By Elias Darido, MD, FACS
Acid Reflux & GERD Surgeon | Houston Heartburn and Reflux Center
15+ years in practice
Published: July 29, 2018 | Last Reviewed: October 14, 2026
Patient Question
Hello,
I had my gallbladder removed a few years ago and am having a recurrence of bile reflux symptoms. I’m normal weight, don’t smoke, eat healthy and sleep elevated. PPIs have no benefit. Is Ursodiol an appropriate medication to try? How often and how much? Thank you!
— Kelly
My Answer
Dear Kelly,
Gallbladder disease and acid reflux, or GERD, are two common but different problems. Gallstones affect roughly 6% of people worldwide, based on a pooled analysis of 139 studies, though rates vary widely by country. [1] Heartburn is far more common. A pooled analysis of over 460,000 people found that about 13% experience heartburn or regurgitation weekly. [2]
Not every patient with gallstones needs gallbladder removal. Not every patient with heartburn has true acid reflux disease.
Gallbladder Surgery Versus Reflux Surgery
Gallbladder surgery, or laparoscopic cholecystectomy, treats acute or chronic cholecystitis and biliary dyskinesia. Acid reflux surgery, in the form of Nissen fundoplication with hiatal hernia repair, treats documented GERD.
I diagnose and stage GERD with a small set of tests. The main ones are upper endoscopy and ambulatory esophageal pH testing. Bile reflux typically occurs alongside acid reflux. Nissen fundoplication rebuilds the antireflux barrier. It stops all forms of reflux from the stomach into the esophagus, not just acid. PPIs mask acid reflux symptoms. They do not cure GERD.
Why Bile Reflux Often Worsens After Gallbladder Removal
Evidence supports that bile reflux increases after gallbladder removal. Removing the gallbladder eliminates the body’s bile reservoir. Bile delivery shifts from a pulsatile, meal-triggered pattern to a continuous one. This allows more bile to reflux backward into the stomach and esophagus.
A study by Shah Gilani and colleagues found that gastric bile pooling roughly doubled after cholecystectomy, from 32% before surgery to 60% at one year and 79% at 10 to 20 years out. Markers of cellular stress at the esophagogastric junction also increased over that time. [3] A 2024 meta-analysis and genetic study found cholecystectomy raises the risk of GERD (RR 1.37; 95% CI, 1.09-1.72), with similar genetic associations to Barrett’s esophagus. Esophageal cancer risk was not increased. [4]
The evidence isn’t unanimous. At least one well-designed study found no significant rise in esophageal acid exposure after cholecystectomy, and found that patients with increased bile reflux were largely asymptomatic.
A prospective study of 19 healthy volunteers found that 30 days of omeprazole 40 mg daily reduced gallbladder motility in 15 of 19 subjects (about 79%), and roughly a quarter of those went on to develop symptoms consistent with a biliary cause.⁵ A separate cohort of nearly 480,000 participants found regular PPI use was associated with an increased risk of gallstones (HR 1.22; 95% CI, 1.16–1.29).⁶ The proposed mechanism is that PPI-induced acid suppression blunts the normal duodenal signal for cholecystokinin release, the hormone that drives gallbladder contraction after a meal.
As a result, patients on chronic PPI treatment for acid reflux are more likely to need gallbladder removal than the general population. In my own practice, I have noticed a higher rate of prior laparoscopic cholecystectomy among patients presenting for acid reflux management.
If you have GERD and then undergo cholecystectomy, your reflux symptoms may worsen afterward. Bile reflux increases once the gallbladder is gone.
Does Ursodiol Treat Bile Reflux?
Ursodiol is a naturally occurring bile acid. It prevents cholesterol gallstones from forming. Ursodiol does not stop or reduce bile reflux.
My Recommendation
I recommend evaluation by a reflux specialist. If testing confirms GERD, laparoscopic hiatal hernia repair with Nissen fundoplication is the right next step. This remains the gold standard treatment for GERD. When performed correctly, Nissen fundoplication and hiatal hernia repair are safe, effective and durable.
Key Clinical Points
- Gallbladder disease and GERD are separate diagnoses. Neither condition automatically means a patient has the other.
- Bile reflux commonly increases after gallbladder removal and often co-exists with acid reflux.
- Chronic PPI use may reduce gallbladder function, which may explain higher cholecystectomy rates in reflux patients.⁵⁶
- Ursodiol prevents cholesterol gallstones. It does not treat bile reflux.
- Nissen fundoplication with hiatal hernia repair addresses acid and bile reflux together by rebuilding the antireflux barrier.
If PPIs are not controlling your symptoms, or you have had your gallbladder removed and your reflux has returned, I encourage you to schedule an evaluation with Houston Heartburn and Reflux Center at 832-945-8717.
Healthy regards,
Elias Darido, MD, FACS
Houston Heartburn and Reflux Center
References
1. Ning Q, Liu F, Fang Y, Zhu X, Liu J, Li Z. Estimating global prevalence of gallbladder stones in general population from 2000 to 2024: systematic review and meta-analysis. Ann Med. 2025;57(1):2570795. doi:10.1080/07853890.2025.2570795
2. Eusebi LH, Ratnakumaran R, Yuan Y, Solaymani-Dodaran M, Bazzoli F, Ford AC. Global prevalence of, and risk factors for, gastro-oesophageal reflux symptoms: a meta-analysis. Gut. 2017;67(3):430-440. doi:10.1136/gutjnl-2016-313589
3. Shah Gilani SN, Bass GA, Kharytaniuk N, et al. Gastroesophageal Mucosal Injury after Cholecystectomy: An Indication for Surveillance? J Am Coll Surg. 2017;224(3):319-326. doi:10.1016/j.jamcollsurg.2016.12.003
4. Huang Y, Cai Y, Chen Y, et al. Cholelithiasis and Cholecystectomy Increase the Risk of Gastroesophageal Reflux Disease and Barrett’s Esophagus. Front Med (Lausanne). 2024;11:1420462. doi:10.3389/fmed.2024.1420462
5. Cahan MA, Balduf L, Colton K, Smith LA, Waters PS, Farrell TM. Proton pump inhibitors reduce gallbladder function. Surg Endosc. 2006;20(9):1364-1367. doi:10.1007/s00464-005-0247-x
6. Yang M, Xia B, Lu Y, et al. Association between regular use of gastric acid suppressants and subsequent risk of cholelithiasis: a prospective cohort study of 0.47 million participants. Front Pharmacol. 2022;13:956880. doi:10.3389/fphar.2022.956880
All references retrieved via PubMed.