Contrary to common believe that heartburn is caused only by an acid reflux, doctors found out that it might also be caused by a bile reflux, which also goes by a name of duodenogastric bile reflux.
There are two critical situations when we have to start thinking seriously about bile reflux. The first case is when person has a chronic heartburn, and heartburn drugs do not work. Second, is the condition when one experiences pain, heartburn, and indigestion after gallbladder removal.
Bile reflux is not something that is new; surgeons have found bile in the stomach with ulcers during surgery, for over a hundred years. Bile is a common finding by gastroscopy in people with gastritis, ulcers, gastroesophageal reflux disease (GERD). There is a high possibility that a bile reflux, not acid reflux causes injury.
Thanks to technology, doctors started to detect bile in the esophagus in 70% stubborn chronic cases of heartburn and Barrett’s Esophagus. About 10%-15% of people with chronic symptoms of GERD get Barrett’s Esophagus. That is a serious precancerous complication of gastroesophageal reflux disease. There are many articles and books discussing potential injury of the stomach and esophagus that could be caused by bile due to bile reflux.
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To be more specific, the bile reflux is also the pancreatic reflux, as well. It means that the mixture of bile and pancreatic juice can do injury. Many people know that the liver produces bile and pancreas manufactures pancreatic juice full of digestive enzymes. However, not too many people know that bile and pancreatic juice are highly alkaline solutions. Alkalinity of these solutions means healthy digestion, contrary, acidic changes lead to poor digestion. My articles and book medically support this idea.
Bile is an alkaline solution with a gentle balance of water, minerals, bicarbonates, cholesterol, lecithin, and bile acids and bile salts. If bile is acidic, there are more precipitated bile acids in it. Bile acids are extremely “aggressive” chemical substances, which make acidic bile so irritable. Acidic bile irritates the surrounding tissues, mucus membranes, and sphincters and leads to bile reflux.
In a healthy person, mixture of alkaline bile and pancreatic juice goes down to the beginning of the small intestine - duodenum. Alkaline environment in the duodenum is a decisive factor of the good digestion and proper transfer of the digested food down to the lower area of the small intestine. Acidifying makes bile particularly “aggressive”. Whole body acidity leads to acidic changes in the bile with precipitation of the bile acids, which irritate the duodenum’s walls causing rough contractions and spasms. This throws the contents of the small intestine with aggressive mix of the bile acids and pancreatic enzymes up into the stomach.
Acidic bile irritates valves, ducts, duodenum wall, causing “the wrong way traffic” - bile/pancreatic reflux into the stomach or even esophagus.
Almost 40-50% of all adults in the U.S. report having some symptoms of gastroesophageal reflux disease (GERD) that is generally called acid reflux.
Commonly treatment for acid reflux is the medications that suppress stomach acidity. In numerous situations with stubborn, chronic heartburn, patients poorly respond to acid-suppressive drugs because acid reflux is only part of the problem. The main culprit is bile/pancreatic reflux.
Another situation when bile reflux can be seen is often in persons’ with sphincter of Oddi dysfunction after gallbladder removal. Normally, when the sphincter of Oddi is closed, bile from liver goes into the gallbladder. Absence of the gallbladder’s buffer capacity can increase the pressure inside the bile ducts and pancreatic duct. Acidic, offensive bile promotes more spasms of the sphincter of Oddi. It can cause bile reflux to the pancreas and possible pancreatitis.
In normal condition, gallbladder contracts and pushes out concentrated bile in the duodenum when food gets there for digestion. After gallbladder removal, bile from liver drips into the duodenum despite the fact that there is no food in the gut. Acidic bile corrodes empty duodenum’s wall resulting bile reflux in the stomach.
It is getting clear that restoration of normal, slightly alkaline environment in the whole body and, particularly in the liver and pancreas, can reduce the bile/pancreatic reflux into the stomach and esophagus. In turn, this can lessen bile reflux and chronic heartburn.