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https://dergipark.org.ten/download/article-file/2696163#:~:text=Results%3A%20The%20presence%20of%20all,treatment%20of%20Sucrafate%20and%20UDCA. READ THE FULL STUDY. 10 patients were able to cure their gastric damage completely in 6 months of Sucralfate + UDCA use.
It was confirmed by biopsy/histopathology. (microscopically).
Sucralfate covers stomach lining and prevents back diffusion of acid, which is its most important mechanism to let the gastric lining fully heal from bile reflux. And yes, it does absorb bile acids too. (PPIS/H2 blockers cannot prevent back diffusion or protect directly from bile acids).
UDCA is important as well because it makes bile acids refluxing less toxic, and it also improves gallbladder function while dissolving gallstones/gallbladder polyps over time (2 years). (which can help restore gallbladder function and thus reduce bile refluxing). (it can also be used in people with no gallbladder). (60-90 percent of gallbladder polyps are actually cholesterol polyps which UDCA can usually dissolve unless they calcify.)
both are needed, and likely will take 6-12 months of use to see great improvements in symptoms. While also seeing great improvement in histopathology of gastric lining. This means that when viewed microscopically, the gastric cells are normalising completely like healthy functional cells and thus can fully work and protect itself like a healthy stomach lining.
However, the caveat is only some people will be able to stop the Sucralfate + UDCA because even once the gastric lining is fully healed, and you recover the stomach acid levels to trigger the gastric hormone cycle correctly and thus induce proper gastric emptying and peristalsis, HOWEVER some people have nerve damage usually related to gastric surgeries/gallbladder removal(some people, not all people as indicated on studies).
So it means that those people will need to continue taking the Sucralfate + UDCA long term, to prevent the gastric lining from being damaged again.
In some individuals, once you can get the stomach lining fully healed, if you are able to also get the gallbladder to work correctly (no gallstones/polyps/inflammation) and have clear bile ducts, then you can reacidify the stomach safely and get the correct motility happening, which will then prevent long term bile reflux. (reacidifying the stomach with betaine HCL/Zinc/B complex vitamins/lemon wate only do this if your stomach lining is fully healed). (The vitamins part in safe doses is safe and needed for general well being and proper gastric motility, check studies further below).
If you have healed your gastric lining fully, and then continue to acidify while lacking proper bile flow (usually due to poor functioning gallbladder or bile sludge etc).
Then you can potentially create duodenal ulcers, because the acid entering the duodenum from the stomach needs to be neutralised by the bile/pancreatic bicarbonate flowing through the cystic ducts into the duodenum. If they are not flowing correctly then the acid entering the duodenum will burn the duodenal lining and cause damage).
Hence this whole matter is very specific to the individual, every person has their own unique situation where they need to consider all matters of gastric lining/gallbladder function/ gallbladder missing/ gastric surgeries/medications and more.
All these factors essentially have their own unique sets of issues with some being more favourable to fully recover than others.
Though there is still some good news for everyone as long term use of the Sucralfate + UDCA likely will reduce the chances of intestinal metaplasia developing and hopefully reverse it, so it doesn't turn into dysplasia which is considered the 'point of no return'.
Sucralfate is generally quite safe, but has some contraindications such as patients who have kidney problems, so speak to your doctor. Side effects are usually mild and is well tolerated.
And UDCA is generally quite safe as well, but has some contraindications, so speak to your doctor. Side effects are usually mild and is well tolerated.
https://www.cghjournal.org/article/S1542-3565(18)30222-2/pdf#:~:text=Although%20the%20prevalence%20of%20bile,be%20associated%20with%20gastroduodenal%20dysmotility.30222-2/pdf#:~:text=Although%20the%20prevalence%20of%20bile,be%20associated%20with%20gastroduodenal%20dysmotility)
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9484982/ Check this study to understand the condition better and the challenges of diagnosing it.
Sucralfate dose is usually 4g to 8g daily. The timing depends on what is best for you, you can either take 2g in the morning, and then 2g in the evening before bed. or you can take 1g every 4-6 hours, speak to your doctor.
Sucralfate works best in an acidic ph in the stomach, so taking strong acid suppression may make its effect weaker, but it can still be used with acid suppression medications. (check the links for more information).
UDCA is usually 600mg daily for dissolving gallstones/polyps however it can go up to 1000mg a day for treating bile reflux. Speak to your doctor.
TUDCA - Tauroursodeoxycholic acid is also used to dissolve gallstones and improve liver conditions.
it is UDCA plus TAURINE, they are very similar but TUDCA is sold as a supplement over the counter. Because of the added taurine, they are not the same in weight.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5134868/ It is also noteworthy that the same amount (750 mg) of TUDCA and UDCA per day is not bioequivalent because of their different molecular weight, and 500 mg TUDCA is approximately 375 mg UDCA in terms of bioequivalence.
1500mg of TUDCA = 1125mg of UDCA.
DO NOT TAKE TUDCA AND UDCA TOGETHER, or at least you need to calculate the doses correctly, do not exceed 15mg PER KG of bodyweight for UDCA. They are basically the same thing, so make your doctor aware.
Higher doses than 15mg per KG of bodyweight are for other conditions. So speak to your DOCTOR.
https://pubmed.ncbi.nlm.nih.gov/8275659/ https://examine.com/supplements/tudca/ https://www.cherokeescout.com/opinion/tudca-and-udca-gallstones-and-sibo Try to take these medications away from each other. (Sucralfate can absorb different medications so wait 1 hour before taking other medications and speak to your doctor).
You can possibly add Troxipide &/OR Rebamipide to your medication healing protocol if your doctor prescribes them to you, as they can further heal the gastric lining by reducing inflammation and producing more mucus. They are medications that work best for NSAID gastritis/gastropathy. But can help with chemical gastropathy in general (bile reflux is a type of chemical gastropathy) Speak to your doctor about them.
Some of these medications are only available in certain countries.
review all these links and studies for further information:
https://en.wikipedia.org/wiki/Troxipide https://en.wikipedia.org/wiki/Rebamipide https://medikamio.com/en-gb/diseases/chronic-gastritis https://my.clevelandclinic.org/health/diseases/24671-gastropathy https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9484982/ https://en.wikipedia.org/wiki/Sucralfate https://en.wikipedia.org/wiki/Ursodeoxycholic_acid https://www.researchgate.net/publication/10578186_The_Impact_of_B12_Treatment_on_Gastric_Emptying_Time_in_Patients_With_Helicobacter_pylori_Infection https://www.eonutrition.co.uk/post/when-sibo-ibs-constipation-are-just-unrecognized-thiamine-deficiency https://med.virginia.edu/ginutrition/wp-content/uploads/sites/199/2015/11/ParrishArticle-Aug-05.pdf https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3746374/#:~:text=A%20dissolution%20rate%20of%2030,rate%5B27%2D29%5D. There's many more studies I can link to, But its
A LOT.
FURTHER GUIDE including diet: Make sure to supplement vitamins in SAFE DOSES to improve gastric emptying/peristalsis and general wellbeing.
All B vitamins IMPORTANT,
https://en.wikipedia.org/wiki/B_vitamins https://en.wikipedia.org/wiki/Mineral_(nutrient))
Zinc/copper (Get the ratio right), (important).
Vitamin D3, K2 (important).
Choline (important).
(Intake the correct safe doses, don't go overboard as that can further injure your stomach lining or cause you symptoms such as nausea). (Lozenges or sublingual vitamins may be better for you as vitamins can be absorbed under the tongue, and can lessen the need for the stomach to be used, though vitamin b12 needs intrinsic factor and thus the stomach is needed generally speaking).
Get enough protein in your diet, you can supplement with collagen peptide powder if you need further help as its already broken down and can be easily absorbed in the small intestine. (collagen powder is very safe but it is incomplete and needs tryptophan essential amino acid in diet so either get a supplement or eat foods with tryptophan).
Get enough fat in your diet, healthy fats. But don't overload your stomach with high amounts of fat per meal, as you likely don't have the proper bile flow to handle this. So its usually best to have 4-5 meals a day, with 10-20 grams of fat per meal, depending on how much you can handle. (its specific to you, check your symptoms and how you feel).
Fat= 9 calories per gram, Protein = 4 calories per gram, Carbohydrate = 4 calories per gram
https://www.cedars-sinai.org/blog/what-are-macronutrients.html macronutrient ratio can vary for health, but generally speaking, 30-40 percent from fat, 30-40 percent protein-30-40 percent carbs, if your struggling with fat digestion possibly lowering it to 20% temporarily.
Make sure you are aware of how much fat, protein, carbs and total calories you are intaking per day to prevent weight loss and make sure you are getting enough macronutrients. The split percentage of the macro's will depend on you individually and how well your stomach can digest fat/protein, usually carbs are the easiest to digest but can have affects on blood sugar potentially in some individuals.
Usually safe carbs are white potatoes (high potassium which is needed for energy) and white rice for most people.
Olive oil, real butter in small to moderate amounts per meal.
Eggs/fish/meat in small to moderate amounts per meal.
Get enough salt intake.
Lactose free milk, whole milk is fine, its all about portion size with the fat content.
Salads are up to you, and how your digestion feels. If you struggle to digest vegetables, steaming/boiling usually helps. Some of the foods added to salads are very gas producing or acidic so be careful.
Use
gastritis.club website
http://gastritis.club/ for good list of foods and their PH. Its free.
Fruit can cause bloating/gas/diarrhoea in some people due to fructose intolerance or sorbitol etc. So see how you feel. Some fruits are easier on the gut than others, such as cantaloupe melon.
white bread and pasta is okay if it doesn't cause much bloating for you. Though I'm personally not a fan.
Avoid rough foods like popcorn, or super high fiber foods.
Avoid anything too spicy or gas producing like onions.
With gastritis/bile reflux/chemical gastropathy/gallbladder issues/ etc often you have inadequate stomach acid PH levels and / OR poor bile flow, thus the strategy is you don't want to overload the stomach with food that it doesn't have the processing power to digest. So as a general rule that's why smaller but more frequent meals are better. If you overload the stomach with protein and fat it cannot digest efficiently then what will result is indigestion, gas/bloating and possibly diarrhoea(fat malabsorption/protein malabsorption). Big meals can also stretch the stomach a lot and slow down healing/cause flare ups.
Chew your food well before swallowing and eat in a relaxed state.
Taking ox bile/ bile salts may help with fat digestion, but may worsen bile reflux gastritis. It depends on how well your stomach is emptying. It's all about chronic exposure to toxic bile acids. Healthy stomachs get exposed to bile acids sometimes, but they get emptied out quickly thus no permanent damage is caused. (studies have shown this).
Review medications that you take which are anticholinergic with your doctors, medications that essentially slow down the gut. Many medications fall into this category.
Strong acid in stomach results in better stomach emptying HOWEVER if you have gastric damage then you will create an ULCER. SO DO NOT ACIDIFY until fully healed. (its a catch-22 I KNOW).
Digestive enzymes such as protease, amylase and lipase may help, but can worsen gastritis (protease digests protein, unprotected stomach lining is protein).
Same with betaine HCL or acidic drinks, until your stomach lining is fully healed it is a bad idea to acidify the stomach, though it can sometimes help with digestion. its a very tight rope. so be careful.
Raise your bed to sleep with less reflux. (As much as you can comfortably sleep on).
Sleep on an empty stomach, don't sleep on your stomach, just side ways or back, your preference.
If you have excessive bloating even on an empty stomach, getting prescribed Bismuth SUBCITRATE for a few weeks can help reduce the bacteria, HOWEVER DO NOT USE Bismuth subsalicylate. (Pepto Bismol) as the salicylate content is contraindicated with gastritis. (it can cause gastric lining damage).
There are other strategies but you need to speak to your doctor about them as they are more extreme steps at wiping out bacteria.
H pylori can sometimes accompany bile reflux gastritis, however it doesn't mean its the cause of the gastritis or the bile reflux, it varies. Though it doesn't seem like a bad idea to get rid of H pylori since your gastric lining is compromised. Stool test and biopsy can be used to diagnose H Pylori.
Ideally you wouldn't take NSAIDS either, as that can easily cause and worsen gastritis.
Ppis/H2 blockers can help a bit, but have their own downsides such as bacterial overgrowths and further indigestion, so use appropriately under your doctors care. Famotidine seems to be a good option.
Coming off PPIS will often cause acid rebound, so always taper off slowly. The same applies to H2 blockers like famotidine, however slightly less. Famotidine is probably the best choice for effective acid suppression, with least side effects.
Stress can make symptoms worse, but symptoms can also make stress worse. So try your best to manage both by living a healthy lifestyle, getting plenty of sun and having a social life to improve mood.
Always speak to your doctor regarding medications.
Read the studies above if you want to know about the challenges of diagnosing this condition.
Not everyone's cause of bile reflux/ Duodenogastric reflux is the same, that's why outcome and treatment can vary. And severity of symptoms can vary too. Sometimes symptoms resolve by them selves such as after gallbladder removal, sometimes gallbladder removal makes symptoms worse and long term.
Sometimes gallstones or gallbladder polyps cause the issue, and dissolving them with UDCA/TUDCA use long term can reverse the bile refluxing.
Sometimes its vitamin deficiencies causing the issue. Due to improper diet/low acid levels.
Sometimes its medications that relax the gut/gallbladdewhole digestive system like antispasmodics/anticholinergics.
Sometimes PPI's themselves can induce bile reflux due to altered gastric hormone cycle, and worsened gastric motility. They can also potentially make Barretts esophagus worse:
https://www.frontiersin.org/journals/oncology/articles/10.3389/fonc.2014.00373/full Risks of PPIS:
https://refluxuk.com/blog/your-questions-answered-about-ppi-treatment-for-reflux/ Sometimes its gastric surgeries which vary.
Diagnosing Bile reflux as the cause of your gastritis is not always straightforward.
Gastroscopy can be used to detect the type of gastric damage and rule out other causes, however seeing bile in the stomach is not always a sign that its the root cause. As patients often due to RETCHING during the procedure bring up bile into the stomach. However if its excessive bile, then it is likely the cause.
You can use a HIDA scan to detect bile refluxing into the stomach, it is a painless scan specialized, and needs to be ordered by your doctor.
Your doctor needs to also eliminate other potential causes of the gastritis, such as NSAID use or H pylori which are very common, however when accompanied by gallbladder issues or gallbladder removal, then the likely cause starts to side with bile reflux.
It's about building up a case with a variety of tests under a good gastroenterologist that understands the complexity of the issue and is up to date with the best medical information.
Sometimes diagnosing bile reflux is very obvious and some good doctors know this.
Show them the above resources if you need to.
Symptoms vary from:
Nausea,
Gas/bloating
Burning pain in the stomach region (navel to sternum),
Acid or alkaline reflux into chest or throat, You may have yellow coloured saliva in the mornings, which indicate the presence of bile.
and more.
In terms of acid suppression, the H2 blocker called famotidine seems to be the safest and is effective, but not super effective at acid suppression like a high dose PPI is, its a balancing act where you need at least a little stomach acid to help digestion, because if you nuke it completely its very difficult to digest anything.
Famotidine 20-40mg a day+ Sucralfate 4g-8g a day + UDCA 600mg - 1000mg a day seems to be a good combination with good effectiveness in decreasing pain, decreasing nausea, protecting the stomach lining and letting it heal, while minimising major side effects of some other medications.
In terms of timing these medications, Sucralfate needs to be taken on an empty stomach, wait 30-60 minutes and then you can take Famotidine, and then UDCA and food.
Do expect some mild side effects from Famotidine/Sucralfate/Udca such as mild nausea, mild diarrhoea, mild constipation, mild bloating/gas, mild headaches depending on the person. But they shouldn't be all the time or extreme. Speak to your doctor.
Always do regular blood tests to make sure you are absorbing vitamins as acid suppression can reduce the bodies ability to absorb nutrients.
Some medications that I have not mentioned in this post cause severe digestive side effects, So I won't bother mentioning them.
Always err on the side of caution when making improvements in symptoms/healing, as you can definitely feel much better without being fully healed, and cause flare ups which set you back several months of diligence.
Have a good day!
Observer2030
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