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Re: Difference between acid and bile reflux

From: Stuart Shipko, M.D.
Date: 06/19/01
Time: 19:45:07


Hi cheryl: Bile is used to emulsify fats for absorption in the small intestine. The primary regulator of bile flow is the hormone/neurotransmittor cholecystokinin (CCK).

Bile is pretty harmless when it is doing its job on fat absorption in the small intestine. Animal studies have shown that after inescapable stress induced analgesia (opiate mediated) that CCK is released -- presumably as an opiate antagonist. This CCK stimulates bile to flow into the duodenum in the absence of food. This is a stress response common to all but is much more common in people with panic disorder. For people, most of this bile release goes on during sleep -- probably the only time that inescapable stress is shut down (at least in Los Angeles).

Depending on the angle that the sphincter of oddi enters the duodenum and depending on the tension in the sphincter of oddi bile can flow into the intestine downstream in which case symptoms similar to irritable bowel syndrome develops or with an uphill angle or a tight valve (that sprays bile in a wide area like a garden hose nozzle) it will enter the stomach.

The stomach is acidic and the alkaline bile is a sticky caustic substance that is highly irritating. The alkalinity causes the stomach to secrete more acid and CCK has gastrin like activity that causes direct stimulation of acid secretion. When the stomach is all full of acid it tends to reflux into the esophagus. Bile itself is far less likely to make it to the esophagus since it is sticky and sort of oozes into the pylorus.

In stress related reflux that tends to occur at night, unassociated with a particular food ingestion, our data suggested that it was CCK mediated. We approached treatment in two ways. First, we found on gastric pH testing that Xanax (alprazolam) at a dose of 0.5 mg before sleep would block bile reflux -- and CCK -- and thereby reduce esophageal reflux. We also found that Carafate would both coat erosions and abrasions in the esophagus and stomach as well as to bind bile and render it less caustic. This has been an enormously successful treatment for reflux which is stress induced.

Xanax may block CCK and clearly is a major treatment for some types of acid reflux that is secondary to bile reflux, but it is highly dependency forming and it is suggested that it be used at the 0.5 mg dose before sleep only for a period of no more than one month to avoid dependency.

Carafate is another very helpful medication for both primary acid reflux and especially acid reflux secondary to bile release.

The proton pump inhibitors (PPIs) can be added to the above for even faster relief and healing although I have observed a pretty significant 'acid rebound' when people stop PPIs and again the best way to avoid PPI dependency is to use it short term.

Stuart Shipko, M.D. Pasadena, CA shipko@ix.netcom.com

Last changed: January 11, 2008