Speaking of Bile: We Should Consider It More Often

Yesterday I wrote about Sphincter of Oddi dysfunction, SOD, a problem where bile accumulates temporarily in the common bile duct.

Burt’s case reminded me of how often I’ve hit the nail on the head suspecting a bile problem to be the cause of a patient’s symptoms.

We certainly have an epidemic of gastroesophageal reflux, in part related to our dietary habits and obesity. So many fast foods can aggravate it, like pizza with red sauce, sweetened and carbonated beverages. Eating late at night and going to bed on a full stomach can also trigger reflux. A big belly, whether from pregnancy or obesity, is also a major trigger.

We have developed more and more acid blockers, yet I see more and more people with reflux symptoms not controlled by these fancy drugs. Surgeons seem to be looking for even small hiatal hernias to operate, and I see many patients who don’t feel much better after their Nissen fundoplications.

So consider this: Endoscopies often show bile reflux. Bile is alkaline, but locally irritating just the way acid is. If we suppress production of stomach acid, is unopposed alkaline bile then more important than if it is present in the stomach along with stomach acid – in a way neutralizing each other? I don’t know, but I wonder.

Following up on my recent case of giardia in the stomach of a patient with stubborn reflux symptoms (skip the inserted post if you read and remember it), this is what happened after the antiparasitic treatment:

When I Escalated His GERD Treatment, My Patient Got Worse. Now I Know Why

Pierre Patenaud was heartburn free when I saw him in followup. Killing the giardia seemed to have done that. But he had developed another problem: Yellow, loose stools that caused him anal pain. He seemed like he had a case of post cholecystectomy bilious diarrhea, except he didn’t just have a cholecystectomy. I prescribed my usual treatment, colestipol. One tablet per day took care of his problem.

My second quiet consideration is: If you bind the bile with colestipol (wherever the two might meet, in the stomach, duodenum, jejunum, ileum or colon), can you control bile reflux, bile gastritis and bilious diarrhea as well as what Pierre called his “burning butt”?

Before statins became available, we used colestipol pills or powder to lower serum cholesterol; by binding to our bile, colestipol prevents reabsorption of cholesterol, a major component of bile, thereby lowering serum cholesterol. So there is plenty of experience giving it to patients even if they don’t have post cholecystectomy diarrhea, its major remaining indication.

I will not hesitate trying it in people with treatment resistant heartburn. I will refer people for endoscopy, but even if there is no bile reflux during a procedure done in the morning, fasting, how do we know it doesn’t happen after pizza and a six pack shortly before bed?

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.


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