What is the medical management of biliary gastritis?

Medical Management of Biliary Gastritis

Medical management of biliary gastritis is largely ineffective, and surgical diversion of bile away from the gastric mucosa via Roux-en-Y procedure remains the definitive treatment for persistent symptomatic cases. 1, 2

Initial Conservative Approach

Bile Acid Sequestrants

• Cholestyramine has been studied but shows no significant benefit for biliary reflux gastritis symptoms including abdominal pain, nausea, vomiting, or bitter taste 3
• Despite cholestyramine's ability to bind 97-100% of bile acids in vitro at gastric pH levels, clinical trials demonstrate no improvement over placebo in symptom frequency 3, 4
• The combination of cholestyramine with alginates (intended to prolong gastric retention) similarly shows no statistical difference compared to placebo for symptoms, endoscopic findings, or histological improvement 5

Proton Pump Inhibitors

• PPIs may be considered for symptomatic management, though evidence specific to biliary gastritis is limited 6
• Long-term PPI use (>3 years) carries risks including cyanocobalamin deficiency, hypomagnesemia, fundic gland polyps, and increased risk of Clostridioides difficile infection 6
• Use the shortest duration appropriate to symptoms, typically not exceeding one year without reassessment 6

Prokinetic Agents

• Drugs promoting gastric motility have shown disappointing results in clinical practice 1
• No specific evidence supports their routine use in biliary gastritis management 1

Dietary Modifications

• Diet and antacids frequently aggravate symptoms rather than improve them in biliary reflux gastritis 1
• Avoid recommending dietary restrictions or ad libitum antacid use as primary therapy 3

When Medical Management Fails

Indications for Surgical Referral

• Persistent symptoms despite medical therapy warrant surgical consultation 1, 2
• Typical symptoms requiring intervention include epigastric pain, bilious vomiting, nausea, and weight loss 1, 2
• Endoscopic confirmation of bile reflux with documented gastritis supports the diagnosis, though these findings are not specific 1

Surgical Options

• Roux-en-Y diversion is the treatment of choice for patients with persistent symptoms after failed medical management 1
• For primary bile reflux gastritis (without previous gastric surgery, often associated with prior cholecystectomy), Roux-en-Y choledochojejunostomy without gastric resection achieves complete symptom relief in 87% of patients 2
• Post-operative outcomes show pain relief in 85% of patients undergoing diversionary procedures 1

Important Caveats

• No current medical therapy cures biliary reflux gastritis—medications may only alter symptoms temporarily 1
• Delayed gastric emptying is a common complication after Roux-en-Y procedures, though modified techniques can reduce this incidence 1
• The Roux-en-Y procedure itself can result in disabling stasis syndrome in some patients 2