Is Acid the Only Cause of Your Heartburn? Let's Talk About Bile Reflux

Do you also get heartburn all the time? It feels like it's on fire, like it's coming up your throat. We often think that this is gastritis or acid reflux. That's true, and most of the time that's the cause. But sometimes the cause of this annoying burning sensation can be something else. That's bile reflux, or as we medically call it, a condition called bile reflux. Let's talk about this simply today, in a way that you can understand.

Simply put, what is bile reflux?

Think of our digestive system as a one-way road. Food enters the mouth, passes through the esophagus, into the stomach, and then into the small intestine. To keep this journey smooth, there are valves (sphincters) that open and close at various points. These allow food and digestive juices to move forward and stop them from flowing backward.

Now let's look at what 'bile' is. Bile is a greenish-yellow fluid produced in our liver and stored in the gallbladder. When we eat fatty foods, this bile enters the small intestine and helps digest those fats.

The food from the stomach enters the small intestine through a valve called the pyloric valve. Normally, this valve closes properly. But if this valve becomes weak or does not close properly, the bile in the small intestine flows backward, into the stomach, where it is not supposed to go. This is what we call Bile Reflux. Sometimes, this bile can come up from the stomach, all the way up to the esophagus.

What is the difference between Bile Reflux and Acid Reflux?

Many people confuse these two because the symptoms are very similar. But there is a fundamental difference between the two. Let's understand this clearly.

• Acid Reflux/GERD: This is when strong stomach acid flows up the esophagus. This is caused by a weakening of the valve between the stomach and esophagus (the lower esophageal sphincter). This allows stomach acid to flow up.
• Bile Reflux: This is when bile from the small intestine flows backward into the stomach. The bile can then mix with stomach acid and travel up the esophagus.

This table will make the difference clearer to you.

How does bile reflux affect the body?

Bile is not an acid. But it is a powerful chemical designed to digest fats. So when this bile gets on the sensitive linings of the stomach and esophagus, where it doesn't belong, it damages those walls.

This damage causes inflammation.

• If it occurs in the stomach: Gastritis
• If it occurs in the esophagus: Esophagitis

Because of this, you may experience stomach pain, chest pain, sore throat, as well as frequent nausea, indigestion, and sometimes vomiting bile.

What are the complications if this situation continues?

Bile reflux is not something to be taken lightly. If this condition persists for a long time, it can lead to serious complications.

• Stomach Ulcers: Continuous exposure to bile can damage the stomach walls.
• Increased risk of stomach cancer: Chronic gastritis has been found to increase the risk of stomach cancer.
• Barrett's Esophagus: Due to prolonged exposure to bile and acid, the cells in the lower part of the esophagus begin to change. This can be a precursor to esophageal cancer.

People with acid reflux also have these risks. But studies have shown that if you have acid reflux along with bile reflux, the risk of this cancer increases several times . So it is very important to be aware of this.

What are the main causes of bile reflux?

Bile reflux is rare in a generally healthy person. There are several specific causes that can affect this.

• Surgery: Surgery, especially gastric surgery and cholecystectomy, is a major cause. When the gallbladder is removed, bile is no longer stored and flows into the small intestine. This increases the risk of bile building up and refluxing into the stomach.
• Pyloric valve obstruction: This valve may not function properly due to ulcers or scarring in the small intestine (duodenal ulcer).
• Impaired Motility: Some people have a very slow digestive system. This can cause food and bile to stay in one place for too long, causing pressure to build up and back up.

How does a doctor accurately diagnose this disease?

Your doctor may suspect this when you tell them about your symptoms. But they will need to do some tests to determine for sure whether it's Acid Reflux, Bile Reflux, or both.

• Upper Endoscopy: This is the most important test. A thin, flexible tube with a camera is inserted through the mouth to examine the esophagus, stomach, and the beginning of the small intestine. This allows the doctor to see the inside walls for damage, inflammation, and bile. If necessary, a small piece of tissue (biopsy) can be taken for testing. You will be given a sedative before this procedure, so you won't feel any discomfort.
• Esophageal Impedance Test: This test can tell exactly whether the acid or non-acidic fluid, such as bile, is coming up the esophagus. This involves placing a thin tube through the nose into the esophagus for 24 hours.
• HIDA Scan: This is a special x-ray test that can look at how bile moves from the liver to the small intestine, and whether there is any delay or reflux in that journey.

What are the treatments for this?

Treating bile reflux is a little more complicated than acid reflux. Your doctor will determine the most appropriate treatment based on your condition.

Medications

• Ursodeoxycholic acid: This medication changes the chemical composition of bile, reducing the damage it causes to the body.
• Bile acid sequestrants: These bind bile that enters the stomach, reducing its harmful effects.
• Sucralfate: This medication acts like a protective coating on the walls of the stomach and esophagus, protecting them from damage caused by bile.
• Prokinetic agents: These speed up the functioning of the digestive system and cause the stomach to empty more quickly.

Surgery

Surgery may be recommended for people with severe bile reflux that cannot be controlled with medication. There are two main types of surgery. One is a diversion surgery that diverts bile from entering the stomach. The other is an anti-reflux surgery that strengthens the lower esophageal sphincter, which is also used for acid reflux.

Are there things you can do at home?

This is a very important question. But the truth is, unlike Acid Reflux, Bile Reflux is difficult to completely control with regular antacids or drastic dietary changes.

However, there are a few things you can try to get some relief from symptoms:

• Keep your head elevated while sleeping: Place two pieces of wood on the head of the bed, about 6 inches high, at the legs. Don't just pile on pillows, your entire upper body should be elevated.
• Lose weight: As body weight increases, pressure in the abdomen can increase and reflux conditions can worsen.
• Eat small meals frequently: Instead of eating a large meal at once, eat small meals several times a day.
• Eat dinner early: Eat dinner at least 2-3 hours before going to bed.
• Avoid smoking: Smoking worsens reflux.
• Avoid wearing tight clothing: Tight clothing can put pressure on the stomach.