From the Guidelines
Bile acid reflux symptoms can be effectively managed with a combination of medications and lifestyle modifications, prioritizing ursodeoxycholic acid (300-600mg daily) or bile acid sequestrants like cholestyramine (4g before meals) or colesevelam (625mg tablets, 3-7 tablets daily), along with proton pump inhibitors such as omeprazole (20-40mg daily) for associated acid reflux, as suggested by recent clinical guidelines 1.
Symptoms and Diagnosis
Bile acid reflux symptoms include a persistent bitter or sour taste in the mouth, upper abdominal pain or burning sensation, nausea, vomiting (sometimes with a greenish-yellow fluid), occasional cough or hoarseness, and unintended weight loss. These symptoms occur when bile flows backward from the small intestine into the stomach and sometimes up into the esophagus. The diagnosis of bile acid reflux can be challenging due to its similarity with other conditions, but it is essential to rule out other potential causes of chronic cough, such as gastroesophageal reflux disease (GERD), asthma, and upper airway cough syndrome, as outlined in the clinical profile championed in the 2006 ACCP cough guideline 2.
Treatment and Management
Treatment typically involves medications like ursodeoxycholic acid, which helps neutralize bile acids, or bile acid sequestrants such as cholestyramine or colesevelam. Proton pump inhibitors like omeprazole may help reduce associated acid reflux. Lifestyle modifications are equally important:
- Elevate the head of your bed 6-8 inches
- Avoid lying down within 3 hours after eating
- Maintain a healthy weight
- Eat smaller meals
- Avoid trigger foods (fatty or spicy foods, caffeine, chocolate, mint) These symptoms result from the irritating effect of bile acids on the stomach and esophageal lining, which lacks the protective mechanisms found in the small intestine where bile normally functions to aid digestion of fats.
Clinical Considerations
The relationship between reflux and cough is complex, and the efficacy of proton pump inhibitor (PPI) therapy for resolving GERD symptoms is substantially less than it is for healing esophagitis, and much less for atypical symptoms than it is for heartburn, as noted in the 2016 Chest guideline and expert panel report 2. Therefore, a comprehensive approach to managing bile acid reflux symptoms, considering both medical therapy and lifestyle modifications, is crucial for improving patient outcomes and quality of life.
From the Research
Bile Acid Reflux Symptoms
- Bile acid reflux symptoms include intractable epigastric pain associated with nausea and bilious vomiting, often following gastric surgery 3
- These symptoms are attributed to the reflux of bile and the irritating effects of endogenous bile acids on the gastric remnant 3
- Treatment with ursodeoxycholic acid has been shown to decrease the intensity and frequency of pain and almost abolish nausea and vomiting in patients with symptomatic alkaline reflux gastritis 3
Mechanisms of Action
- Ursodeoxycholic acid increases the proportion of ursodeoxycholic acid in refluxed gastric bile, reducing the pain and frequency of symptoms associated with bile reflux 3
- Ursodeoxycholic acid also exerts anticholestatic, antifibrotic, and antiproliferative effects in primary biliary cirrhosis via mechanisms not yet fully understood 4
- Bile acid sequestrants, such as cholestyramine, can bind to bile acids in the intestine and form an insoluble complex that is excreted in the feces, which may help manage bile acid reflux symptoms 5
Therapeutic Agents
- Ursodeoxycholic acid and bile-acid mimetics, such as obeticholic acid, are therapeutic agents for cholestatic liver diseases, with mechanisms of action that include anti-inflammatory and immunomodulatory properties 6
- Ursodeoxycholic acid has been shown to protect cholangiocytes against hydrophobic bile acid cytotoxicity, stimulate hepatobiliary excretion, and protect hepatocytes against bile acid-induced apoptosis 7