Category: Bile Reflux
Cholangitis
May 24, 2026 11:33 am
Cholangitis refers to infection and inflammation of the bile ducts because of obstruction and introduction of bacteria or other pathogens from the GI tract.
The treatment for biliary cholangitis requires intervention, surgical or advanced gastroenterology, and involves
- Hydration with IV fluids,
- Broad coverage with IV antibiotics administration and
- Drainage procedure (ERCP, papillotomy, Stent placement, Cholecystectomy with common duct exploration, and T-tube placement)
These steps are almost all taking place concurrently and urgently. This is not something a patient waits and sees how it goes- it only goes one direction, from bad to worse. This is not to sound alarmist; a correct diagnosis is critical.
Risk factors for cholangitis may include gallstones that travel down the bile duct and cause jaundice, pancreatitis if passed, immunosuppression, malnutrition, and diabetes, to name a few.
If a patient has gallstones in the bile duct less than 2 years after cholecystectomy, it is a Retained Stone(s), meaning there was a small stone that was not in the gallbladder and was not seen on US, intraoperative cholangiogram, or ERCP (if performed before surgery).
If a patient has gallstones in the bile duct more than 2 years after cholecystectomy, they are Primary Biliary Stone(s), meaning the stone(s) formed in the biliary tree after cholecystectomy.
Bile Reflux Gastritis
May 19, 2026 4:13 pm
Hello, it’s best to clarify a few points:
- The difference between prevalence and incidence.
- Incidence means new cases over
- Prevalence refers to existing cases at any time
- The difference between causation, coexistence, and correlation
- Causation refers to a condition causing an effect.
- Coincidence refers to two conditions present together at the same time, with neither causing the other.
- Correlation refers to two conditions that may occur together, with no causation.
- Study size refers to the research data on which the information is based. The larger the population size studied, the better the sample data and the more conclusive the results.
- Confounding factors.
Let’s discuss the publication:
The Prevalence of Bile Reflux Gastritis Following Cholecystectomy: A Meta-Analysis and Systematic Review.
If we read past the title and conclusion, all of the points 1-4 noted above are outlined, addressed, and discussed in the provided publication.
This study is very small and limited. The review article is based on 135 patients from hundreds of articles that they reviewed from multiple sources, between 2000 and 2004.
In the introduction, the authors clearly indicate that the “…loss of storage function…, loss of neuro hormonal responses causing motility changes in the upper GI may lead to duodenogastric reflux…” They further state that “The mechanism leading to bile reflux following cholecystectomy is not fully understood.” The authors state that cholecystectomy may increase the risk of bile reflux gastritis, but other factors, such as H. pylori, diabetes, motility dysfunction, hormonal changes, and the Sphincter of Oddi, may also be risk factors.
There is no causation, only correlation and coexistence. To be clear, bile reflux gastritis is common after cholecystectomy, but not clear whether it is caused by it.
This leads to a discussion of prevalence and incidence. The prevalence of bile reflux gastritis in a support group for the condition is extremely high, but the incidence in the general population is very small. The authors clearly state that the prevalence is nearly 50%.
Patients who develop bile reflux gastritis may have other contributing factors that should be evaluated. There is no clear evidence that cholecystectomy causes bile reflux gastritis, even though there is a higher incidence than in the general population. This distinction suggests that other risk factors may contribute to the onset of bile reflux gastritis, in addition to cholecystectomy.
Sphincter of Oddi Dysfunction
April 26, 2026 8:43 am
Description:
Sphincter of Oddi Dysfunction (SOD) is a clinical syndrome characterized by biliary/ pancreatic pain from abnormal function or obstruction of the.
Diagnostic and classification
- The SOD spectrum includes biliary, pancreatic, or combined sphincter dysfunction, with symptoms driven by dyskinesia or mechanical obstruction. The term SOD encompasses both functional motility disorders (biliary or pancreatic sphincter dysfunction) and mechanical obstructions such as papillary stenosis.
- SOM has been considered the gold standard for diagnosing elevated basal sphincter pressure. It is invasive and carries complications, including pancreatitis. SOM can also not be done in those who have had gastric bypass or duodenal switch operations. Sphincterotomy outcome is not uniform. Consequently, many centers have moved toward empiric endoscopic therapy for appropriately selected patients and toward noninvasive or less invasive diagnostic approaches for others.
Treatment approaches
- Endoscopic biliary sphincterotomy (EST) is the most established nonpharmacologic treatment for biliary SOD, particularly in type I and many type II patients with objective ductal dilation and/or enzyme elevation.
- In type II SOD, outcomes after EST correlate with objective evidence of obstruction or sphincter hypertension on SOM. Empiric sphincterotomy without manometry is controversial.
- Type III SOD has emerged as predominantly functional pain rather than a mechanical obstacle. Alternative management emphasizes risk stratification, noninvasive strategies, and multidisciplinary approaches.
- Medical and non-sphincterotomy options (calcium-channel blockers, nitrates, antidepressants, and lifestyle modifications) have been discussed as potential adjuncts or alternatives.
Summary
- SOD is a multifactorial biliary and pancreatic sphincter disorder with a spectrum from mechanical obstruction to pure dyskinesia. Type I and II retain treatment relevance, particularly EST for biliary obstruction. Type II management requires clear identification of the cause.
- SOM is a diagnostic tool with significant limitations.
- Endoscopic sphincterotomy offers meaningful symptom relief in type I and select type II with objective obstruction. It carries a risk of complications, including pancreatitis; risk mitigation strategies are integral to practice. In type III SOD, sphincterotomy generally has limited benefit, necessitating a move toward noninvasive management and careful patient counseling. Patients post- gastric bypass, or duodenal switch, can not have ERCP or SOM done.
Surgery for Reflux
August 02, 2025 6:58 pm
Surgery for Reflux
Gastroesophageal reflux disease (GERD) is a common gastrointestinal problem in both the general population and post-weight-loss surgical patients.
The general population may have GERD symptoms with weight gain, pregnancy, hiatal hernia, Helicobacter pylori infection, gallstones, ulcers, motility issues of the esophagus or stomach, and other conditions. With proper workup, they all have their specific treatment plans. In a post-weight-loss surgical patient, some of the exact causes may be present in addition to those that may be specifically related to the type of surgery and its unique side effects and complications.
There is a subset of patients with hiatal hernia who should undergo surgical repair, but do not. There has been a series of publications from over 15 years ago that have been embraced by the gastroenterologist who frequently, incorrectly, dismisses Nissen fundoplication as an effective surgical tool for the treatment of GERD and hiatal hernia.
The treatment for GERD with a hiatal hernia, regardless of size, is Nissen Fundoplication and not lifelong use of proton pump inhibitors (omeprazole, pantoprazole) and other classes of medication. It should be noted that these medications were never approved for long-term use and can cause significant metabolic and gastrointestinal side effects.
Recent publications have shown that not only the old data that gastroenterologists frequently rely on was not reliable, but also that surgery is very safe and effective with a very low rate of short and long-term complications.
Three Different Problems: Gastritis, Gastroesophageal Reflux, and Bile reflux Gastritis
June 05, 2025 4:52 am
Gastritis is a general term used for the description of symptoms associated with several very different physical conditions and require different treatments based on their ideology . Gastritis, gastroesophageal reflux, and bile reflux gastritis
Gastritis may be caused by excess acid or bile in the stomach. Some patients may have gastroesophageal reflux due to a hiatal hernia, which needs to be treated surgically with Nissen fundoplication, regardless of the size of the hernia, contrary to what gastroenterologists recommend by prescribing antacids for an extended period. I have seen patients who have had one cm hiatal hernia and have been very symptomatic, and others who have had larger hiatal hernias and have been asymptomatic. Size should not be a determinant of whether the patient has had or will have a hernia repair or not.
Billiary Diversion is the definitive surgical procedure for Bile Reflux Gastritis.
Bile Reflux Gastritis and Cholecystectomy
May 21, 2025 2:41 pm
Bile reflux gastritis is not a the result of the cholecystectomy but may be seen in a subset of patient with other confounding conditions. Bile is produced in the liver and stored in the gallbladder. In response to high fat and protein in the stomach, the gallbladder contracts to ” squeeze” the bile stored in the gallbladder into the small bowel to help absorb the fat and protein.
With the gallbladder removed, the bile produced by the liver cannot be stored and goes directly to the small bowel via the biliary tree.
It is possible and likely that some of the bile will find its way back to the stomach. In some patients, due to compounding circumstances, the bile may collect and cause gastritis. We need to dissect this a little for it to make sense.
- Not every patient after cholecystectomy will have bile in their stomach.
- Not every patient with bile in the stomach has gastritis.
To appreciate this, let’s remember that for bile to get from the small bowel to the stomach, it needs to:
- Go upstream, against the peristalsis of the small bowel, and do not be washed down by the flow of the gastric
- juices coming out of the stomach.
- Go through the pyloric valve.
- If it reaches the stomach, the acid in the stomach does not neutralize it, causing gastritis.
As I’m sure we all appreciate, other contributing factors besides cholecystectomy may cause bile reflux and bile reflux gastritis. This is why it’s also emphasized that bile in the stomach alone does not confirm biliary reflux gastritis. It is also why we always state that bile reflux gastritis is a disease of exclusion, where other conditions such as gastroparesis, acid reflux, and hiatal hernia (regardless of size, as some patients are unfortunately told that since the hernia is small it does not need to be fixed, which is incorrect) must be considered. Further information on Bile Reflux.
Billary Diversion is the only definitive surgical procedure for Bile Reflux Gastritis.
Bile Reflux Gastritis
August 02, 2024 10:53 am
Bile Reflux
Bile Reflux is primarily a diagnosis of exclusion. All other possible causes must be ruled out, and bile reflux gastritis is made with the pertinent symptoms. The reason for this is that there is no primary test that can prove the diagnosis. When it comes to treatment, the surgical option requires preventing the bile from coming back to the stomach. The procedure we have performed routinely for bile reflux gastritis is the duodenal switch (without a reduction in the stomach size). This allows the food to go through an intact stomach and pyloric valve with normal stomach physiology (to prevent dumping syndrome). The bile is diverted through 100 cm of the small bowel as the biliary and alimentary limbs to prevent backflow of bile to the stomach (if it’s made too short). The procedure referenced (https://www.americanjournalofsurgery.com/article/S0002-9610(03)00213-7/abstract) is nearly 20 years old. It is rarely, if at all, performed due to its very complex and relatively high-risk nature. Its primary role for a surgeon is to reconstruct the biliary tract flow. This operation involved transecting the common bile duct and creating a biliary tree to small bowel anastomosis. This is, at times, done when there is injury, obstruction, or a tumor of the bile duct. This anastomosis has its complications, including stricture and sump syndrome. Therefore, hepaticojejunostomy or hepato-duodenostomy anastomosis is reserved for cases with no alternatives.
Gastroesophageal Reflux: Bile Vs. Acid
May 14, 2019 12:52 pm
Gastroesophageal (GE) reflux is the condition when the stomach contents are able to “reflux” back through an incompetent lower esophageal sphincter (LES) into the esophagus.
Gastroesophageal reflux Disease (GERD) is a clinical condition caused by long-standing reflux that results in microscopic and visible changes to the inner lining of the esophagus and esophageal mucosa.
GERD is nondescript as to the cause of the condition. It only states that the stomach contents have been irritating the lining of the esophagus on a chronic basis. This can be caused by an anatomical abnormality of the GE junction (hiatal hernia) or may be related to dysfunction of the LES. Other possible causes of GERD may be infection (H. Pylori), environmental (stress), and dietary (nicotine, alcohol, caffeine, spicy food) in origin.
So far, we have not clarified the chemical nature of the refluxed content.
In Acid Reflux, the relative acid overproduction of acidic secretion and the exposure of the esophageal mucosa need to be addressed. This is accomplished by acid suppression medications, anti-histamine (H2 blockers), and Proton pump inhibitors (PPIs). The physiology and the mechanism involving this condition are well understood. As a surgeon, however, I do see patients who should have had surgical intervention. The initial mode of therapy for a patient with documented acid reflux and or symptomatic hiatal hernia is placing them on medication. These patients are then recommended to have a related upper endoscopy. Patients who do not improve or where deterioration of the esophageal mucosa and the presence of precancerous cells are referred for surgical intervention.
Bile Reflux, contrary to acid reflux, may have tiny, if anything, to do with the LES. The symptoms experienced by the patient may be as after related to the excessive bile in the stomach, which is seen frequently
after cholecystectomy, or in those patients with a dysfunctional gallbladder (low EF on HIDA scan).
The treatment of Bile reflux is Duodenal Switch without the associated sleeve gastrectomy component in addition to repair of hiatal hernia if present. Ann Surg. 2007 Feb; 245(2): 247–253.
Bile Reflux Gastritis
January 10, 2018 1:45 pm
Bile reflux gastritis has been recognized as a significant cause of dyspepsia in a subset of patients. This patient group set does not respond to the standard treatment (not expected to) and some get improvement with the treatment of H.Pylori infection if one is diagnosed at the time of upper endoscopy and biopsy.
Inflammation and Foveolar hyperplasia are some of the findings that can be seen endoscopically. This and other findings have all been documented in the literature. An article published in 2005, reported over 40% incidence of Foveolar hyperplasia in patient with bile relax.
It is been noted that bile causes the thickening of the mucosa lining of the GI track. This is called Foveolar hyperplasia when the mucosa of the stomach is noted to be thicker with more numerous and deeper folds.
The treatment for this is reduction and prevention of bile reflux to the stomach, in some cases this can only achieved by surgical diversion of the bile from the stomach. Additional information on Bile Reflux and the surgical treatment can be found here.
Billroth I & II, SIPS, SADI, Loop
July 27, 2015 1:30 pm
In 1881, Dr. Theodore Billroth performed the first successful gastrectomy for pyloric tumor. He removed the distal part of the stomach and tumor of the pyloric region and reconnected the distal end of the transected stomach directly to the segment of the duodenum. This was later renamed as Billroth I procedure. In Billroth I the anastomosis allows the food pathway to stay in the same directional flow with the exception of pyloric valve having been removed. There is, however, increased incidence of bile reflux with the pyloric value removal.
There are incidences where the resected segment is so large that the proximal stomach and the distal duodenal can not be mobilized and brought close to each other to be able to create the Billroth-I anastomosis. Larger resection, where the Billroth I could not be completed Dr. Billroth in 1885 created a procedure call the Billroth II. The Billroth II was performed when the tumor was very large and the continuity of the GI track was created by a loop gastrojejunostomy. This procedure was named Billroth II.
In the Billroth II the bile flow from the small bowel flows toward the stomach, and this results in a much higher incidence of Bile reflux and its associated complication.
The lesson learned from Billroth I and Billroth II was that bile reflux can be a significant problem when creating the continuity of the proximal GI track with exclusion of the pyloric valve. In Bilroth II, there is the additional burden of the bile flowing toward the stomach unlike the Billroth I.
The SADI or SIPS, Loop procedures that are incorrectly promoted as “duodenal switch” employ a loop anastomosis, which results in a biliary flow toward the post pyloric duodenum significantly increasing the chance and the possible incidence of Bile reflux.
All these unknowns about the SIPS, SADI Loop are yet to be investigated.