WHAT IS BILE REFLUX

Bile reflux is a condition characterized by the rise of bile, a digestive fluid produced by the liver and stored in the gallbladder, from the intestine to the stomach; in some cases it is associated with gastroesophageal reflux, thus reaching the throat and mouth.

Unlike gastric reflux, biliary reflux does not respond as well to an improvement in diet and lifestyle, often requiring drugs or, in the most severe cases, a surgical approach.

CAUSES

Eating a meal requires subsequent digestion that the gallbladder empties its bile content into the duodenum. The first track of the intestine is found at the exit of the stomach.

Normally the pylorus, a valve that separates the two organs, prevents the ascent towards the stomach, opening instead only for the discharge of the food present in the stomach; in the event of a malfunction. On the other hand, a displacement in the opposite direction can be observed. Due to the tissues unsuitable to resist the digestive action of bile. The stomach and possibly the esophagus develop a more or less severe inflammatory condition.

When the same mechanism also occurs between the stomach and esophagus. Due to insufficient sealing of the cardia, biliary reflux overlaps with gastroesophageal reflux.

However, it is an uncommon condition in healthy subjects, while it is easier to develop in the presence of gastroesophageal reflux disease, particularly in those with severe esophagitis and/or Barrett’s esophagus.

The main risk factors that can predispose the patient to the development of the disorder include:

• Complications from surgical interventions, for example, bariatric surgery (aimed at weight loss), as in the case of gastrectomy and gastric bypass ;
• Peptic ulcer
• Cholecystectomy (removal of the gallbladder, typically due to the presence of gallstones ).

In any case, the reason why some patients only develop gastric reflux and others associated with biliary disease is not clear, among the hypotheses two are the most shared:

• The presence of biliary reflux predisposes to the development of the gastric one,
• Formation of an accumulation of bile and gastric acids in the stomach.

SYMPTOMS

Signs and symptoms are in part superimposable to gastroesophageal reflux, also because it is often associated with it; in fact, the most common symptoms of bile reflux include:

• Abdominal pain
• Burning in the abdomen and chest, which in some cases reaches the throat and mouth (where it is accompanied by the sensation of a bitter taste)
• Yellowish-green nausea and vomiting.
• More rarely, hoarseness, dry cough, and weight loss have been reported.

COMPLICATIONS

Persistent bile reflux has been linked to an increased risk of developing stomach cancer, possibly due to the irritating action of bile on the organ walls.

Other possible complications include:

• Gastroesophageal reflux disease  (gerd), in which the symptom acquires a systematic and persistent character,
• Barrett’s esophagus is a condition of altered nature of the walls of the esophagus that predisposes to the risk of organ tumor development.

DIAGNOSIS

Distinguishing biliary reflux from gastric reflux can be difficult and is rarely possible through a medical examination alone; instrumental tests may be necessary such as:

• Gastroscopy,
• Ph-esophageal impedance meter is an examination that allows evaluating the possible presence of acidic (from the stomach) and non-acidic (bile) gastro-oesophageal refluxes.

TREATMENT AND REMEDIES

If lifestyle changes are often sufficient to ensure optimal management of gastroesophageal reflux, unfortunately, the same cannot be said of bile reflux, also due to an objective difficulty in distinguishing the real impact between the two from the patient’s point of view.

Among the drugs that can be used, the most common include:

• Ursodeoxycholic acid (deursil®, ursacol®, …)
• Sucralfate (sucralfin®, …)
• Sequestrants of bile acids, also used as anti-cholesterol as they can prevent or at least reduce the reabsorption of bile at the end of digestion (questran®,)
• Prokinetic agents promote gastric emptying in a short time.

In patients in whom it is not possible to achieve adequate control of symptoms, surgery can be evaluated in this way, also to reduce the tumor risk associated with the disorder. Even if the real evidence of efficacy is not totally convincing to justify all cases.

DIET AND LIFESTYLE

Bile reflux seems to respond less well than gastric reflux to lifestyle improvement. However, since they are often associated, it is undoubtedly recommended to take the following advice:

• Limit the consumption of fats, which slow down gastric emptying.
• Reduce the consumption of foods that are at risk for gastroesophageal reflux.
• Consume small and frequent meals instead of the traditional 2-3 main meals.
• Reduce or avoid alcohol consumption.
• Avoid going to bed immediately after meals, to make sure that the force of gravity hinders the ascent of bile and acids.
• Lose weight if necessary.
• Stop smoking.
• Lift the bed from the head side, using shims placed under the legs of the bed.
• Reduce the impact of stress on your life.