Bile Reflux – a Lesser-Known Form of Reflux
STEVEN SANDBERG-LEWIS
N.D., DHANP
As I discussed in a previous blog post, bile is produced in the liver and stored in the gallbladder. Released into the upper small intestine when a meal containing fat or protein leaves the stomach, one function of bile is to allow oil and water to mix. This enables absorption of most dietary fat including essential fatty acids (such as those in fish oil) and the fat-soluble vitamins A, D, E and K into the blood.
After bile is released from the gallbladder at the top of the small intestine, it flows through the 18-20 feet of small intestine to eventually be reabsorbed in the terminal ileum (the end of the small intestine). 95% of the bile is absorbed into the blood and therefore only about 5% goes into the colon. If too much bile enters the colon (large intestine) it acts as an irritant and can be a cause of severe diarrhea (called bile acid diarrhea).
Digestion is said to be a north to south process (normally everything moves down from mouth to anus). Bile reflux is the reverse flow of bile. Instead of moving down, it refluxes up through the pyloric valve and then into the stomach. The most common antecedent to bile reflux is cholecystectomy (surgical removal of the gallbladder). I also find this to be a digestive issue that may be associated with poorly controlled diabetes – a condition also called diabetic enteropathy.
The symptoms of bile reflux can range from mild to extreme. The most common symptoms I have seen in my patients include low appetite, nausea, vomiting after meals and burning pains. If the bile refluxes from the stomach into the esophagus or throat, patients may suffer from typical esophageal reflux symptoms. It is also likely that they will not get much relief from standard acid-blocking drug treatments. The reason for this is that bile is very irritating to the mucus lining in the stomach, esophagus and throat - whether it is mixed with stomach acid or not. In addition, some research shows that chronic bile reflux may increase the damaging effect of stomach acid on the lower esophagus. Barrett’s esophagus, a long-term complication of gastroesophageal reflux (GERD) may be more severe in those who also have bile reflux.
Common treatments that I recommend for bile reflux fall into 4 categories.
1) Treat excess abdominal pressure levels that promote reflux
2) Improve the bile composition so it is more healing and less irritating to the mucus surfaces
3) Strengthen the lower esophageal sphincter (at the lower esophagus) and pyloric valve (at the lower stomach) to prevent reflux through either of these
4) Improve peristalsis – the coordinated muscular waves that move food, bacteria, and waste from mouth to anus
5) Soothe and protect the mucus lining of the stomach
Some of the treatments that address the four factors above include:
- Prokinetics – herbal or prescription substances that promote downward flow in the gut
- TUDCA, ursodiol, NAC and lecithin – bile salts and related substances that improve bile composition
- Huperzine A, mindfulness and other vagus nerve tonification agents – to improve sphincter tone and muscular coordination
- DGL (licorice extract), aloe vera and other herbal demulcents or the prescription medicine called sucralfate - to coat and protect the stomach lining against the irritating effects of bile
- Low fermentation diets, herbal antibiotics, rifaximin, and related prescription antibiotics or elemental diet– to reduce bacterial overgrowth and thereby reduce intra-abdominal pressure
Bile reflux is an under-researched and poorly understood medical condition. It is complex and needs to be treated in a highly individualized fashion. It should be distinguished from gastroparesis, biliary dyskinesia and other types of reflux. There is hope for improvement if one pursues an organized, thorough approach that recognizes and addresses underlying causes.
Steven Sandberg-Lewis, ND, DHANP, has been in clinical practice for 44 years, with a focus on functional gastroenterology. He has been a professor since 1985, teaching a variety of courses but primarily focusing on gastroenterology and GI physical medicine. In 2019, Dr. Sandberg-Lewis co-founded Hive Mind Medicine, continuing his specialization in gastroenterology with a focus on reflux, SIBO, inflammatory bowel disease and functional GI disorders. He is currently working on his latest book, Let's Be Real About Reflux: Getting to the Heart of Heartburn, written to help non-medical and medical professionals alike develop a better understanding of diseases affecting the gastrointestinal tract.
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