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Bile reflux

Having experienced bile reflux myself I can make a few comments about it. Unlike acid reflux - which can be easily controlled by PPIs or antacids, there is no medically effective remedy for bile reflux, so the doctors simply aren't interested - which is disgraceful as bile reflux is often caused by PPIs. Furthermore bile reflux is difficult to distinguish from acid reflux. However an understanding of the bile system and how it goes wrong can give some pointers.

Contents this page.

Bile in the stomach

In a healthy person, bile should not be present in the stomach except in vary exceptional circumstances, such as heavy vomiting, or mechanical shock to the abdomen, such as a punch in the stomach. See The bile production system for how it should work. So what might cause bile to be present regularly in the stomach? I can only guess - for, before I was prescribed omeprazole, I did not have bile present as far as I can tell.

Recent research is enough to convince most doctors that bile is necessary to induce Barrett's oesophagus. However I find the evidence unconvincing - it was done in vitro and there is no quantitative assessment: what percentage of bile and over what period? In science it is extremely difficult to prove a negative - so it's really not possible to prove that Barretts cannot develop in the absence of bile!

I can think of the following possible reasons why bile should back-up into the stomach:

Being overweight
Fat is deposited around the internal organs. This will displace organs and it seems likely that such fat could mechanically interfere with the pyloric sphincter, causing it to leak backwards allowing bile into the stomach.
Too much fat in the diet.
It has been hypothesised that if fat is present in the stomach the pyloric sphincter can deliberately leak to allow bile to enter. This was first observed by William Beaumont in his study of the case of Alexis St Martin, entitled Experiments and Observations on the Gastric Juice, and the Physiology of Digestion which is available via Google Books.

However there is ample evidence that bile mixed with acid is harmful and I think such a harmful system could not likely evolve. And why would such digestion need to take place in the stomach rather than in the small intestine?

Bad diet causing very slow digestive transit time,
In theory, if the gut is congested too much, chyme might not easily flow out of the stomach, so bile might flow back in by virtue of the mechanical mixing effects in the stomach.
Malfunctioning or absent gallbladder
The job of the gallbladder is to store and concentrate the flow of bile from the liver and to release it into the digestive system at the correct time then food is flowing out of the stomach. With a compromised (or no) gallbladder bile will leak into the digestive system at the wrong time when it will very likely get back into the stomach. Gastric bile is strongly implicated as a cause of stomach cancer and in the formation of Barrett's oesophagus, hence progression to oesophageal adenocarcinoma. The removal of the gallbladder will cause constant bile release into the pylorus when it may well get into the stomach. There are indeed medical papers that find a link between cholesysectomy (removal of the gall bladder) and cancer.
It is well known that PPIs affect the biliary system. But there are conflicting opinions as to how and why. I know for a fact that, in myself, as a dose of PPIs wore off the first symptom I would experience was a dry, tickly cough (caused by irritation of the oesophageal cough sensors). Then I would taste bile in the refluxate. Only after that would the refluxate become acid.

The above are mostly only theories: it seems that it would not be difficult for the medical profession to actually measure bile presence and record whether any medication has been used. There are measurements of bile, but none seem to state that PPIs or other medication had not been used.

The bile production system.

Bile is produced in the liver and stored in the gall bladder. When food is eaten, bile is released into the duodenum (the upper part of the small intestine) via the sphincter of Oddi (Google will show you some interesting pictures and much more information) to mix with the food as it leaves the stomach.

This timing is very complicated: there is a hormonally-controlled feedback and timing system involving several hormones. It seems this system is not entirely understood - and few doctors seem to know anything about it!

Bile production is controlled by the hormones cholecystokinin, secretin, gastrin, and somatostatin. The main hormone involved in bile reflux seems to be cholecystokinin, which itself is intimately controlled by Gastrin. Gastrin is secreted into the blood stream by the stomach. It's secretion is triggered by the presence of food - in particular peptides, certain amino acids and calcium. Certain compounds in coffee, beer and wine are also potent. See Colorado State University's ebook Pathology of the endocrine system for more detail.

Gastrin causes acid to be secreted into the stomach. Its production is switched off again when the pH in the stomach falls - i.e. when the acidity gets high. This is why hypergastrinaema (excess blood gastrin levels) is a well documented side effect of long-term PPI usage.

Gastrin also interacts with many other hormones. It relaxes the lower oesophageal sphincter. It probably also relaxes the pyloric sphincter (via other hormones) and it (also via other hormones) triggers bile production and release.

So interfering with acid production by taking PPIs and, probably, also H2 receptor antagonists (Ranitdine and similar drugs) is likely to affect the bile system allowing bile to flow at the wrong time and also allowing bile back into the stomach via a relaxed pyloric sphincter.

I found, when I first started experimenting on PPI dosage, that I could taste bile as the PPI dosage wore off. See my page Hiatus Hernia, Bronchiectasis, Barrett's oesophagus, so I was well aware of bile. Later (as I lost weight) I would not taste refluxate and differentiating between bile and acid reflux then became more difficult.

There is a documented link between PPI usage and gall-bladder malfunction. See: Gallbladder function before and after fundoplication from which a quote:

Unexpectedly, 58% of patients with GERD demonstrated gall bladder motor dysfunction prior to fundoplication, with improvement to normal occurring in most of those studied postoperatively.
The authors realised that it could be the PPIs that caused the malfunction! Naturally, after fundoplication, PPIs are withdrawn - hence the gallbladder recovery. So they did another test. See their paper Proton pump inhibitors reduce gallbladder function.

What does bile taste like?

Bile tastes like little else! It is intensely bitter but a taste difficult to get out of your mouth. It is a digestive fluid so in any concentration almost starts to digest the membranes in your mouth.

It can taste of vomit - for severe vomiting can bring up bile. But bile isn't just one substance: any waste product from the liver is voided in the bile, so its taste can vary depending on your health and diet.

The gall bladder stores bile and releases it at the proper time, when chyme (the processed food leaving the stomach) is flowing. The gall bladder is in close contact with the liver and when liver is used as food, great care has to be taken to keep the gall bladder intact as liver (or any meat) contaminated by bile is inedible.

When you regurgitate bile it will of course be diluted with stomach fluid so may not taste quite te same, but the taste is still very difficult to remove from your mouth.

How can you tell the difference between acid and bile reflux?

This is usually difficult: the symptoms of both are generally extremely similar. If you can regurgitate to taste the fluid, then Bile is bitter. Stomach acid untainted is just acid, rather like vinegar or lemon juice. And pure stomach acid doesn't cling - a drink of water will neutralise it - especially if you add some sodium bicarbonate (baking soda) to the water.

Otherwise possibly the easiest way to tell is sodium bicarbonate (ordinary baking soda). A small dose (half a level teaspoonfull) in water almost always brings immediate relief from acid indigestion. It does absolutely nothing for bile reflux.

Sodium bicarbonate (SodiBic) also releases carbon dioxide as soon as it hits stomach acid - so is quite likely to cause almost immediate belching. This is not 100% - it depends on the amount of acid and bicarbonate. SodiBic has no such reaction with bile!

If you are unlucky enough to regurgitate stomach fluids, you will easily know the difference between acid and bile. Bile is hugely more unpleasant, being very bitter!

My early experiments taught me that my first symptom of reflux was a tickly cough. That is triggered by bile and, slightly less so, by acid. So if the cough is relieved, almost instantaneously, by an antacid, it is caused by acid, not bile. However - there are many other cause of a tickly cough and differentiating between reflux or other cause is very difficult, other that when an antacid stops it.

What can I do to relieve bile reflux?

Immediate relief seems impossible. However once you realise that bile flow is triggered by reduced stomach acidity and switched off by acids, it seems logical that an acid drink will help. Diluted vinegar - cider vinegar is generally the most palatable and said to be the most healthy - or lemon or lime juice or plain citric acid may therefore help. I found that cider vinegar did indeed seem to help when I experienced bile reflux, but the relief is not immediate.

PPIs and bile

The digestive system is hugely complicated: there are many known hormones - Gastrin, Secretin, Cholecystokinin, Ghrelin, Motilin - and probably more to be discovered. They interact with stomach acidity in ways that are still being explored.

Switching off stomach acid by any means is like throwing a spanner into a complex machine. Amazingly it does not cause more trouble: PPUs are reputed to be some of the safest drugs around. However - their long term use is evidently problematical.

I was lucky enough to realise it was affecting my bile system. I was luck enough to be able to withdraw from the drug - totally against medical advice - before any damage was done! I did not listen to the doctors - chiefly because I found they were nor prepared to listen to me! My father was a consultant surgeon, and he always said that any doctor who was not prepared to openly listen and discuss their views was not to be trusted. Very good advice!

However - once you suspect PPI usage is affecting your bile production, there is enough evidence in medical papers on the www about PPIs and gall bladder malfunction to be totally convincing. Long term PPI usage is dangerous! See How and why PPIs can cause Barrett's oesophagus which changes to oesophageal adenocarcinoma

If a drug is affecting you negatively - clearly you must withdraw from its usage! This is not easy with PPIs! Rebound acidity is a known and admitted problem. In my case - I found the main rebound was bile - not acid. This intermittent bile reflux occurred chiefly at night (as is widely admitted for acid rebound). However as few people can tell the difference between acid and bile reflux symptoms, the rebound acid reflux reported may indeed be rebound bile reflux rather than acid.

PPI withdrawal causes bile reflux

I found that, after ceasing PPI usage, it look a very long time - 100 days or so - for bile reflux episodes to subside completely. The mechanism for that escapes me completely! I experimented to find ideal PPI dosage: elsewhere I have written up more about my experimentation with PPIs. On both occasions I had severe bile nocturnal reflux which was clearly to do with the PPI withdrawal. Whilst the above link on experimentation does explain some of the mechanisms, it cannot explain the extremely long time it took for my system to settle!

I kept a diary of these events and the timing was

The above is anecdotal and proves little. However the extreme similarity of the two scenarios is strong indication.

Of course - my system may be atypical. However the various papers I have found on the www and the contacts I have had lead me to fear that such bile interference is the norm for PPI usage, especially as the liver learns to metabolise the drug quicker, so it becomes less effective, and with PPI withdrawal. However there are several papers that prove it's not uncommon:

Why there are mixed opinions about PPI effects on bile

The initial effect of Proton Pump Inhibitor, in most people, is that they inhibit bile flow. There are two studies (link is to them in my list of papers) that clearly demonstrate than even short term use causes biliary dyskinesia - reduced bile flow. So PPIs can indeed reduce bile reflux.

However I discovered that, as a dose of PPI wore off things happened in this order:

So it seems that the biliary dyskinesia started to ease as the PPIs wore off. But either this was not timed to coincide with chyme flow from the stomach, or the pyloric sphincter was misbehaving. I have not found the exact mechanism - it could be because of the massive upset to the digestive hormonal system, or could it be some more direct action on the biliary system?

See also my notes above on PPI withdrawal causes bile reflux. The effect is far more severe long term!

There are many medical papers linking bile disorder with PPIs. See my list of medical papers. It is concerning that, in view of the acknowledged danger of gastric bile, none of this has been followed up. There are no papers to be found saying how bad the biliary dyskinesia is - or is it choleostasis? If the gall bladder is not working properly one likely scenario seems to be gallstone formation.

PPIs can damage the gall-bladder

Furthermore - if, as I had reason to suspect, tolerance does develop to PPIs, then bile flow interference and gall-bladder damage are probable effects of any long-term usage of PPIs.

There are, on the www two papers of relevance. The first entitled Gallbladder function before and after fundoplication. found that gall-bladder functioning actually improved after fundpolication. This unexpected finding clearly set the team thinking as they later tested the gall-bladder functioning of 19 healthy volunteers. Then the volunteers took a course of PPIs and had their gall-bladder function retested. In 15 out of the 19 volunteers, gall-bladder functioning had indeed been adversely affected. The paper is Proton pump inhibitors reduce gallbladder function.

These two papers are strong evidence that PPIs do compromise gall-bladder function. If mine was compromised I would theorise that the bile reflux events after PPI withdrawal were my gall-bladder recovering from the effects of the PPIs.

Gall stones

There is much thought that PPIs might cause gallstones, but there is little real evidence that I can find. If you are a person whose ball bladder is affected by PPIs, it seems that biliary dyskinesia is the result - so bile would not be released as it should, but would stay in the gall bladder longer and could then, in theory, concentrate and form stones.

Gall stones (according to wikipedia) have four main constituents:

Testing for bile

Most endoscopy equipment has the ability to draw a sample of gastric fluid for analysis: this can be tested for pH (acid level, presence of blood, micro-organisms. One test which is not commonly performed if the presence of bile, but the test can be done - and probably will be done of you ask.

The doctors can do nothing about bile in the stomach, so they are not interested. However as PPIs very commonly affect the gallbladder, they should be concerned as bile-tainted gastric fluid is one cause of Barrett's progression.


I would be interested to hear more on this subject, so please contact me if you can add anything.

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Page first published: 25th July 2014
Last modified: February 15 2021 15:51:46.
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