This study reports on ten patients with typical bile gastritis who had no prior gastric surgery. Clinical symptoms included burning epigastric pain unrelieved by food or antacid, episodic nausea, and vomiting of bile. In all patients the symptoms appeared after cholecystectomy, with (four patients) or without (six patients) transduodenal sphincterotomy; the symptoms were often initially attributed to chronic pancreatitis. Six patients had hypochromic, microcytic anemia. Eight patients had basal achlorhydria; stimulated acid secretion was low or absent in seven patients. Gastroscopic examination revealed gastritis, most prominent in the prepyloric antrum, and abundant bile lakes. Mucosal biopsy disclosed chronic gastritis. Although medical therapy failed, seven of eight patients treated by vagotomy, hemigastrectomy, and long Roux-en-Y gastrojejunostomy had immediate and sustained relief. Cholecystectomy appears to be a critical factor in the pathogenesis of bile gastritis in patients who have not had prior gastric surgery. Without the reservoir function of the gallbladder, the unregulated flow of bile into the duodenum probably promotes the access of bile to the unprotected gastric mucosa.