Bile Reflux: Causes, Symptoms, Complications, and Treatments

You are probably familiar with the term acid reflux. But bile reflux may be a relatively new one in your vocabulary.

Commonly known as heartburn, acid reflux occurs when stomach acids flow back up from the stomach into the food pipe. This causes a burning sensation in the lower chest area.

Bile reflux occurs when bile flows back from the intestines into the stomach. It may even reflux into the food pipe sometimes. 

The food pipe is also called the esophagus. It connects your mouth to your stomach. Bile reflux may join with stomach acid reflux and travel up to the esophagus. That’s when you throw up greenish-yellow vomit.

When acid reflux occurs frequently, it can irritate and inflame the lining of your esophagus. This can lead to Gastroesophageal reflux disease (GERD) (1). Changes in diet and lifestyle help improve acid reflux. But bile reflux treatments require medications and in more serious cases, surgery.

What is Bile and Bile Reflux?

Bile is a digestive liquid that is essential for the digestion and absorption of fats and fat-soluble vitamins from the intestines. Bile also plays a key role in eliminating toxins and worn-out red blood cells from our bodies (2).

This greenish-yellow secretion is produced by the liver and then stored in the gall bladder. It is released into the small intestine during the digestion process.

Bile is made up mostly of cholesterol, bile salts, bilirubin, electrolytes, and water. 

A Quick Look at our Digestive System

Image credit: WebMD

When we eat food, it passes through the food pipe into our stomach. The lower esophageal sphincter (LES) is the muscle that acts like a valve to separate the esophagus from the stomach.

The LES acts as a one-way door that opens to allow the food to move into the stomach. It also prevents the contents of the stomach from going back up the same way. But during acid reflux, this valve is forced backward and the gastric acids move into the esophagus.

Bile Reflux into the Stomach

Just like the door between your food pipe and stomach, there is another door between your stomach and the small intestine. This is a ring of muscle called the pyloric valve. It allows your stomach contents to pass into the upper part of your small intestine. This part of the intestine is known as the duodenum.

When the partially-digested food from the stomach moves into the duodenum, it gets mixed with bile from the gallbladder and digestive juices from the pancreas.

Bile reflux occurs when the pyloric valve doesn’t close properly, allowing some of the bile and/or other contents from the small intestine to flow into the stomach. When this happens frequently, the stomach lining can get irritated and inflamed, leading to bile reflux gastritis. As mentioned earlier, bile reflux may combine with acid reflux and move into the esophagus as well.

The Causes of Bile Reflux

Bile reflux may be due to: 

  • SIBO (Small Intestine Bacterial Growth) occurs when the bacteria that are normally found in the stomach start growing in the small intestine. This causes the fermentation of food in the small intestine. But the small intestine doesn’t have the proper arrangements to handle this fermentation. When the fermentation gas tries to escape through the upper GI and the mouth, it picks up some bile with it, leading to bile reflux.
  • Valve damage: If there is any damage to the pyloric valve between the stomach and the duodenum, bile reflux may occur.
  • Surgery complications: Gastric bypass surgery for weight loss may have complications that lead to bile reflux. Any stomach surgery that involves total or partial removal of the stomach may also have complications such as bile reflux.
  • Gallbladder surgery: Considering it is the gallbladder that stores the bile produced by the liver, it’s no surprise that those who had their gallbladders removed experience more bile reflux than those who haven’t had the surgery.
  • Peptic ulcers: Such ulcers may block the pyloric valve and prevent it from closing and opening properly.
  • A blockage in your intestines: Bile reflux may occur due to blockages in the intestines. This can happen from adhesions (areas of band-like scarring) in the intestines after abdominal surgery. Diverticulitis may cause blockages as small pouches form in the intestinal wall. Weakening in any part of the intestine can lead to a hernia which may bulge out into the abdomen.
  • Food poisoning: If you have food poisoning, you may throw up bile. This symptom usually resolves on its own. Just make sure to avoid eating contaminated food.
  • Heavy alcohol consumption: Binge drinking can cause you to throw up bile. Cut down to a glass or two of alcohol when you have a drink.

Symptoms of Bile Reflux

Bile reflux is quite often misdiagnosed as gastric acid reflux. It can get difficult to distinguish bile reflux from acid reflux since they have similar symptoms and they can both occur together. While you can experience relief from acid reflux with diet changes and acid-suppressing medications, bile reflux does not resolve completely with such treatments.

  • Heartburn – Burning sensations in your lower chest frequently, along with a bitter or sour taste in your mouth
  • Cough or hoarseness – Acid reflux and bile reflux can both cause a chronic cough. It is more prominent after a meal or at night. Lying down may trigger the cough rather than while sitting or standing.
  • Nausea – When bile refluxes from the intestine, it can cause stomach discomfort and a sensation of wanting to vomit.
  • Vomiting – The greenish-yellow color of the vomit is due to the bile reflux
  • Upper abdominal pain – bile reflux can cause scarring of the stomach lining, leading to abdominal pain.
  • Unintended weight loss – Calories and nutrients are absorbed from the small intestine. Frequent bile reflux can interrupt this process. When the body is unable to absorb adequate calories, unintended weight loss can occur. If the bile reflux is caused by SIBO, then it can also lead to malnutrition since the bacteria use up the nutrients.

Complications of Bile Reflux

Bile reflux can lead to complications such as:

Gastroesophageal reflux disease: GERD is usually associated with acid reflux. It causes inflammation of the esophagus. But when potent acid-suppressant medications are unable to provide adequate relief, bile reflux is suspected. GERD, in turn, leads to other problems such as Barrett’s esophagus, Esophageal cancer, Esophageal narrowing (3)

  • Gastritis: If not treated, bile reflux may cause inflammation and damage the mucosal lining of the stomach.
  • Barrett’s esophagus: Bile reflux can be even more damaging to the esophagus since the food pipe does not have a protective lining like the stomach. Exposure to acid and bile over the long term causes scarring of the lower esophagus tissue (4). 
  • Esophageal cancer: Frequent bile reflux and damage to the esophagus increases the risk of esophageal cancer (5).
  • Gastric cancer: Bile reflux is considered a risk factor for gastric cancer (6).

Hypochlorhydria: When bile refluxes into the stomach, it can neutralize the acids in the stomach. Hypochlorhydria refers to a low level of stomach acid. This can lead to digestive disorders. Since stomach acid is required to destroy the overgrowth of bacteria in the gut, hypochlorhydria can worsen SIBO (7). This, in turn, can cause nutritional deficiencies due to the poor assimilation of iron, B12, iodine, etc.

Bile Reflux Diagnosis

The symptoms mentioned earlier, such as heartburn and cough, along with your medical history helps with the diagnosis of reflux. To differentiate between acid reflux and bile reflux, further testing is required. These tests are aimed at checking the damage to the stomach, esophagus, and for precancerous changes, if any.

  • Endoscopy – To observe the inflammation or scarring in the esophagus, a long, thin tube having a camera and light is inserted into the esophagus. Although a bit uncomfortable, an endoscopy is not a painful procedure.
  • Bilitec Monitoring System – The Bilitec monitoring system is a photo colorimetric device that can detect bile reflux by utilizing the optical properties of bilirubin
  • Ambulatory acid test – If you are experiencing symptoms of GERD, then the ambulatory acid test helps identify if bile reflux is the probable cause rather than acid reflux (8). A thin, flexible, acid-sensing tube with a probe is inserted into the esophagus, through the nostrils, to measure the acid in your esophagus. If the test proves negative, then acid reflux is ruled out. Bile reflux is suspected as the cause of the symptoms.
  • Esophageal Impedance Test – Non-acidic reflux can be recognized only by impedance-pH monitoring (9) This is a diagnostic test for evaluating the amount and type of reflux in the esophagus. It helps identify non-acidic substances such as bile, which cannot be identified by an acid probe. A flexible, thin catheter is passed through the nostrils, into the esophagus. The other end of this tube is attached to a small data recorder. This test is conducted over a 24-hour time period.

Treatments for Bile Reflux

Bile reflux can be treated with medications or surgery. Treatment of bile reflux includes the use of:

NMT

  • If SIBO is the cause of bile reflux, then it is usually treated with antibiotics. But the bacteria may return when the antibiotics are discontinued. Bile reflux often improves when SIBO is treated using: 
    • Low carbohydrate diet: A diet low in carbohydrates may help overcome SIBO. Not all carbohydrates are the same. It’s best to avoid refined carbs. But you must include some healthy low carbohydrate vegetables in your diet such as cauliflower, cabbage, and zucchini. This not only helps get valuable nutrients, but the fiber content also helps prevent constipation. On the other hand, eating too many high-fiber foods can worsen gas and bloating problems. The gut bacteria break down the indigestible fiber, fermenting it and releasing gas.
    • Adding stomach acid: Since low stomach acid levels can trigger SIBO, adding acidifiers such as betaine hydrochloride and apple cider vinegar (ACV) can help release your own bile salts that in turn will help reduce bile reflux. However, if you have an ulcer, then you should avoid taking them as the acidifier will irritate and inflame the area.
    • Taking probiotics: Taking probiotics have been found to be effective in treating SIBO (10)

Medications

  • Bile acid sequestrants – Drugs such as cholestyramine disrupt the circulation of bile into the digestive tract. This helps decrease the bile reflux, but you may experience side effects such as bloating.
  • Ursodeoxycholic acid This medication is a bile acid and it changes the composition of bile enabling it to flow more easily. This drug offers symptomatic relief from bile reflux, but it may have side effects like diarrhea.
  • Prokinetic agents Medication such as cisapride, metoclopramide, and domperidone increases the contractions of the small intestine. They enhance gastrointestinal motility and gastric emptying (the time it takes for food to empty from the stomach and enter the small intestine). 
  • Proton pump inhibitors – Since bile reflux is often accompanied by acid reflux, proton pump inhibitors such as pantoprazole and rabeprazole, can help reduce acid production. 

Roux-en-y Surgery 

If the above-mentioned treatments are not working for you, then Roux-en-y Surgery may be the next step. During this procedure, a bypass is created to divert the flow of bile away from the stomach.

Commonly known as gastric bypass surgery, it is popular as weight-loss surgery. After the surgery, the food you eat bypasses the duodenum as it passes from the stomach into the jejunum (the second part of the small intestine). This diverts the bile away from the stomach (11).

Lifestyle changes for Prevention of Bile Reflux 

If you are suffering from bile reflux, then here are a few lifestyle changes that help ease your symptoms:

  • Diet: Make sure to follow a diet that’s low in carbohydrates. Avoid high carbohydrate foods such as pasta and potatoes. Instead, include more low carbohydrate vegetables in your daily meals.
  • Smaller meals: Avoid overeating and filling up your stomach too much. Too much food at a time increases the chances of reflux.
  • Do not lie down immediately after eating: Give the food some time to digest. Have your dinner early, at least 3 hours before your bedtime.
  • Quit smoking: Cigarette smoking is associated with barrier dysfunction in the small intestine (12). Quitting smoking has been found to improve the intestinal microbiota (13).

FAQs on Bile Reflux

1. What color is bile?

Bile is a dark-green-to-yellowish-brown fluid. 

2. What does bile taste in the mouth mean?

When bile reflux occurs, it can travel up your food pipe into your mouth, leaving you with a sour, bitter taste.

3. Does bile have a smell?

Bile does have an alkaline odor, but it’s not a strong smell.

4. How serious is bile reflux?

If untreated, bile reflux can lead to Barrett’s esophagus and Esophageal cancer.

5. Is bile reflux common after gallbladder removal?

After gallbladder surgery, bile reflux into the stomach is reported at a rate of 80%-90% (14).

6. How do I know if I have GERD or bile reflux?

Although the symptoms of GERD and bile reflux are similar, the medications and diet changes prescribed for treating GERD do not help with bile reflux. If symptoms still persist after using acid-suppressing medications, then tests such as the Bilitec Monitoring System can help diagnose bile reflux.

7. How do you get rid of bile reflux?

Following a low-carb diet and avoiding high-carb foods have been found to help overcome SIBO, one of the most probable causes of bile reflux. Increasing stomach acid levels is another way to treat SIBO and reduce bile reflux.

8. Do probiotics help with bile reflux?

Probiotics have been found to help with bile reflux caused by SIBO.

9. What foods should you avoid if you have no gallbladder?

The gallbladder stores the bile required for breaking down fat during digestion in the small intestine. The liver still releases the bile, but it’s best to avoid meals that are laden with fat. Without a gallbladder, the risk of bile reflux is higher. A low carbohydrate diet is recommended if you experience bile reflux.

10. Why does bile back up into the stomach?

When the pyloric valve that separates the stomach from the intestine gets weakened, bile can back up into the stomach. SIBO can cause gas to be released from the fermentation of food in the small intestine. This pushes up the pyloric valve and some bile may also spill into the stomach along with the gases.

Conclusion

Most of the time bile reflux is misdiagnosed as just acid reflux. But if your antacids and diet changes are not helping resolve your heartburns and stomach discomforts, then bile reflux is probably the culprit.

Low levels of stomach acid can lead to an overgrowth of bacteria in your small intestines. If this is the cause of your bile reflux, then a diet low in carbohydrates can help relieve symptoms.