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Vera918
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Quote Vera918 Replybullet Topic: Gallbladder removal and reflux
    Posted: 19 Apr 2018 at 6:03pm
I was wondering if anyone else has had their gallbladder removed and if they noticed a increase in bile reflux after surgery. I never had any symptoms of reflux until after my gallbladder removal which prompted my endoscopy that diagnosed my Barrett’s. And it was specifically bile reflux. My understanding is that PPI don’t do much for bile like they do acid. I have also been on PPI protonix now for 1.5 weeks 40mg twice daily and still burp after eating or drinking- even water. Is this a sign it may not be working? Anyone with similar issues?
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chrisrob
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Quote chrisrob Replybullet Posted: 19 Apr 2018 at 10:11pm
Hi Vera,

I had my gallbladder out some years ago, a few months after my origin fundoplication. (My blog of that event may be read here.)

For your Barrett's to form, you will have been refluxing bile along with the acid, as explained here.
PPIs reduce the acid but not the bile - though without the acid, the bile is no more dangerous than other refluxate (eg pain water).

You most probably did have acid reflux prior to your cholecystectomy but were unaware of it (40% of acid refluxers claim not to experience the expected symptoms.

Burping is good. Transient Lower Oesophageal Sphincter Relaxation is the natural way to relieve pressure in the stomach and remove unwanted gas - which is usually the result of swallowed air (aerophagia), a bi-product of chemical interactions of foods and stomach acid or produced by bacteria normally in the digestive tract.
The problem is, uncontrolled burping will reflux stomach contents into the oesophagus.
You may find sipping sparkling water a good way to produce controlled burps when you can ensure your body is uprightto expel the gas from your stomach.

PPIs (like Protonix - pantoprazole) do not reduce burps.
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Vera918
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Quote Vera918 Replybullet Posted: 20 Apr 2018 at 1:14am
Thanks Chris! I had a horrible recovery after my gallbladder surgery- and I was fine through 2 c-sections which is odd that i was that uncomfortable. Mine was not a emergency like yours, but they were hoping to help with the pain in my shoulder blades and I had a few stones. I now believe the pain was actually a symptom of reflux - and maybe the only one I was having.
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Vera918
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Quote Vera918 Replybullet Posted: 21 Apr 2018 at 12:12pm
So I am waking up with the taste of bile in my mouth, but am experiencing no discomfort and taking my PPIs. I read somewhere that bile reflux can cause Barrett’s to progress even in the absence of acid. Should I bring this up to my doctor. I know you said that is not any different than refluxing plain water without the acid, but I am wondering if it still causing damage. I feel as though my reflux has gotten worse since starting the PPIs and I do now sleep with the head of my bed elevated, no eating 3-4 hrs before bed and am careful about activity after eating. Is there anything else that I can do to prevent the actual reflux? Would I be a good candidate for surgery?
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chrisrob
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Quote chrisrob Replybullet Posted: 21 Apr 2018 at 12:34pm
Bile has been shown to have a role in the development of Barrett's - but only when acidic.

This paper published in 2013 in the Journal of Gastrointestinal Surgery, concluded: "Results suggest that bile at low pH [i.e. acidic], but not bile or low pH alone, promotes loss of differentiation status of stratified squamous esophageal epithelium in vitro, possibly by initiating a mucosal repair response through epidermal growth factor activation."
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Vera918
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Quote Vera918 Replybullet Posted: 21 Apr 2018 at 2:41pm
http://www.jnmjournal.org/journal/view.html?uid=46&vmd=Full

what are your thoughts on this journal? you seem to be very aware and I just want to make sure that I am correctly interpreting what I am reading. Thanks Chris!
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chrisrob
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Quote chrisrob Replybullet Posted: 21 Apr 2018 at 3:35pm
The article reports a valid piece of research but looking at "bile acid" ie bile that is acidic because of the stomach acids rather than neutral bile. Most researchers have not examined bile alone but in combination with the stomach acid in the form it is usually found to be refluxing.

The term "bile reflux" can be misleading. It is actually reflux through the pyloric sphincter from the duodenum into the stomach rather than gastro-oesophageal reflux.

Bile in the oesophagus is not usually found to be non-acidic because it is usually only permitted into the stomach to help break up foods when acid alone hasn't helped and thence mixes with acid before it can reflux into the oesophagus.
The process of bile reflux was first described by William Beaumont (called the father of gastroenterology) in a fascinating book "Experiments and Observations on the Gastric Juice, and the Physiology of Digestion" in 1833 - still essential reading for anyone studying digestive disorders. - "I have observed that when the use of fat or oily food has been persevered in for some time, there is generally the presence of bile in the gastric fluids.”

This does, however, raise the possibility that in the absence of acid, some foods may reside in the stomach longer and trigger a bile reflux (duodenum to stomach) response.

Bile is like washing up liquid: it is not caustic by itself but forms molecular bonds between acids and fats. So by reducing the acid, the bile is really fairly innocuous.

There are numerous studies that show acidic bile is a main causative agent for the development of Barrett's, which is why it's necessary to take acid suppressants.

(You may also see referenced "Bile salts" or even "bile acid salts" which would make any chemist cringe. Salts are neutral - the result of a chemical reaction between an acid and an alkaline.)


Returning to your original question, on checking through the research archive, I did happen across this research in the Jurnal of the American College of Surgeons March 2017: Gastroesophageal Mucosal Injury after Cholecystectomy: An Indication for Surveillance? finding "Duodeno-gastric bile reflux was more common in patients with gallstones than in controls, and its incidence doubled after cholecystectomy".
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Vera918
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Quote Vera918 Replybullet Posted: 21 Apr 2018 at 4:26pm
thank you for your response. I am formulating a list of questions to take with me on my second opinion appt. next week at the Barretts Institute at the cleveland clinic. I ask all these questions because I am a nurse, and never having experience much acid reflux in my life until after my gallbladder surgery is perplexing to me. And two weeks post I also had a few instances of vomiting just bile from my stomach and had burning/sore pain in my stomach since surgery. I was 144lb at surgery 4 months and and now weigh 124. that is dramatic weightloss even with diet control. I want to make sure I address it when speaking to my physician because i do not want my Barretts to progress due to bile reflux that is not being controlled. I am only 31 and do not want to die because of this condition. it is a debilitating feeling knowing this is happening in your body and nothing is working to control it. Thank you for all of your help Chris, I really do appreciate it.
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