Reflux – Acid or Bile? Know the difference

If you’ve ever suffered through a bout of severe vomiting, you also may have experienced the uncomfortable occurrence of regurgitating a bitter, greenish-yellow fluid. That fluid is bile, a substance produced by the liver and stored in the gallbladder that aids in the digestion of fats.

If you’re suffering from chronic heartburn or have been diagnosed with GERD that is not responding to treatment, bile reflux may be the source of your problem.

As discussed in a prior blog post, GERD is a digestive disorder that affects the lower esophageal sphincter (LES), the muscle that connects the esophagus with the stomach. When functioning properly, the LES opens briefly when you swallow food and quickly closes after allowing food to pass from the esophagus to the stomach. In GERD, the LES malfunctions and allows food and stomach acid to flow back (reflux) into the esophagus.

Bile reflux may occur in conjunction with GERD or may be misdiagnosed as GERD because the symptoms of the two conditions are very similar. Only a physician can tell the difference, and patients should see a gastroenterologist for proper diagnosis. Symptoms of bile reflux typically include one or more of the following:

  • Chronic heartburn – burning sensation in your chest that occurs more than two times per week or persists over a long period of time
  • Upper abdominal pain – burning or gnawing pain in the stomach that may be severe
  • Nausea – feeling the need to vomit
  • Vomiting greenish-yellow fluid (bile)
  • Cough or hoarseness
  • Unintentional weight loss


Like GERD, identifying and treating bile reflux is important. When left untreated it can result in serious, sometimes life-threatening problems, such as esophageal ulcers that bleed and Barrett’s esophagus, a condition in which the cells in the lining of the esophagus transform into tissue similar to the type that lines the stomach. It occurs when the esophagus tries to protect itself from erosion caused by chronic reflux and is a possible precursor to esophageal cancer.

When should I consider the possibility of bile reflux?

If you are undergoing treatment for GERD but are not experiencing complete relief of your symptoms, it is time to check with your physician to find out if bile reflux is the culprit.

Unlike acid reflux, bile reflux typically does not respond to such lifestyle changes as diet, weight loss, smoking cessation and reduced alcohol consumption. Nor is it resolved by medications designed to reduce acid production (Tagamet and Zantac) or proton pump inhibitors (Prevacid and Prilosec) to block acid production.

If you have both acid and bile reflux, lifestyle changes and medications will provide partial but not complete relief of your symptoms.

What causes bile reflux?

Bile reflux is common in individuals who have had surgery to remove their gallbladder or those who have undergone gastric surgery, including a total or partial removal of the stomach (gastrectomy) or gastric bypass surgery for weight loss. It also is common in patients with peptic ulcers.

How is bile reflux diagnosed?

Because the symptoms of acid reflux and bile reflux are so similar, it is impossible to make a diagnosis of bile reflux based on symptoms alone. Common tests include an endoscopy, where a thin, flexible tube with a camera is passed down your throat; a test to check for acid in the esophagus; and/or tests to determine if gas or liquids are backing up into the esophagus.

The most important thing to remember is this: If you are suffering from chronic heartburn or other symptoms listed in the post, it is time to see your physician for a proper diagnosis and treatment plan.