Case Reviews
Thoughts on Bile Reflux.
The Heidelberg pH Diagnostic test analyzes the ACID PUMPING cells of the stomach, to determine if there is an abnormally low, or abnormally high, stomach acid pumping issue.
The Heidelberg pH Diagnostic test is highly valuable, particularly because both low and high stomach acid problems have similar symptoms, meaning you could have either problem but the feeling it gives you is identical. Because of this similarity of symptoms, even the most experienced of Clinicians can remain unsure if the true nature of the problem is due to the acid pumping being too rapid, or sluggish, without the Heidelberg pH Diagnostic test.
In traditional medicine, the similarity between low stomach acid (Hypochlorhydria), and high stomach acid (hyperchlorhydria), doesn’t alter the approach to treatment. When a clinician hears the symptoms, (which could be caused by either problem), consideration goes to high stomach acid. They prescribe an acid-suppressing medication to see if it helps. If it does help, they were right. If it doesn’t help, then maybe the medication dose is too low, maybe the medication didn’t work, and another is better, or, maybe - (the last resort) the stomach acid is low.
The issue with this approach is that it’s a round-a-bout way of helping someone who you suspect has a low stomach acid issue. In fact, the last thing you want to do is prescribe an acid-suppressing medication, for a low-acid issue. This is because acid is crucial for digestion. Suppressing an already sluggish acid-pumping output has the potential to make an already compromised digestive tract, MUCH worse, leading to problems with the absorption of nutrients, and bacterial overgrowth of the small bowel (SIBO).
The Heidelberg pH Test can determine if either low stomach acid, or high stomach acid is causing the symptoms, but then there is another additional HUGE advantage to having a Heidelberg pH Test, if you suspect that there is a possibility that your acid pumping is in fact low, not high. Similar to how the symptoms of both high and low stomach acid problems are similar in presentation, the same also goes for the similarities between LOW STOMACH ACID, (Hypochlorhydria), and BILE REFLUX.
Bile is an alkaline agent, that is secreted by the liver, and stored in the gallbladder. Bile enters the small intestine and travels along this region, where it assists in breaking down fats into fatty acids until it gets reabsorbed at the very end of the small intestine and sent back to the liver for recirculation. Bile should not enter the stomach, but when the small intestine has issues, it can. When bile inappropriately backs up through the pylorus, into the stomach - it is called BILE REFLUX.
Thankfully, the Heidelberg pH Test can differentiate between Bile Reflux and Hypochlorhydria. It is incredibly challenging to determine the difference between these two very different medical issues, without this test.
Here is an example of a Heidelberg pH DIagnostic test, with findings that are suggestive of Bile Reflux and Pyloric Insufficiency. The first neutralizing challenge was actually demonstrative of Hyperactive secretion of stomach acid, which is not uncommonly seen with bile reflux cases, however, as soon as reacidification of the forst challenge was complete, the pH baseline started to waver and spontaneously neutralize. Demonstrative of bile reluxing through the pylorus in to the stomach.
Fortunately this patient has an endoscopy the following morning, the findings were confirmed.
Large amounts of bile in the stomach
Comments:
When you search through the medical textbooks on Bile Reflux, you quickly realize that there really isn’t much of a focus on this problem. However, Dr. Farshid Rahbar, MD, and Dr. Michael Erdman, MBBS, have numerous cases of suspected Low Acid secretion, which has been in fact due to bile reflux.
It has been most intriguing to also observe that such patients with bile reflux, usually test positive for SIBO, SIFO, or Parasite infections of the GI Tract. It begs the question, why does bile reflux occur with such issues?
Hypochlorhydria
Background:
A 50-year-old female requested a Heidelberg pH Test to evaluate her stomach acidity.
Medical Issues:
History of H-Pylori gastritis - treated.
Colonic polyps.
Long-standing bloating and gas, after meals, which can make her look 7-8 months pregnant.
A recent endoscopy required multiple biopsies. She had biopsy-related pains lasting 2-3 weeks after the procedure, which is quite unusual.
Symptoms at the time of the Heidelberg pH Diagnostic Test:
Right Upper Quadrant Pains - recent ultrasound of abdomen showed no gallstones, however, it did report dilation of the common bile dict.
Nausea, coming on more than 5 hours after eating, lasting for 3 hours duration,
GERD type symptoms
Her gastroenterologist wanted to trial a PPI for GERD. She was apprehensive to do so before having the test to establish if her stomach acidity.
The Heidelberg pH Test Results:
Comments:
This is Hypochlorhydria. This test starts with a fasting baseline pH of 0.5, the acidic side of normal. The neutralizing challenge did not result in acidification for 51 minutes (slow production). At this juncture, Two 500mg Betaine capsules were administered, 20 minutes later they resulted in reasonable acidification, without any symptom of heartburn.
The betaine test was also used to confirm that the capsule was indeed still in the stomach, and had not migrated into the small bowel.
An interesting case.
Intro:
Case 1 is based on a 30-year-old, chronically ill female, who was experiencing multiple GI and non-GI-related symptoms. A Heidelberg pH test had been requested to establish if she had low stomach acid, (hypochlorhydria) because betaine HCl periodically provided some of her with symptoms with relief.
The GI symptoms:
Starting a decade ago, the symptoms occur daily and have been progressively getting worse. The number of symptoms indicates a lot of dysregulation in the digestive tract. The worst symptoms, are right upper abdominal pain, vomiting, & nausea. The RUQ pain typically comes on unexpectedly, in waves, reaching a severity of 10/10. It wakes her in the night and is particularly bad after eating. She also had been unable to sleep on her right side because of the pain. The vomiting is unpredictable, with episodes lasting for 12 -16 hours at times. The episodes can be triggered by stressful events, anxiety, and lying on the right side. The vomit is usually bile-tinged, and nothing makes it stop. There has also been 40lbs weight loss in the last 2 years.
Past Medical History:
Esophageal Candidiasis - confirmed during endoscopy at the onset of her illness.
Lyme disease - bitten by a tick at the time that symptoms started. Reported a classical bullseye rash. took a prolonged course of oral antibiotics, the Lyme was reported to have been successfully eradicated.
Some other diagnostic testing had been carried out, results are outlined :
Results:
- Abdominal ultrasound: biliary sludge in the gallbladder.
- Blood testing: reasonably high mercury and lead levels.
- Urinary mycotoxins: negative.
- SIBO breath test: negative.
- Comprehensive stool test with parasitology: negative for parasites, negative for small bowel-related bacteria, negative for fungus.
First Impressions:
This is a very complex case. This lady has multiple active GI symptoms, which are affecting the mouth, esophagus, stomach, small bowel, and large bowel - almost her entire digestive tract is affected. It is easy to lose sight of all the symptoms - especially during a Heidelberg pH session, which focuses predominantly on the stomach.
I ask myself… “what is the body’s life purpose, and what is going wrong here?”. I strongly believe that health is centered from the gut - outward. A very simplified answer to the question goes like this… the digestive tract is trying to suck up all the nutrients from the food that we eat, to convert the food into energy, to fuel the brain, and the body, so that its host can live a long and fruitful life, as well as reproduce. The body also has the responsibility to excrete waste products, repair itself, and protect itself from infection, to keep its host thriving.
So what is going wrong here? This person has a very disturbed digestive system, that is mostly centered around the upper GI region (proximal small bowel, stomach, esophagus, mouth), There is a relationship between right upper quadrant pain, nausea, and yellow-tinged vomit (bile). When bile appears in the vomit, as it is supposed to be in the small bowel, it clearly indicates that bile has traveled through the stomach, and esophagus to get there, (bile reflux).
A note on Bile:
Bile is synthesized in the liver, stored in the gallbladder, and is secreted into the small bowel to neutralize acidic content as it passes from the stomach, into the small bowel. The pylorus; the sphincter that separates the small bowel from the stomach, remains closed unless food is exiting the stomach to journey into the small bowel. The normal flow through the pylorus is in a one-way direction, traveling from the stomach toward the small bowel.
The stomach is sack-shaped, with two entry points. The stomach needs to be in an acidic state to carry out crucial responsibilities. When bile inappropriately enters the stomach, it flows through the pylorus in the wrong direction, (pyloric insufficiency). The bile neutralizes the acidic environment of the stomach too soon in the digestion process, the weakened stomach acid prevents the stomach from carrying out vital digestion tasks, which include: killing off bacteria & fungi that are attempting to enter the small bowel from our contaminated mouths/sinuses; breaking down protein; and activating enzymes for digestion.
Impression continued:
The patient has hard signs of Bile reflux. Bile neutralizes acidity. Bile in the stomach neutralizes acid. Weakened stomach acid caused by bile reflux lowers the functionality of the stomach. Low stomach acid can weaken the stomach’s ability to kill off bacteria. Low stomach acid can lead to bacteria overgrowth in the small bowel, and can also potentially contribute to a small bowel fungal overgrowth (SIFO). Because of the bile, the suspicion of a small bowel issue is high, as an association is often seen in patients with bile reflux, having a contaminated small bowel from SIBO, SIFO, or intestinal parasites.
The SIBO test and stool test were both negative. However, SIBO can be easily missed by the breath test, and when a stool test is negative for SIBO or SIFO, it is important to remember what the test represents. It is a sample of stool from the large bowel, not the small bowel itself. The small bowel has a bigger surface area than that of a soccer pitch, these small-bowel pathogens, (SIBO, SIFO) are easy to miss if you are analyzing a tiny bit of poop from the large bowel- (it’s like hoping to find the needle in the haystack, but by looking at only a fistful of hay).
This patients history of a prolonged course of antibiotics for Lyme disease treatment, as well as candida noted in the esophagus, visualized during endoscopy at the onset of her illness - keeps SIFO (fungal overgrowth) as a suspected “active player” contributing to the bile vomit/reflux problem - even despite a negative fungus stool test result. Fungus can be opportunistically persistent.
As for the extra-intestinal symptoms; (night sweats, anxiety, fatigue). They don't fit with a classical GI scenario, the night sweats particularly suggest infection. So perhaps there is an underlying process that is driving the GI problems; chronically dampening the immune response, and dysregulating the body's normal detoxification pathways. Could it possibly be an infective process, that is responsible at least in part for the very severe vomiting issues that last for hours?
Note: Patients who experience multiple, active, GI symptoms, and Non-GI symptoms should at least consider stealth infections to be the potential underlying root cause of their Issues - for more information click here to read an article, recently published by myself and Dr. Farshid Rahbar MD on this subject.
The negative urinary mycotoxin test lowered the chances of this particular case being related to a mold issue, despite her having an old AC unit and carpets at home. More likely is a residual stealth infection from the original tick bite, as the symptoms all started at the time of the tick bite, and they never went away. It is possible that other infections were also transmitted with the bite, besides just Lyme disease, which may not have responded to classical Lyme treatment. Another thought could be that Lyme disease was not successfully eradicated after all?
Making sense of the symptoms.
Bile, neutralizing acidity in the stomach can lead to the symptoms of early fullness, lack of appetite, and nausea - and if severe, bile could also possibly instigate vomiting. Bile reflux can lead to decreased oral intake, as eating food prompts bile to flow - creating a vicious cycle toward unintentional weight loss and micronutrient deficiency, which go on to contribute to malaise and fatigue. Malabsorption - (distension, bloating, flatulence); reflects a gassy proximal gut, making one consider fermentation of bacteria or fungi in the small bowel.
It is therefore worth considering if such pathogens are contributing to the bile reflux, by perhaps relaxing the pylorus, and affecting the bile flow from traveling its typical downstream route, by creating a retroperistalsis, causing the bile to inappropriately back up from the small bowel into the stomach. The Right upper quadrant pain could be related to the biliary sludge in the gallbladder, seen on ultrasound, or perhaps a poor-functioning gallbladder. There are a number of other possibilities but the small bowel issues are affecting the stomach, and esophagus (GERD, vomiting), and as a consequence of the malabsorption in the upper GI tract, the bile in the stomach is causing a poorly prepared, primary stage of digestion, which is affecting the large bowel defecatory habits (alternating diarrhea and constipation).
The Heidelberg pH test is appropriate in this case, to evaluate the stomach acidity, to determine if the cells of the stomach are directly fatiguing (hypochlorhydria), or if the bile is causing a pseudo-type (similar) effect, and the parietal cells are totally functional.
The Heidelberg pH test basics:
When the stomach functions normally, it is acidic in the fasting state. As food enters the stomach, the pH of the stomach juice becomes neutralized, this signals the stomach to pump acid in response, so as to bring the stomach contents back to the acidic pH baseline - This is a key part of the initial digestion process.
The Heidelberg pH test replicates this digestive sequence, to understand a subject's stomach digestion habits at the time of a meal. A neutralizing agent replicates the effect of food. We then assess the stomach cell’s ability to reacidify and our analysis determines if the stomach acid cells are behaving appropriately, or pumping too fast, or too slow. This is vital information when trying to understand the driving force behind upper GI distress.
Her Heidelberg pH report:
Observations:
4 Challenges were administered in this test (marked by the red lines), and the reacidification times were varied. The first challenge was 34 minutes duration, (similar to that of hypochlorhydria); the challenges all get faster over time, to the final challenge, which is 5 minutes duration, (similar to that of hyperchlorhydria).
Challenge 2 is 13 minutes duration, and demonstrates a normal curve, and return to baseline. Challenge 2 is how a normal reacidification curve should appear. Challenge 1 and Challenge 4, however, are not normal. Review the reacidification of challenge 1, and the upswings of the green tracer after the reacidification is complete in challenge 4. The green tracer is more erratic, and has difficulty reaching the baseline in the first challenge, and rises to a pH of 5, after reacidification is complete in the 4th challenge. These are both abnormal findings, that are suggestive of bile entering the stomach, from pyloric insufficiency.
The findings make sense, in light of the patient’s story.
Bile in the vomit is the hardest sign of bile reflux that you can get. For the bile to exit the mouth, it must travel from the small bowel and pass through the stomach. We can therefore assume that the pyloric sphincter, (the sphincter that divides the small bowel and stomach), is inappropriately open, allowing this process to take place (pyloric insufficiency).
This patient’s report is suggestive of bile, and not true hypochlorhydria. The reacidifications get faster with each challenge. The parietal cell’s function is not compromised when the reacidification times speed up. The cells have the ability in fact to pump MUCH faster than they normally should when they are repetitively stressed - this goes against a true hypochlorhydria case, where such cells are injured, and tire out.
As for the abdominal pains???
Case Update:
The patient presented to Dr. Rahbar during an episode of acute abdominal pains.
Dr. Rahbar repeated her endoscopy. The pyloric sphincter was inappropriately open. Bile was evident in the stomach. Bile aspirates were taken and analyzed by a specialist lab which came back positive for parasites, that were not picked up on stool test. Yet no fungus was detected.
Tick-borne testing came back positive for active rickettsia rickettsii infection and the patient received treatment from a Lyme literate physician.
The patient had a poorly functioning gallbladder and elective gallbladder surgery was carried out. Once removed, the gallbladder was analyzed by a specialist lab for various pathogens - and tested positive for fungus.
In this case, the patient got symptomatic relief from having the gallbladder removed, which significantly reduced the episodes of vomiting, although they have not completely subsided. She benefited immensely from anti-fungal treatment, and treatment for the stealth infection seems to be improving the vomiting episodes. The abdominal pains are much better. This case is ongoing, but progress is continuing to be made.
Summary of Findings:
Mixed Hyperchlorhydria and Hypochlorhydria, caused by Bile reflux. Underlying Small bowel fungal overgrowth, Gallbladder fungal overgrowth. Stealth infection.