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BILE REFLUX

By: Goodness M.C

DEFINITION
Bile reflux occurs when bile — a digestive liquid produced in your liver — backs up (refluxes) into your stomach and the tube that connects your mouth and stomach (esophagus).

Bile reflux may accompany acid reflux, the medical term for the backwash of stomach acids into your esophagus. However, bile acid reflux and acid reflux are separate conditions.

Whether bile is important in reflux is controversial. Bile is often a suspected cause of reflux when people respond incompletely or not at all to powerful acid-suppressant medications. But there is little evidence pinpointing the effects of bile reflux in people.

Unlike acid reflux, bile reflux usually can't be completely controlled by changes in diet or lifestyle. Treatment involves medications or, in severe cases, surgery.

SYMPTOMS
Bile reflux can be difficult to distinguish from acid reflux. The signs and symptoms are similar, and the two conditions may occur at the same time. It isn't clear what role bile plays in reflux conditions.

Bile reflux signs and symptoms include:

Upper abdominal pain that may be severe.

Frequent Heartburn — a burning sensation in your chest that sometimes spreads to your throat, along with a sour taste in your mouth.

Nausea

Vomiting a greenish-yellow Fluid (bile)

Occasionally, a cough or hoarseness

Unintended weight loss

When to see a doctor?
Make an appointment with your doctor if you frequently experience symptoms of reflux, or if you're losing weight without trying.

If you've been diagnosed with gastroesophageal reflux disease (GERD) but aren't getting adequate relief from your medications, call your doctor. You may need additional treatment for bile reflux.

CAUSES
Bile is a greenish-yellow Fluid that is essential for digesting fats and for eliminating worn-out red blood cells and certain toxins from your body.
Bile is produced in your liver and stored in your gallbladder.

Eating a meal that contains even a small amount of fat signals your gallbladder to release bile, which flows through two small tubes (cystic duct and common bile duct) into the upper part of your small intestine (duodenum).

Bile reflux into the stomach
Bile and food mix in the duodenum and enter your small intestine through the pyloric valve, a heavy ring of muscle located at the outlet of your stomach.
The pyloric valve usually opens only slightly — enough to release about an eighth of an ounce (about 3.5 milliliters) of liquefied food at a time, but not enough to allow digestive juices to reflux into the stomach. In many cases of bile reflux, the valve doesn't close properly, and bile washes back into the stomach.

Bile reflux into the esophagus
Bile and stomach acid can reflux into the esophagus when another muscular valve, the lower esophageal sphincter, malfunctions. The lower esophageal sphincter separates the esophagus and stomach. The valve normally opens just long enough to allow food to pass into the stomach. But if the valve weakens or relaxes abnormally, bile can wash back into the esophagus.

What leads to bile reflux?
Bile reflux may be caused by:

Surgery complications.
Gastric surgery, including total removal of the stomach (gastrectomy) and gastric bypass surgery for weight loss, is responsible for most bile reflux.

Peptic ulcers.
A Peptic ulcer can block the pyloric valve so that it doesn't open enough to allow the stomach to empty as quickly as it should.
Stagnant food in the stomach can lead to increased gastric pressure and allow bile and stomach acid to back up into the esophagus.

Gallbladder surgery (cholecystectomy). People who have had their gallbladders removed have significantly more bile reflux than do people who haven't had this surgery.

COMPLICATIONS
Sticky mucus coats and protects the lining of your stomach from the corrosive effects of stomach acid.

The esophagus lacks this protection, so acid and bile reflux can seriously damage esophageal tissue.

The combination of bile and acid reflux increases the risk of complications, including:

GERD. Occasional Heartburn usually isn't a concern. But frequent or continual Heartburn is the most common symptom of GERD, a potentially serious problem that causes irritation and inflammation of esophageal tissue (Esophagitis).
GERD is most often due to excess acid. Although bile has been implicated, its importance in reflux is controversial.

Barrett's esophagus. This serious condition can occur when long-term exposure to stomach acid, or to acid and bile, damages tissue in the lower esophagus.
The damaged esophageal cells have an increased risk of becoming Cancerous.
Animal studies have also linked bile reflux to the occurrence of Barrett's esophagus.

Esophageal cancer. This form of Cancer may not be diagnosed until it's quite advanced. The possible link between bile and acid reflux and Esophageal cancer remains controversial, but many experts think a direct connection exists. In animal studies, bile reflux alone has been shown to cause Cancer of the esophagus.

PREPARING FOR YOUR APPOINTMENT

Make an appointment with your doctor if you have signs or symptoms common to bile reflux. After your doctor's initial evaluation, you may be referred to a specialist in digestive disorders (gastroenterologist).

TESTS AND DIAGNOSIS
A description of your symptoms is often enough for your doctor to diagnose a reflux problem. But distinguishing between acid reflux and bile reflux is difficult and requires further testing. You're also likely to have tests to check for damage to your esophagus and stomach, as well as for precancerous changes.

Tests may include:

Endoscopy. A thin, flexible tube with a camera (endoscope) is passed down your throat. The endoscope can show Peptic ulcers or inflammation in your stomach and esophagus.

Your doctor also may take tissue samples to test for Barrett's esophagus or Esophageal cancer.

Ambulatory acid tests.
These tests use an acid-measuring probe to identify when, and for how long, acid refluxes into your esophagus.

In one test, a thin, flexible tube (catheter) with a probe at the end is threaded through your nose into your esophagus.

In another (the Bravo test), the probe is attached to the lower portion of your esophagus during endoscopy. Ambulatory acid tests can help your doctor rule out acid reflux but not bile reflux.

Esophageal impedance. This test measures whether gas or liquids reflux into the esophagus. It's helpful for people who regurgitate substances that aren't acidic (such as bile) and can't be detected by an acid probe. As in a standard probe test, esophageal impedance uses a probe that's placed into the esophagus with a catheter.

TREATMENTS AND DRUGS
Lifestyle adjustments and medications can be very effective for acid reflux, but bile reflux medications is harder to treat. There is little evidence assessing the effectiveness of bile reflux treatments, in part because of the difficulty of establishing bile reflux as the cause of symptoms.

Medications
Ursodeoxycholic acid. This medication helps promote bile flow. It may lessen the frequency and severity of your symptoms.

Bile acid sequestrants. Doctors often prescribe bile acid sequestrants, which disrupt the circulation of bile, but studies show that these drugs are less effective than other treatments. Side effects, such as bloating, may be severe.

Proton pump inhibitors.
These medications are often prescribed to block acid production, but they don't have a clear role in treating bile reflux.

Surgical treatments
Doctors may recommend surgery if medications fail to reduce severe symptoms or there are precancerous changes in your esophagus. Some types of surgery can be more successful than others, so be sure to discuss the pros and cons carefully with your doctor.

The options include:

Diversion surgery (Roux-en-Y). This procedure, which is also a type of weight-loss surgery, may be recommended for people who have had previous gastric surgery with pylorus removal. In Roux-en-Y, surgeons make a new connection for bile drainage farther down in the small intestine, diverting bile away from the stomach.
Anti-reflux surgery (fundoplication). The part of the stomach closest to the esophagus (fundus) is wrapped and then sewn around the lower esophageal sphincter. This procedure strengthens the valve and can reduce acid reflux. There is little evidence about the surgery's effectiveness for bile reflux.

LIFESTYLE AND HOME REMEDIES
Unlike acid reflux, bile reflux seems unrelated to lifestyle factors. But because many people experience both acid reflux and bile reflux, your symptoms may be eased by lifestyle changes:

Stop smoking. Smoking increases the production of stomach acid and dries up saliva, which helps protect the esophagus.

Eat smaller meals. Eating smaller, more-frequent meals reduces pressure on the lower esophageal sphincter, helping to prevent the valve from opening at the wrong time.

Stay upright after eating.

After a meal, waiting two to three hours before lying down allows time for your stomach to empty.

Limit fatty foods. High-fat meals relax the lower esophageal sphincter and slow the rate at which food leaves your stomach.

Avoid problem foods and beverages. Some foods increase the production of stomach acid and may relax the lower esophageal sphincter. Among the foods with this effect are caffeinated and carbonated drinks, chocolate, citrus foods and juices, vinegar-based dressings, onions, tomato-based foods, spicy foods and mint.

Limit or avoid alcohol.

Drinking alcohol relaxes the lower esophageal sphincter and irritates the esophagus.

Lose excess weight. Heartburn and acid reflux are more likely to occur when excess weight puts added pressure on your stomach.

Raise your bed. Sleeping with your upper body raised 4 to 6 inches (10 to 15 centimeters) may help prevent reflux symptoms. Raising the head of your bed with blocks or sleeping on a foam wedge is more effective than is using extra pillows.

Relax. When you're under stress, digestion slows, possibly worsening reflux symptoms. Relaxation techniques, such as deep breathing, meditation or yoga, may help.

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