In describing an instance of intense anger, you might say, as a figure of speech, that bile rose in your throat. But for some people bile does indeed rise, perhaps not as far as the throat but far enough to cause digestive distress and serious damage to the lining of the stomach and esophagus.
The symptoms are similar to heartburn, and many sufferers are told they have gastroesophageal reflux disease, known as acid reflux. Yet treatment with popular remedies for acid reflux, like the acid-suppressing proton-pump inhibitors Prilosec, Prevacid and Nexium, fails to work or gives only partial relief.
That’s because acid reflux is, at most, only part of the problem. The main culprit is bile reflux, a back-up of digestive fluid that is supposed to remain in the small intestine, where it aids the digestion of fats.
Bile is not acid. It’s an alkaline fluid consisting of bile salts, bile pigments, cholesterol and lecithin. It is produced by the liver, stored in the gallbladder and released intermittently into the duodenum, the upper part of the small intestine, when needed to digest fat. (Bile continues to be produced as a digestive aid even after the gallbladder is removed.)
Misdiagnosis of bile reflux and failure to control it can result in serious, sometimes life-threatening problems — stomach ulcers that bleed and Barrett’s esophagus, a possible precursor to esophageal cancer. Yet misdiagnosis is common, and even when the condition is properly identified, doctors are often fatalistic about its management.
Raymond Kozma of Staten Island, New York, said his wife, Lynne, 52, developed bile reflux after surgery to remove her gallbladder and had been “in constant daily pain” for the last two years.
“We have had doctors say everything from ‘There’s no such thing as bile reflux’ to ‘There’s bile reflux but we can’t do anything about it’ to ‘You just have to learn to live with the pain,’” Kozma wrote in an e-mail message. He urged me to write about the condition, saying that “thousands of suffering people live in a ‘shadow land’ because of the denial and disinterest of the medical profession” in bile reflux.
Although the condition is certainly not unknown, there is a relative lack of information on it in major medical journals read by nonspecialists. Kozma said his wife had now developed Barrett’s esophagus and, instead of being offered treatment, was told to return in three years to have another endoscopic look at her damaged esophagus. “What are we supposed to do? Wait and see if this develops into cancer?”
No one with bile reflux needs to just wait for worse to come, although the remedies are not as simple and well known as they are for acid reflux. The condition usually can be managed with medications, but severe cases may require surgery.
SYMPTOMS AND CAUSES
Both acid reflux and bile reflux may afflict the same person, which can make diagnosis a challenge. But the stomach inflammation that results from bile reflux often causes a burning or gnawing pain in the upper abdomen that is not felt with acid reflux, according to experts at the Mayo Clinic. Other symptoms of bile reflux may include frequent heartburn (the main symptom of acid reflux), nausea, vomiting bile, sometimes a cough or hoarseness and unintended weight loss.
A brief anatomy lesson makes the problem easier to understand. The main organs of the digestive tract are separated by valvelike tissues that, when functioning properly, allow food and digestive fluids to pass in only one direction: down. Thus, as food and liquids pass through the digestive process, they normally travel from the mouth to the throat, then down the esophagus into the stomach, and finally into the small intestine. The opening between the esophagus and stomach, a muscular ring called the lower esophageal sphincter, is meant to keep stomach acid from backing up. When it malfunctions, acid reflux — chronic heartburn — is the usual result.