)
Bile reflux: Causes, symptoms, complications, and prevention tips (Bel Marra Health)
Acid Reflux, Bile Reflux, and Gastritis (risingsunyoga)
The Damage of Reflux (Bile, Not Acid) (nytimes)
Bile Reflux Gastritis Symptoms  (livestrong)