Causes and Symptoms of Bile Reflux | Gastroenterology

Bile Reflux

What is bile reflux?

Bile reflux is a condition in which bile flows up from the duodenum into the stomach and esophagus. Bile is a yellowish-green fluid formed by the liver and kept in the gallbladder. It is necessary for the absorption and digestion of fats. Contains bile salts and bile pigments necessary for fat emulsification.

This mainly occurs in conjunction with acid reflux. Acid reflux is a condition in which acids from the stomach move up the esophagus.

Causes of bile reflux

Created by the liver, bile is a mixture of green to dark yellow digestive salts that pass from the liver to the gallbladder and then later to the upper part of the small intestine. Bile is specially equipped to help the body digest fats, as the digestive acids within separate and isolate fats to break them down from other components of food. Bile is less acidic than stomach acid, helping it serve its second purpose: to remove stomach acid before it reaches the small intestine.

When you eat a fatty meal, your gallbladder receives signals from your stomach to release bile into your small intestine in preparation for the digestion of fat. Bile collects in the upper part of the small intestine and normally stays there as food and stomach acid pass from the stomach.

In the onset of bile reflux, the section of the stomach that connects to the small intestine known as the pyloric valve does not close quickly enough or firmly enough, causing the bile to flow back into the stomach. From there, it can come into 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, the bile can flow up (reflux) into the esophagus and cause a number of unpleasant symptoms.

Sometimes bile reflux and acid reflux can occur at the same time since this disease often mixes with stomach acid.

When there is damage to the valves or sphincters that control the movement of food from the esophagus to the stomach and then to the duodenum, bile reflux occurs. Other causes can be:

  • Abnormal movements of the duodenum
  • An operative stoma (an artificial opening made by surgery)
  • Poisoned food

Risk factors for bile reflux

Narrowing of the esophagus due to scarring or inflammation can increase the risk of bile reflux. Other risk factors are:

  • Presence of peptic ulcers
  • Gallbladder surgery (cholecystectomy)
  • Gastric band surgery
  • Excessive alcohol consumption
  • Smoke

Symptoms of bile reflux

Bile reflux is often misdiagnosed as acid reflux, as they part mutual symptoms. However, bile reflux does not resolve completely with the use of acid-suppressing medications. The symptoms are:

Burning pain in your upper abdomen, often in your chest and sometimes in your throat.

  • Cough or sore throat
  • Vomiting, especially if there is a green or yellow fluid
  • The feeling of nausea
  • Unexpected weight loss that is not linked to any significant change in lifestyle

It is main to pay special attention to any happening of vomiting in which bile is clearly present. While rare occurrences of severe vomiting can lead to the expulsion of bile, vomiting that occurs regularly with bile present should be taken as a possible sign 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 identify than acid reflux. If you experience frequent heartburn, choking while sleeping, and a bad taste in the back of your throat, you should talk to your doctor about seeking acid reflux treatments.

If acid reflux treatments are not effective, it may be related to bile rather than stomach acid. Due to the difference in chemical composition between bile and stomach acid, many of the treatments that alleviate the overproduction and/or build-up of stomach acid do not remove or nullify bile. This fact means that a removal process may be necessary to identify bile reflux.

Diagnosis of bile reflux

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

Your doctor can easily diagnose disease with symptoms. However, to rule out acid reflux, a diagnosis is required.

  • Endoscopy: A thin, flexible tube containing light and a camera is sent into the esophagus through the mouth. Then changes in the esophagus such as scarring or inflammation are observed.
  • Bilitec monitoring system: A photocolorimetric device is used to identify bile reflux. Reflux is aspirated and examined for bile using the optical properties of bilirubin.
  • The ambulatory acid test: A thin, acid-sensitive probe is sent into the esophagus through one of the nostrils to detect the presence of acid. This test rules out acid reflux. If the test is negative, bile reflux is considered the sole cause of the symptoms.
  • Esophageal impedance test: Includes manometry (strength and coordination of muscle activity in the esophagus) and pH test (a measurement of acid levels in the stomach and esophagus). This test helps evaluate the extent of reflux and the duration of bolus movement within the esophagus.

Treatment for bile reflux

Changes in lifestyle

As mentioned above, unlike acid reflux, bile reflux symptoms are generally not relieved by changes in diet or lifestyle. Because people often experience acid reflux and bile reflux at the same time, their symptoms can be alleviated with the following recommended lifestyle changes for those with acid reflux:

  • Give up smoking
  • Change eating habits
  • Eat smaller meals: Avoiding oversized meals is a great first step
  • Mealtimes: Wait before going to bed after eating
  • Food choices: Limit fatty and problematic foods and drinks and avoid alcohol
  • Lose weight
  • Sleeping habits: Raise the head of your bed and avoid sleeping in clothes that can constrict your waist or stomach
  • Regular relaxation and stress relief


Once bile reflux has been identified, treatment usually involves taking a medication such as ursodiol, which helps your body move bile more easily through the intestines, reducing the risk of reflux (reflux).


If medication is not effective, surgery may be the next step. Three procedures are typically used to treat.

Bile reflux: Roux-en-Y bypass surgery, fundoplication, and Linx implant.

Roux-en-Y bypass surgery involves the relocation of the tubes that help drain bile into the small intestine so that bile does not collect near the opening of the stomach. The Roux-en-Y procedure is also commonly used as a form of weight loss treatment, which means that it is not ideal for all patients, especially those who do not want or should not lose weight. It is usually best for patients who have already had other types of gastric surgery with the removal of the pylorus.

Both fundoplication (anti-reflux surgery) and the Linx implant are commonly used to treat acid reflux because they both work to strengthen the lower esophageal sphincter. The fundoplication involves wrapping a part of the upper stomach around the esophageal sphincter to reinforce it, while the Linx implant involves placing a specially designed titanium ring around the sphincter. Both procedures reinforce and strengthen the esophageal sphincter; Linx surgery, although much more recent, is considerably less invasive than a fundoplication.

Home remedies

As there is not much indication for the effectiveness of conventional treatment, trying home medications would help reduce bile reflux and its symptoms. Some of the home medications are:

  • Chamomile tea, apple cider vinegar, and orange peel source can decrease reflux
  • Cold milk relieves heartburn
  • Eating apples can reduce bile reflux


Lifestyle modifications do not affect bile reflux. However, as it is often accompanied by acid reflux, making certain lifestyle changes can lower your risk. They are:

  • Decrease weight if you are overweight or fat
  • Avoid sleeping immediately after meals. Keep a gap of at least two hours between mealtime and bedtime.
  • Avoid spicy foods and foods that aggravate acid production, such as onions, peppers, chocolate, and caffeinated beverages
  • Give up smoking
  • Avoid foods that are high in fat
  • Reduce stress. Practice yoga or meditation
  • Restrict alcohol consumption


A sticky mucous layer protects your stomach from the corrosive effects of stomach acid, but the esophagus lacks this protection, which is why bile and acid reflux can seriously damage esophageal tissue. And while bile reflux can damage the esophagus on its own, even when the pH of the reflux is neutral or alkaline, the combination of bile and acid reflux appears to be particularly harmful, increasing the risk of complications, such as:

Heartburn and gastroesophageal reflux disease (GERD): Millions of people experience heartburn, sometimes on a regular basis. Occasional heartburn is not usually a cause for 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 the esophageal tissue (esophagitis).

Esophageal narrowing (stenosis): Repeated exposure to stomach acid, bile, or both can cause scar tissue to form in the lower esophagus. This narrows the tube, which interferes with swallowing and increases the risk of suffocation.

Barrett’s esophagus: In this rare but 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 part of the esophagus (metaplasia). The new cells resemble the glandular tissue of the stomach (under a microscope, they look like carpets of long hair) and, although they are resistant to stomach acid, they have a high potential for malignancy. Only a small percentage of people with GERD have Barrett’s esophagus, but those who do have a much higher risk of esophageal cancer.

Esophagus cancer: This serious form of cancer can occur almost anywhere along the esophagus, but it often begins in the glandular cells closest to the stomach (adenocarcinoma). Because esophageal cancer cannot be diagnosed until it is quite advanced, the prognosis for people with the disease is usually poor. The link between esophageal cancer and bile reflux and acid reflux remains controversial, but many experts believe there is a direct connection. In animal models, 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 irritation of the stomach (gastritis). Although not always serious, untreated gastritis can lead to stomach ulcers and bleeding, a life-threatening problem that requires immediate medical attention. Chronic gastritis can also increase the risk of stomach cancer, especially when there is extensive thinning of the stomach lining or a change in the composition of the stomach cells.

Departments to consult for this condition

  • Department of Gastroenterology

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