Bile Reflux: Symptoms, Causes and How It Differs From Acid Reflux

Bile reflux is bile, the digestive fluid made by the liver, flowing backward from the small intestine into the stomach and sometimes up into the esophagus, where it can cause upper abdominal pain, heartburn, nausea and a bitter taste. It often happens alongside ordinary acid reflux and feels much the same, which is why it is identified with tests rather than by symptoms, and why the treatment can differ.

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Bile reflux is less familiar than acid reflux, and many people first hear the term after months of burning, a bitter taste or nausea that heartburn medicine never quite settled, or after gallbladder or stomach surgery.

The two are easy to mix up, and much of what is written online is more confident about telling them apart than the research is. This guide sets out what the evidence does and does not show.

What Is Bile Reflux?

Bile reflux is the backward flow of bile from the first part of the small intestine, the duodenum, into the stomach and, in some people, on up into the esophagus [1]. Bile is the fluid the liver makes to help you digest fat [2], and it is meant to travel one way, down through the intestine.

Two muscular valves normally keep it moving in that direction. The pyloric valve, at the outlet of the stomach, opens only slightly as food leaves, releasing about 1/8 ounce (3.75 milliliters) or less of liquefied food at a time [3]. When it does not close properly, bile can wash back into the stomach and inflame its lining, a condition called bile reflux gastritis [3]. Higher up, when the lower esophageal sphincter weakens or relaxes too much, bile can rise into the esophagus along with stomach acid [3].

Some backward flow of bile into the stomach also happens in healthy people, particularly after meals [4], so what matters is how often it happens, how much rises and whether it causes symptoms or inflammation.

What Are the Symptoms of Bile Reflux?

Cleveland Clinic lists these symptoms of bile reflux [1]:

• abdominal pain
• heartburn and indigestion
• a bitter taste in the mouth
• nausea and loss of appetite
• regurgitation, food or fluid coming back up
• a sore throat or hoarse voice
• vomiting yellow-green fluid

Mayo Clinic adds that upper belly pain may be severe and that heartburn tends to be frequent [3]. Many people notice symptoms most on an empty stomach.

Bile Reflux vs Acid Reflux: What Is the Difference?

The main difference is where the fluid comes from. Acid reflux is stomach acid rising into the esophagus, while bile reflux starts one step lower, in the duodenum, and brings bile into the stomach and esophagus [1, 3]. Bile reflux is less common than acid reflux [1], and it does not respond to the same antacid treatments [1].

How they feel is a poor guide: reflux specialists point out that symptoms cannot dependably distinguish bile reflux from acid reflux [4]. A bitter taste, yellow-green vomit and heartburn that persists despite acid medicine are reasonable clues to mention to your doctor. They are not a test.

	Acid reflux	Bile reflux
Where it starts	The stomach	The duodenum, the first part of the small intestine
Valve involved	Lower esophageal sphincter	Pyloric valve, and often the lower esophageal sphincter too
Possible clues	Burning that eases with acid medicine	Bitter taste, yellow-green vomit, burning that acid medicine does not settle [3]
Acid medicine	Usually the main treatment [5]	Lowers the acid and can reduce bile reflux, but does not stop it in everyone [6, 7]

Can You Have Bile Reflux and GERD at the Same Time?

Yes. GERD, gastroesophageal reflux disease, is reflux that happens often enough to cause troublesome symptoms or damage [8], and bile reflux can happen at the same time [1]. In a study that measured acid and bile in the esophagus together, exposure to both rose with the severity of reflux disease and was highest in people with Barrett's esophagus [9].

That overlap explains a common experience: the burning improves on a proton pump inhibitor (PPI), such as omeprazole, but never fully clears. PPIs lower the acid, and in one study they also reduced bile reflux into the esophagus [6], but bile reflux can continue in some people who take them [7, 4].

What Causes Bile Reflux?

Bile reflux usually follows something that bypasses or weakens the stomach's outlet valve, blocks or narrows it, or slows digestion so that bile lingers where it can flow back [1, 3].

1. Stomach surgery

Mayo Clinic notes that most bile reflux follows stomach surgery, including total or partial gastrectomy and gastric bypass for weight loss [3], operations that can change or bypass the pyloric valve [1].

2. Gallbladder removal

People who have had their gallbladder removed have significantly more bile reflux than people who have not, according to Mayo Clinic [3], and Cleveland Clinic lists gallbladder removal as a risk factor [1].

3. Peptic ulcers and slow emptying

A peptic ulcer, or the scar tissue it leaves, can block or narrow the pyloric valve [1]; food then stagnates in the stomach, pressure builds, and bile and stomach acid can back up into the esophagus [3]. Conditions that slow digestion can do something similar, causing what Cleveland Clinic describes as a kind of traffic jam that exposes the stomach and esophagus to bile [1].

Why Do Some People Get Bile Reflux After Gallbladder Removal?

The reason is not fully settled. Without a gallbladder, bile no longer waits in storage between meals and instead flows into the intestine around the clock [10], and in the same people studied before and after surgery, the concentration of bile acids in the duodenum during fasting roughly tripled [11]. More bile in the duodenum between meals is a plausible reason for more backward flow, although studies have not shown it to be the main cause.

How often it happens depends heavily on how it is measured. In one small endoscopy study of 50 people before and after the operation, signs of bile reflux into the stomach rose from 48 to 78 percent two months after surgery [12], while studies that measured reflux with scans or probes have disagreed: some found an increase [13] and others no change [14, 15]. Bile found on a test is also not the same as bile reflux that causes symptoms, and published figures vary widely with the test used.

Many people report that it began in the first weeks after surgery, often as nausea or bile coming up on an empty stomach, and that small, regular meals helped. Others first notice it years later. Reflux esophagitis, inflammation of the esophagus from reflux, is one of the recognized causes of ongoing symptoms after gallbladder removal [16], which our guide to post-cholecystectomy syndrome explains. Burping with a bitter taste is covered in our article on gas after gallbladder removal, and a swollen, full belly in our guide to bloating after gallbladder surgery.

How Is Bile Reflux Diagnosed?

Bile reflux is diagnosed with tests, because symptoms alone cannot confirm it, and even with tests it can be difficult to pin down [4, 17]. Cleveland Clinic names the main options [1]:

• Upper endoscopy, a thin camera passed into the esophagus and stomach to look for inflammation and bile, with small tissue samples taken if needed [17].
• Esophageal impedance testing, which detects reflux whether or not it is acidic [17].
• Bilitec monitoring, a probe that detects bilirubin, the pigment in bile, as a marker of bile reflux [9].
• A HIDA scan, an imaging test that follows a tracer through the bile system and can show it passing back into the stomach [13].

What can be mistaken for bile reflux?

Several common conditions cause similar upper abdominal pain, burning, nausea or fullness. Acid reflux is the most obvious [1], and others include functional dyspepsia, stomach irritation from medicines such as NSAIDs, peptic ulcers and H. pylori infection [18]. After gallbladder removal, a stone in the bile duct can also cause upper abdominal pain and nausea [19].

Is Bile Reflux Dangerous?

Bile reflux itself is not considered dangerous, but untreated, it can damage the lining of the stomach and esophagus over time [1]. Cleveland Clinic notes that chronic inflammation from bile reflux can change the cells of the lining and lead to ulcers and, rarely, cancer [1]. Mayo Clinic notes that bile reflux gastritis has been linked to stomach cancer, and that bile and acid reflux together raise the risk of Barrett's esophagus and esophageal cancer [3].

The complication most often discussed is Barrett's esophagus, in which the lining of the lower esophagus changes to tissue more like the lining of the intestine. People with Barrett's esophagus have a higher risk of esophageal adenocarcinoma, a type of cancer, but most of them never develop it [20]. These risks are a reason to have persistent symptoms checked and treated, not a reason for alarm.

How Do You Get Rid of Bile Reflux?

Diet and lifestyle changes alone do not completely relieve bile reflux [3], so treatment often combines them with prescription medicine and, rarely, surgery.

1. Medicines your doctor may prescribe

No drug in routine use specifically targets bile [4], so doctors use medicines approved for other conditions; apart from acid-reducing medicines prescribed for GERD, that is off-label use. Cleveland Clinic and Mayo Clinic name several [1, 17], and Mayo notes there is little evidence on how well bile reflux treatments work [17].

• PPIs ease symptoms by blocking stomach acid, which helps when acid reflux is part of the picture [17].
• Sucralfate, approved for the short-term treatment of duodenal ulcers, forms a protective layer over an ulcer; constipation is its most frequent side effect [21].
• Baclofen, a muscle relaxant approved for spasticity, reduces how often the lower esophageal sphincter relaxes, and it eased bile reflux and symptoms in a small, uncontrolled study of people still symptomatic on PPIs [7]; drowsiness, dizziness and weakness are common side effects [22].
• Bile acid binders such as cholestyramine are approved for high cholesterol [23]. An older randomized trial in 16 people with bile reflux gastritis after stomach surgery found cholestyramine eased symptoms no better than placebo [24], and binders reduce the absorption of other drugs, which are taken at least 1 hour before or 4 to 6 hours after a dose [25].
• Prokinetics, medicines that help the stomach empty, are sometimes added [4].

2. Surgery in severe cases

Mayo Clinic suggests surgery when medicines fail to ease severe symptoms or there are precancerous changes [17]. For reflux into the esophagus, fundoplication wraps the top of the stomach around the lower esophagus to strengthen the valve, though there is little evidence on how well it works for bile reflux [17]. Diversion surgery creates a new connection farther down the small intestine so that bile drains away from the stomach [17].

3. Bile reflux treatment at home

Bile reflux itself seems unrelated to lifestyle, but because many people have acid reflux too, general reflux measures may ease symptoms [17]:

• Eat smaller, more frequent meals, and wait 2 to 3 hours after eating before lying down [17].
• Raise the head of your bed by 6 to 8 inches with blocks under the bed's legs or a foam wedge, rather than extra pillows [17].
• Lose excess weight if you are carrying it [1, 17].
• Limit alcohol, stop smoking and cut back on fatty foods and anything you notice sets off symptoms [17].

Of these, raising the head of the bed and losing weight have the best evidence: a systematic review of lifestyle measures for GERD found both effective, while it found no evidence that stopping smoking, cutting alcohol or changing diet improved GERD [26]. Psyllium is popular online for bile reflux after gallbladder removal, but we found no trial testing it, and fiber is best added slowly [27].

When Should You See a Doctor About Bile Reflux?

See a doctor if you have reflux symptoms often or are losing weight without trying [3], and say so if heartburn medicine has not helped, because bile reflux needs different treatment [1]. Get medical care promptly if you have [18, 28]:

• pain in the chest, jaw, neck or arm, or shortness of breath
• trouble swallowing, or pain when you swallow
• frequent vomiting, or vomit that contains blood or looks like coffee grounds
• black, tarlike stools
• severe, constant abdominal pain
• weight loss you cannot explain, or yellowing of the skin or eyes

In Summary: Bile Reflux

Bile reflux, bile flowing backward into the stomach and sometimes the esophagus, often comes with acid reflux, and symptoms alone cannot reliably tell the two apart. Stomach surgery is the commonest cause, and gallbladder removal, ulcers and slow stomach emptying raise the risk.

Diagnosis rests on endoscopy and reflux testing, and treatment combines reflux habits with prescription medicines, most of them off-label for bile reflux, and, in severe cases, surgery. Heaviness after richer meals is a separate matter from reflux, and for that, Dr.Primal's TUDCA, a hydrophilic, or water-loving, bile acid that occurs naturally in small amounts in human bile [29], is used to support healthy bile flow and fat digestion. If you want a starting point, our short digestion quiz is a quick way to put your digestion symptoms and habits in order.

This article is for general education and is not a substitute for advice from your doctor. TUDCA is sold as a dietary supplement. These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease.