Biliary reflux

Generality

Bile reflux consists of the rising of bile in the upper digestive tract, particularly in the stomach and, in some situations, also in the esophagus.

Figure: Bile reflux: note the rising of the bile (green), from the duodenum where it is poured through the common bile duct, to the stomach and from there to the esophagus. From the site: barrettsinfo.com

A cause of bile reflux is the malfunction of the valves located between the stomach and duodenum and between the esophagus and the stomach.

The excessive presence of bile irritates and inflames the gastric and esophageal mucosa. The main symptoms that follow are pain in the upper part of the abdomen, heartburn and vomiting containing a yellow-green substance.

For a correct diagnosis, several tests are required, including gastroscopy.

Treatment is usually pharmacological, while surgery is used only in special cases.

What is bile reflux?

Bile reflux is the rise of bile from the duodenum to the stomach and, in more severe cases, also to the esophagus.

The persistent presence of bile in the stomach and esophagus irritates and inflames the mucosa of these two organs.

WHAT IS BILE?

Bile is a yellow-green aqueous solution, produced by the liver and preserved in the gall bladder (or gallbladder ).

Composed of water (95%), electrolytes, lipids (bile acids, cholesterol and phospholipids), proteins and pigments (bilirubin), bile has various functions:

• It allows the digestion and absorption of fat and fat-soluble vitamins taken with the diet (main function)
• Neutralizes the acidity of gastric secretions
• Stimulates intestinal peristalsis
• Eliminates products resulting from the degradation of red blood cells
• Eliminates toxic, pharmacological or endogenous substances (thyroid hormones, estrogens, etc.) present in the body

After a meal containing fats, the bile leaves the gall bladder and first takes the cystic duct and then the common bile duct . The latter is connected to the duodenum and allows the bile to flow from within.

BILIARY REFLUX AND ACID REFLUX (OR GASTROESOFAGEO REFLUX) ARE THE SAME WHAT?

Gastroesophageal reflux is the rise of gastric juices (ie produced by the stomach) towards the esophagus. Gastric juices have an acid pH and this explains why we also talk about acid reflux .

Bile reflux and gastroesophageal reflux are two different pathological conditions, although the symptoms caused are very similar and often indistinguishable. Furthermore, it is not uncommon for both types of reflux to exist in the same individual.

Causes

How can the bile that is found in the duodenum go up to the stomach or, even, to the esophagus, overcoming two containment valves?

REFLUX BILIARE IN THE STOMACH

Under normal conditions, the valve called pylorus opens just enough to allow the ingested food to flow from the stomach to the duodenum.

In the presence of a damage to this valvular structure, or of an affection to the digestive tract, the pylorus can become incontinent and allow the bile and the duodenal contents to go up again in the stomach.

REFLUX BILIARE IN THE ESOFAGO

As in the previous case, a valve defect causes bile to rise up into the esophagus.

In fact, when even the cardia (in addition to the aforementioned pylorus) loses its continence, the bile that rises to the gastric level can also reach the esophagus.

Generally, this phenomenon is accompanied by a reflux of acid juices, produced by the stomach; there is therefore the simultaneous presence of bile and gastroesophageal reflux.

WHAT CAN DETERIORATE THE VALVES AND THEIR CONTAINING MECHANISM?

The malfunction of the pylori and cardias valves may be due to:

• Post-surgery stomach complications . Surgery involving partial or total removal of the stomach (partial or total gastrectomy) and gastric bypass can lead to pyloric deterioration. As a result of this deterioration, the bile is easier to ascend in the remaining upper compartment.
• Peptic ulcers . The presence of a peptic ulcer at the duodenal or gastric level can alter the functioning of the pylorus and cause the bile to rise towards the stomach and, possibly, also towards the esophagus.
• Cholecystectomy . Many individuals who are surgically removed from the gall bladder are prone to bile reflux. The precise physiological mechanism of all this is still unclear.
• Deterioration of the cardia or excessive stagnation of food in the stomach . These are the two main reasons why food, contained in the stomach, goes up into the esophagus.

  NB: obviously, there is bile reflux in the esophagus when the pylorus is also damaged and allows bile to rise in the stomach.

Symptoms and Complications

The typical signs and symptoms of bile reflux are:

• Pain (sometimes very strong) in the upper part of the abdomen
• Frequent heartburn
• Nausea
• Vomiting with the presence of a yellow-green substance
• Cough and hoarseness
• Unwanted weight loss

WHEN TO REFER TO THE DOCTOR?

If you frequently experience the aforementioned symptoms and signs, you should contact your doctor and undergo a thorough examination.

COMPLICATIONS

Bile contains substances which, if they come into contact with the stomach and esophagus frequently, can profoundly deteriorate the lining mucosa.

In particular, when acid reflux (equally persistent) is added to persistent bile reflux, the following complications may arise:

• Reflux esophagitis . It is the inflammation of the esophagus due to continuous bile / acid reflux.
• Barrett's Esophagus . It is the pathological condition for which the normal lining of the esophagus is replaced by a tissue similar to the one that covers the duodenum. This histological change makes the onset of an esophageal tumor more likely.
• Esophagus tumor . Researchers are still trying to scientifically demonstrate the connection between bile reflux / acid and esophageal cancer. From the experiments carried out on animals, the bond was evident; as for the man, there are still pending points.

Diagnosis

To diagnose a reflux problem from the stomach to the esophagus, the objective examination is almost always sufficient, that is the description given by the patient of the symptoms experienced.

To understand the exact nature of reflux, however, the physical examination is not enough: in fact, to determine whether in what goes up into the esophagus there is also bile, it is necessary to perform the following tests:

• Esophagus-gastric endoscopy (or gastroscopy) . Through the mouth, the doctor inserts into the esophagus (and, if necessary, into the stomach) a tubular instrument, flexible and equipped with a camera. This instrument, called an endoscope, allows the appearance of an esophageal mucosa and gastric mucosa to be shown on an external monitor. Furthermore, it also allows the collection of a cell sample for a laboratory analysis (biopsy).
• Esophageal pH measurement test . Nasally or via an endoscope, the doctor inserts a probe capable of measuring the acidity of the material rising up into the esophagus. A situation characterized by strong acidity is usually an indicator of acid reflux. On the contrary, a situation characterized by moderate acidity could mean that the symptoms experienced are due to bile reflux
• Esophageal impedance (or esophageal impedance) . It is, in fact, another method for measuring the pH of the esophagus. Today, it is considered one of the most reliable tests to determine whether bile, bile / acid or just acid reflux is taking place.

  Also in this case, a probe is used to be inserted into the esophagus.

Treatment

The treatments available for treating bile reflux are less effective than those available for treating acid reflux.

Therefore, the ascent of bile from the duodenum represents a problem more difficult to manage than gastroesophageal reflux.

Therapy is usually pharmacological; if, however, the drugs prove to be ineffective or there is a real risk of cancer of the esophagus, the doctor could resort to surgery. It is good to remember that the potential surgical interventions are quite delicate and could lead to various complications. Not by chance, before their execution, the patient is informed of all the possible dangers that lie behind the operation.

PHARMACOLOGICAL TREATMENT

The medicines used for bile reflux are:

• Resins sequestering bile acids, such as colestyramine . These drugs bind bile acids poured from the gallbladder into the duodenum, so as to prevent their reabsorption and promote fecal excretion. Therefore, they reduce the acid level of bile which causes irritation and inflammation.
• Prokinetics, such as domperidone and metoclopramide . They serve to promote the progression of food at the gastrointestinal level.

Proton pump inhibitors and H2 receptor antagonists ( anti H2 ), while representing the pharmacological treatment of choice for acid reflux, have no appreciable effects in the case of duodenal-gastric bile reflux.

SURGERY

The surgical operations that allow to reduce or stop the bile reflux are:

• Roux-en-Y reconstruction (or esophageal-jejunal reconstruction on a Y-shaped bend according to Roux ). Reserved for those who have undergone total gastrectomy, the intervention basically consists in creating a drainage pathway for bile.
• Laparoscopic fundoplication . It consists in wrapping and suturing, around the last section of the esophagus, the upper part of the stomach, in such a way as to offer greater resistance to reflux coming from the stomach.

SOME ADVICES

Although to a lesser extent than in situations of gastroesophageal reflux, do not smoke, eat moderate meals, do not lie down after eating, avoid foods that are too fatty or that favor gastric acidity (spicy foods, orangeade, tomatoes, caffeine-based drinks, chocolate etc.), avoiding alcoholic beverages, losing excess weight and sleeping with a raised head are all good remedies to alleviate symptoms induced by bile reflux.