In describing an instance of intense anger,you might say,as a figure of speech,that bile rose in your throat. But for some people,bile does indeed rise,perhaps not as far as the throat but far enough to cause digestive distress and serious damage to the lining of the stomach and oesophagus.
The symptoms are similar to heartburn,and many sufferers are told they have gastro-oesophageal reflux disease,known as acid reflux.
Yet,treatment with popular remedies for acid reflux,like the acid-suppressing proton-pump inhibitors fails to work or gives only partial relief.
That’s because acid reflux is,at most,only part of the problem. The main culprit is bile reflux,a back-up of digestive fluid that is supposed to remain in the small intestine,where it aids the digestion of fats.
Bile is not acid. It is an alkaline fluid,consisting of bile salts,bile pigments,cholesterol and lecithin. It is produced by the liver,stored in the gallbladder and released intermittently into the duodenum,the upper part of the small intestine,when needed to digest fat. (Bile continues to be produced as a digestive aid even after the gallbladder is removed.)
Misdiagnosis of bile reflux and failure to control it can result in serious,sometimes life-threatening problems stomach ulcers that bleed and Barrett’s oesophagus,a possible precursor to oesophageal cancer. Yet misdiagnosis is common,and even when the condition is properly identified,doctors are often fatalistic about its management.
Although the condition is certainly not unknown,there is a relative lack of information on it in major medical journals read by nonspecialists.
But no one with bile reflux needs to just wait for worse to come,although the remedies are not as simple and well known as they are for acid reflux. The condition usually can be managed with medications,but severe cases may require surgery.
Symptoms and Causes
Both acid reflux and bile reflux may afflict the same person,which can make diagnosis a challenge. But the stomach inflammation that results from bile reflux often causes a burning or gnawing pain in the upper abdomen that is not felt with acid reflux,according to experts at the Mayo Clinic.
Other symptoms of bile reflux may include frequent heartburn (the main symptom of acid reflux),nausea,vomiting bile,sometimes a cough or hoarseness and unintended weight loss.
A brief anatomy lesson makes the problem easier to understand. The main organs of the digestive tract are separated by valve-like tissues that,when functioning properly,allow food and digestive fluids to pass in only one direction: down. Thus,as food and liquids pass through the digestive process,they normally travel from the mouth to the throat,then down the oesophagus into the stomach,and finally into the small intestine. The opening between the oesophagus and stomach,a muscular ring called the lower oesophageal sphincter,is meant to keep stomach acid from backing up.
When it malfunctions,acid reflux chronic heartburn is the usual result.
Likewise,the pyloric valve,the muscular ring between the stomach and small intestine,is supposed to open just enough to permit a fraction of an ounce of liquefied food to pass into the small intestine,but not enough to allow bile to back up into the stomach. When this valve fails to close properly,refluxed bile can cause gastritis,an irritation and inflammation of the stomach lining. Untreated,that can result in a bleeding ulcer or even stomach cancer.
If the oesophageal sphincter malfunctions at the same time,or there is a build-up of pressure in the stomach,bile and acid can reach the lower portion of the oesophagus,inflaming the delicate lining of this organ. If the problem persists,it can cause scarring that narrows the oesophagus,which may result in choking,or the cellular abnormality called Barrett’s oesophagus,which can become precancerous and eventually develop into cancer that is nearly always fatal.
Gastroenterologists have recently demonstrated that Barrett’s oesophagus can often be effectively treated with radiofrequency therapy.
Bile reflux can occur as a complication of certain surgeries,like gallbladder surgery.
More often,though,damage to the pyloric valve results from gastric surgery total removal of the stomach or the gastric bypass operation used to treat morbid obesity.
Occasionally,the pyloric valve is obstructed by a peptic ulcer,for example,or scar tissue,which prevents the valve from opening enough to permit quick transport of stomach contents into the intestine. That causes pressure to build up in the stomach,pushing both acid and bile into the oesophagus.
Diagnosis and Treatment
The main diagnostic tests include an endoscopic examination of the oesophagus and stomach to check for inflammation or ulceration; a test to check for acid in the oesophagus (this would be negative if bile reflux is the only problem),and a test to determine if gas or liquids reflux into the oesophagus.
A medication called ursodeoxycholic acid can be prescribed to promote the flow of bile and reduce the symptoms and pain of bile reflux. Other drugs might be used to speed the rate at which food leaves the stomach.
Surgery is a treatment of last resort,used if nothing else reduces severe symptoms of bile reflux or when the oesophagus develops precancerous changes. The most common operation,called Roux-en-Y surgery,involves creation of a new connection to the small intestine to keep bile away from the stomach.
If acid reflux is also a problem,treatment with a proton-pump inhibitor should help,as should non-medical remedies including weight loss; limiting high-fat foods and alcohol; avoiding carbonated and acidic beverages,spicy foods,onions,vinegar,chocolate and mint; eating small meals; practicing stress-reducing techniques like meditation or exercise; not eating within two to three hours of bedtime; and sleeping with the upper body and head elevated.
WHAT,WHY AND HOW
• The lower oesophageal sphincter,a muscular ring between oesophagus and stomach,keeps stomach acids from backing up. Malfunctioning results in acid reflux
• Malfunctioning of Pyloric valve the muscular ring between the stomach and small intestine leads to bile reflux. Untreated,this can result in a bleeding ulcer or even stomach cancer
• Bile reflux can also occur as a of certain surgeries like gallbladder surgery or gastric surgery,otherwise known as stomach stapling
• If acid reflux and bile reflux happens together,it can inflame the oesophagal lining. This can cause scarring that narrows the oesophagus,which may result in choking or a cellular abnormality called Barretts oesophagus,which can lead to cancer
• Bile reflux can cause a burning or gnawing pain in the upper abdomen that is not felt with acid reflux
• Other symptoms include frequent heartburn,nausea,vomiting bile,sometimes a cough or hoarseness and unintended weight loss