Bile Reflux with intact valve/no GERD?

[juleerudolf]

I am an active, healthy (before this) 41 year old.  The only surgeries I have had have been two C Sections 4.5 & 6.5 years ago.  15 months ago I noticed a strange acid/bitter taste in my mouth.  Prevacid 30 mg was prescribed, the taste disappeared.  6 months later the taste was unresponsive even to 30 mg twice a day.  Gastro Dr. "A" performed an endoscopy/ biopsy for H Pylori (neg), LES and pyloric valve normal, "low to moderate" amt of bile in the duodenum and stomach.  He said, "You are producing a lot of bile," requested a liver panel blood test (normal), and a gb/pancreas sonogram (normal), took me off the Prevacid, and prescribed Carafate 1mg twice a day which did not help, upped it to four times a day which made it worse.  He prescribed Reglan 10 mg 3 times a day for 6 weeks with the Carafate, which was better than Carafate alone and said that I "have a motility problem."  Seems like I had an hour's? worth of relief from "the taste" after meals with Reglan.  At the follow up was taken off Reglan and put on Zelnorm 2 mg but felt worse.  Soon I experienced - extreme/suicidal anxiety - ended up off Zelnorm and on Ativan 0.5 mg to 2 mg for 6 weeks and Celexa 30 mg for three months - having never previously experienced anxiety/depression/mental problems.  Urged by friends, I saw Gasro Dr. "B" who ordered a CT scan of my head (normal), abdomen/pelvis (normal), chest (normal).  A CBC was ordered (normal except glucose of 100), other blood work to test for intestinal parasites, etc. (normal).  A gastric emptying scan showed an emptying half time of 85 to 88 minutes (78 +- 11 minutes is normal).  At the follow up exam he said that I'm not experiencing reflux (bile or otherwise) because (1) the bile can't travel all that way to my mouth (2) low to moderate bile is not abnormal.  After struggling through the affects of getting off Ativan and Celexa, the taste bothered me as much as before (maybe more, since it seems like it had now become chronic and untreatable) so I called Dr. "B" who ordered a manometry test which showed "essentially normal esophageal motility with some decreased amplitude in distal esophagus (normal in prox/mid esoph).  LES pressure 13mmHG, UES 55mmHG, relaxation both normal, amplitude 40mmHG (22-62) nl 50-180."  Had pH monitoring done (twice) sort of on meds DeMeester score was 3.6 at LES and 0.5 at UES, off meds 6.0 at LES and 0.5 at UES (normal).  The reflux occurred daytime only in conjuction with belching which has gone from minimal before four months ago to 75 times a day (during the pH test) maybe a little less now - which I absolutely don't believe is from aerophagia, as I don't do the things that cause it and my anxiety is under control.  Is it possible to have a motility problem with only the (bile?) taste and belching as symptoms?  If I am not experiencing GERD, could I still be refluxing bile?  Could the belching be do to a motility problem vs. aerophagia?  I've never had nausea/bloating/vomiting/heartburn or pain.

[robles]

A related discussion, bile secretion / bitter yellow secretion after meals was started.

[juleerudolf]

Have not had my gb removed.  I did find a study done on people with bile reflux gastritis who had a different type of surgery done than the one that is commonly done.  It involves relocating the bile duct so that it is attached about 40 cm/16 inches further along the intestine so that the bile is "injected" far from the pyloric valve, thus reducing the amount of bile refluxing into the stomach.  The point of doing it this way is to avoid an extremely common side effect of the other type of surgery - gastroparesis.

[princess7780]

Have you had your gallbladder removed?

[dizzy2]

My father had a Jtube placed a month ago.  He is constantly having bile reflux.  It seems that he gets something like the hiccups at first, then his stomach moves about 4 time (4 fast hiccups) then he reluxes.  It is never the formula he is taking, only the bile.  He was told he had a motility problem with his stomach, then when the test was done again he didn't.  They want to give him a Hickman catheter.  From what I understand, this has a high risk of infection?  Doctors do not know what else to do.  Afraid to feed him through the tube, because he also has a swallowing problem and aspirates when he has reflux.  He has a trache with a cuff right now that kind of protects his airway.  Has not been on any food for 3 days now, just IV liquid.  Anyone know about the catheter or any other way to feed my dad.  Anyone ever had an procedures that got rid of the reflux?

[dizzy2]

My father had a Jtube placed a month ago.  He is constantly having bile reflux.  It seems that he gets something like the hiccups at first, then his stomach moves about 4 time (4 fast hiccups) then he reluxes.  It is never the formula he is taking, only the bile.  He was told he had a motility problem with his stomach, then when the test was done again he didn't.  They want to give him a Hickman catheter.  From what I understand, this has a high risk of infection?  Doctors do not know what else to do.  Afraid to feed him through the tube, because he also has a swallowing problem and aspirates when he has reflux.  He has a trache with a cuff right now that kind of protects his airway.  Has not been on any food for 3 days now, just IV liquid.  Anyone know about the catheter or any other way to feed my dad.  Anyone ever had an procedures that got rid of the reflux?

[Kevin Pho, MD]

The diagnosis of bile acid reflux is normally made when there is evidence of inflammation in the stomach (seen on an endoscopy), in the abscence of any other cause (i.e. a normal pH study ruling out GERD).  

A more definitive study would be bile acid analysis in the gastic juice.  

To answer your questions - yes, if you are not experiencing GERD, bile acid reflux is still possible.  

The belching can be either due to a motility problem or aerophagia.  

If bile acid reflux is present, medications like Ursodiol can be helpful.  Surgery however, is the definitive treatment.

You can discuss these options with your personal physician or GI referral.

Followup with your personal physician is essential.

This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.

Kevin, M.D.
Medical Weblog:
kevinmd_b

[yoshi]

just curious,when you are on Reglan,did you notice any undigested particles in your bowel movement??

[juleerudolf]

Yoshi,

No - bm's normal with/without Reglan but more frequent both with Reglan and Zelnorm.  Forgot to include that I've never experienced indigestion and I think that test is 60% emptying vs. 50% - whatever they use for the standard test.

Thanks,

JuLee