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Oesophageal Patients Association
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Acid reflux or bile? Which?

My query follows on from Alan's answer to Griff. Is it possible to tell if you have acid reflux, or bile, please and is Zantac the same "raft" type of medication as gaviscon? I ended up on 2 lanzaprole a day, 3 domperidone and 2 Zantac and had bad tummy pains. I went down to two halves per day of lanzaprole the last 2 days and nothing else as I felt so rotten. There has been an improvement though still some discomfort but on the whole, much better. Is it only trial and error or is there any other way of getting a better idea of what is causing what in there:-)


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An interesting question. Bile is produced in the liver, stored in the gall bladder and injected into the duodenum for digestion of fats.

Acid is produced in the lining of the stomach.

Bile may reflux via the pyloric sphincter into the stomach. Bile and acid can reflux through the lower oesophageal sphincter into the oesophagus.

We may feel the acid burning and damaging the lining though it may be the bile that actually causes changes to the cells.(http://www.urmc.rochester.edu/news/story/index.cfm?id=3476 ).

Lifestyle changes can help us manage reflux - imagine the stomach like an open polythene bag half full of liquid you don't want to spill: keep it upright, don't overfill it and don't squash it.

Medication can neutralise or inhibit production of acid but we cannot control bile production this way.

Acid can be managed in 4 basic ways:

Antacids (like rennie, Tums) neutralise the acid. They act immediately but are not long lasting.

Alginates (like Gaviscon) float on top of stomach acid like oil on water to dmap down splashing.

Zantac (ranitidine) is a histamine receptor antagonist (H2RA). It works by disrupting the signals to the acid producing pumps in the stomach.

Lansoprazole is a proton pump inhibitor (PPI) that works by effectively destroying some of the acid pumps.

Domperidone is an anti-emetic / prokinetic drug to help peristalsis (the muscular contractions that help propel the food through the digestive canal.

Unfortunately most drugs have side effects. PPIs (and to a lesser extent H2RAs), by reducing the stomach acid mean essential minerals may not get dissolved out of food sufficiently. And the acid is also required to destroy bad bacteria in the gut.

So, if taking acid suppressant drugs, we have to be careful what we eat as we are more likely to be prone to disorders of the bowel. These may cause the tummy pains you describe.

It is a question of trial and error getting the medication (and dosage) right. But the side effects of taking the medication are preferable to the possible consequences of not taking it.


What about Ezomeprazole? I take 1 40mg twice a day, metoclopremide 1 three times a day for my stomach acid and nausea and i take 2 15mg four times a day of codeine to harden my stools. How does Ezomeprazole work as a ppi?


Thankyou for that explanation. iIs there anyway to know if one is producing bile or acid tho? I may have got this wrong but if we need acid in our gut to break down and process the food, is there a danger that lack of acid from taking so many antacids can interfere with the food being digested properly? If it can, can this cause problems with the undigested food being left in the gut and possibly fermenting? At the risk out sounding dense, would this itself cause problems, bloating, pain, wind etc? Do either off these scenarios mean we need to adjust our diet re acid or alkilie foods/drinks in order not to cause damage to the gut. I have a 3 week wait here to see a GP so thanks for anyone's help.



The acidity of your stomach can be measured using 24hr pH manometry or 48hr Bravo test. I am not sure about measuring bile production.

Most digestion takes place in the intestines and requires digestive enzymes. Stomach acid, although initiating dissolving minerals from food, is not an essential element in the absorption of nutrients in the gut.


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I have to take Creon 40000 3 times a day to help me to digest my food and i don't know but i sometimes produce too much acid that refluxes up into my mouth burning it. How can this be if i am taking Ezomeprazole?


Good questions!

Have a look at the notes from the talks given by Frances Hughes and Robert Mason on our OPA website for a starter. opa.org.uk/regional-shop/lo...

I think that the route for the bile to pass from liver/gall bladder might change according to how much plumbing has been done and where your joins are for your individual surgery. So some operations will have more issues with bile than others.

My own experience is that stomach acid tastes bad, but bile is really foul, but that is probably not so helpful as it should be! I will ask for some advice and come back to you.

There are medications like cholestyramine (questran) and sucralfate that might be able to help with bile.

It sounds like a review of your medication would be a good idea, perhaps with some help from the specialist nurses or even a gastroenterologist.

Lack of stomach acid can potentially make your stomach more susceptible to infection. The whole issue is an after-effect of surgery ie that acid reflux can be a problem, leading to taking PPIs which reduce stomach acid, which in turn, over some years, make the body less able to process things like calcium and therefore affects susceptibility for osteoporosis. So things all affect one another, but having had the major change, the side effects can usually be managed.

Undigested food lying in the stomach is not a good thing, but the usual problem is whether things clear through the pylorus sphincter or not. Once through that point, it is a general issue of motility. The vagus nerve has been cut so the steady control of food passing through can tend to go haywire. The usual approach for this side of things is for various medication options.

Digestion takes place over a number of hours. The first stage in the stomach reservoir with plenty of acid about will be very much shorter, but the process continues as food progresses down your intestines. You system may not therefore be so efficient at absorbing nutrition or medication.

I do not think that food normally damages the gut as such. Our stomach lining is designed to cope with acid (but our oesophagus isn't) But some food may be higher in, say, refined sugar, and that may give you problems.

Bloating and diarrhoea occur because the colon cannot cope with the rapid fluctuations. Sometimes it is an imbalance between water and food.

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I will let you know when I get a better answer about a test for acid or bile, but I have just remembered that if you have been on a PPI (like lansoprazole) for a period, and then leave it off, you may well then get a 'bounce' for a couple of weeks where your system creates more acid because of the change of chemicals. So having something like gaviscon can be a really good thing to have on a temporary basis whilst the effects of stopping / reducing other medication is taking place.

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Just had an answer from an experienced surgeon who says that it is difficult to tell whether reflux is acid or bile, but that after an oesophagectomy bile is more likely than acid and that it won't respond well to PPI medication like omeprazole.


Just had an answer from an experienced surgeon who says that it is difficult to tell whether reflux is acid or bile, but that after an oesophagectomy bile is more likely than acid and that it won't respond well to PPI medication like omeprazole.


I am interested in your answers for this question too as i have issues with my pylorus sphincter going into spasms requiring botox, but the medication is getting out of control. This morning after having a milky cup of tes instead of eating breakfast i had issues straight away in that yellow acid tasting liquid came up to the back of my throat and splashed out of my mouth. horrible. This only used to happen at night while i was on a jejunal feed but now it happens whatever i eat or drink. I am due for surgical review on December 17th and am getting worried that none of my meds seem to be working except the metoclopremide for the nausea!!!


I think it would be worth contacting the specialist nurses for advice, and perhaps whether the appointment could be brought forward. If it happens whatever you are trying to eat or drink there is something going awry, and I am sure that they will be able to tackle it.


I find this correspondence regarding acid or bile very interesting. I have been relatively lucky with probably only 6 or 7 major incidents of acid reflux during the night in my 8+ years since op. On each occasion I have felt "rough" for 36 hours afterwards (aggravated by loss of sleep). About 3 months ago I had a further quite vile attack which left me feeling off colour for 3 weeks, much longer than previous bouts, and therefore I wondered if this were bile rather than acid. The concern is that bile is not managed by PPIs and Gaviscon and any information in this arena is helpful.


Hello sportsman

I have wrestled with the conundrum of acid/bile/enzyme for 22 years since my IL and, frankly am none the wiser as no medic seems to know (or care).

To be fair there probably is no practical method of making a determination between the three villains. Yes acid can be titrated and there are many suppressants available but none are desirable for the long-term.This leaves the remaining two.

I am particularly susceptible in the bile department as my gallbladder was removed so I have a continuous stream of un-aged bile entering the duodenum , with consequent reflux and BAD (bile acid diarrhea) .Since starting on Cholestyramine (Questran) I am much improved.

I have never discovered anything in connection with enzymes .Some medical opinion believes that these are more irritant and injurious that either acid or bile.

The only comfort I can offer is lifestyle change -- what you eat , when you eat and, crucially raising the head of your bed.

Never forget that reflux kills more of us post-op than any other single cause; it is so easy to inhale and induce pneumonia.

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