Seeing yellow-green bile in the stomach during a gastroscopy can show that bile-containing fluid from the duodenum has flowed back into the stomach. This is called duodenogastric reflux or bile reflux.
If this backflow is accompanied by irritation and damage to the stomach lining, phrases such as bile reflux gastritis, alkaline reflux gastritis or reactive gastropathy may be used.
Seeing bile in the stomach does not mean cancer.
Where is bile normally?
Bile is produced in the liver, stored in the gallbladder and emptied into the duodenum after meals. The normal flow runs roughly:
Liver → bile ducts → duodenum
The pylorus, the region between the stomach and the duodenum, helps limit the backflow of duodenal contents into the stomach.
When bile flows back from the duodenum into the stomach, duodenogastric reflux occurs in the direction duodenum → pylorus → stomach.
Does seeing bile at endoscopy always mean disease?
No. This is an important point.
Seeing some bile in the stomach during a gastroscopy does not on its own make a diagnosis of alkaline reflux gastritis. Retching during the procedure, or duodenal contents temporarily coming back into the stomach, can also produce bile.
So bile in the stomach + changes in the lining + the patient’s symptoms + biopsy where needed all have to be weighed together.
How does the stomach look in alkaline reflux gastritis?
At endoscopy there may be a pool of yellow-green bile in the stomach, redness and swelling of the lining, a lining that damages easily, and erosions.
On biopsy, changes consistent with reactive gastropathy may be found.
What causes it?
Bile reflux can be more marked particularly after stomach operations, in situations where the function of the pylorus is disturbed, and in disorders of stomach and duodenal motility.
But it can also be seen in people who have never had a stomach operation.
What symptoms can it cause?
Some people have no symptoms at all. Others may have pain or burning in the upper abdomen, nausea, vomiting bile, indigestion, bloating and discomfort after meals.
These symptoms are not specific to bile reflux; similar complaints can be seen in many conditions, including gastritis, functional dyspepsia and acid reflux.
Can bile reach the oesophagus too?
Yes. Duodenal contents can reach the stomach first and then pass the gastro-oesophageal junction into the oesophagus.
But “acid reflux” and “bile reflux” as patients use the terms in everyday speech are not the same thing. In some patients both can be present together.
Is it the same as H. pylori?
No.
H. pylori gastritis is due to a bacterium; bile reflux gastritis is related to chemical/reactive damage to the lining.
But both can be present in the same patient. H. pylori is investigated separately where needed.
Is a biopsy needed?
A biopsy does not have to be taken from every patient in whom bile is seen in the stomach.
But a biopsy may be taken where there is an appearance of gastritis or where another condition of the lining needs assessing. Pathology can help assess changes such as reactive gastropathy, H. pylori, atrophy and intestinal metaplasia.
A biopsy being taken does not mean there is cancer.
How is it treated?
Treatment is determined according to the patient and the underlying cause.
Treating bile reflux can be more difficult than classic acid reflux. Adjusting meals, weight control, stopping smoking and not eating close to bedtime can help.
Depending on the patient’s situation, the doctor may consider acid-suppressing medicines, treatments that protect the lining, or medicines aimed at reducing the effect of bile.
But giving everyone the same medication simply because “bile was seen in the stomach” at endoscopy is not right.
Does it turn into cancer?
Alkaline reflux gastritis is not cancer.
Although the relationship between long-standing bile reflux and chronic changes in the stomach lining has been studied, seeing bile once at endoscopy does not mean “cancer will develop”.
When assessing the risk of cancer, factors such as any atrophic gastritis, intestinal metaplasia, dysplasia, H. pylori and family history are considered separately.
Is a follow-up endoscopy needed?
Repeating an endoscopy routinely simply because bile was seen in the stomach is not needed.
The decision about follow-up is made according to whether symptoms continue, the degree of endoscopic mucosal damage, biopsy results and the presence of other accompanying conditions.
When should more care be taken?
More detailed assessment is needed if these are present
Difficulty swallowing · persistent vomiting · vomiting blood · black, tarry stools · unexplained anaemia · unintended weight loss.
Remember
- Bile in the stomach Can show that duodenal contents have flowed back into the stomach.
- Seeing bile in the stomach Does not on its own make a diagnosis of gastritis.
- Alkaline reflux gastritis Relates to the chemical/reactive damage bile causes to the stomach lining.
- Bile reflux Is not the same thing as H. pylori gastritis.
- Alkaline reflux gastritis Is not cancer.
- Treatment Is not the same for every patient; it is planned according to symptoms and accompanying findings.
This is not enough to make a diagnosis
If a gastroscopy report says “bile in the stomach”, “duodenogastric reflux” or “alkaline reflux gastritis”, it is not the bile alone that should be looked at but the appearance of the stomach lining, the patient’s symptoms and any biopsy result together.
Sources
- Prof. Ali Tüzün İnce, MD