Mayo Clinic Health Library

Bile reflux

Updated: 03-14-2012

Definition

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.

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Symptoms

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. It isn't clear what role bile plays in reflux conditions.

Bile reflux signs and 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 a greenish-yellow fluid (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 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.

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Causes

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.
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Complications

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.
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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 doctor.

Don't hesitate to ask questions during your appointment. Some questions to ask your doctor include:

  • Do I have bile reflux?
  • What treatment approach do you recommend trying?
  • Are there any side effects associated with these treatments?
  • Are there any lifestyle or dietary changes I can make to help reduce or manage my symptoms?
  • I have these other health conditions. How can I best manage them together?

What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to answer them may give you 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?
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Tests and diagnosis

A description of your symptoms is often enough for your doctor to diagnose a reflux problem. 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.

Tests may include:

  • Endoscopy. A thin, flexible tube with a camera (endoscope) is passed down your throat. The endoscope can show peptic ulcers or inflammation in your stomach and esophagus. Your doctor also may take tissue samples to test for Barrett's esophagus or esophageal cancer.
  • Ambulatory acid tests. These tests use an acid-measuring probe to identify when, and for how long, acid refluxes into your esophagus. In one test, a thin, flexible tube (catheter) with a probe at the end is threaded through your nose into your esophagus. In another (the Bravo test), the probe is attached to the lower portion of your esophagus during endoscopy. Ambulatory acid tests can help your doctor rule out acid reflux but not bile reflux.
  • Esophageal impedance. This test measures whether gas or liquids reflux into the esophagus. It's helpful for people who regurgitate substances that aren't acidic (such as bile) and can't be detected by an acid probe. As in a standard probe test, esophageal impedance uses a probe that's placed into the esophagus with a catheter.
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Treatments and drugs

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.
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Lifestyle and home remedies

Unlike acid reflux, bile reflux seems less related to lifestyle factors. But many people experience both acid reflux and bile reflux, so your symptoms may be eased by lifestyle changes:

  • Stop smoking. Smoking increases the production of stomach acid and dries up saliva, which 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 two to three hours before lying down 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. Foods that increase the production of stomach acid and may relax the lower esophageal sphincter include caffeinated and carbonated drinks, chocolate, citrus foods and juices, vinegar-based dressings, onions, tomato-based foods, spicy foods and mint.
  • 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. Sleeping with your upper body raised four to six inches may help prevent reflux symptoms. Raising your bed with blocks or sleeping on a foam wedge is more effective than is using extra pillows.
  • Relax. When you're under stress, digestion slows, possibly worsening reflux symptoms. Relaxation techniques, such as deep breathing, meditation or yoga, may help.
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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 specifically to relieve bile reflux, some may help protect against and relieve esophageal inflammation. If you decide to start any of these therapies, discuss them with your doctor. They 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 chemical called glycyrrhizin (gly-cyr-RIH-zin) 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 glycyrrhizin.
  • Slippery elm, a product of a tree bark and root, may help soothe the digestive tract. Slippery elm can be mixed with water and taken after meals and before bed. But slippery elm may decrease the absorption of prescription medications.
  • Marshmallow (Althea officinalis) is an herb — not the puffy white candy — that has been used for GERD symptom relief. Like slippery elm, marshmallow may cause problems with the absorption of medications.
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