I’ve been getting lots of enquiries from people, particularly women, who have been diagnosed with IBD (D). Here the (D) stands for diarrhoea. However, some of these women have been misdiagnosed.
Occasionally, what the person has is a condition known as Bile Acid Malabsorption (BAM) or Bile Acid Diarrhoea (BAD). However, this can be treated using medications so they may be suffering unnecessarily.
It’s estimated that bile acid diarrhoea affects about 1 in every 100 people in the UK. Though it’s thought to affect about 1 in 3 people who are diagnosed as having IBS (D).
So, let’s look at what it is, what causes it, what the symptoms are and how it can be managed.
What is Bile Acid Malabsorption?
Bile Acid Malabsorption (BAM), also called Bile Acid Diarrhoea (BAD) is a condition that occurs when your intestines cannot absorb bile acids properly. This results in extra bile acids in your intestines, which can cause watery diarrhoea.
Bile is a natural fluid your body makes in the liver. It’s necessary for proper digestion. Bile contains acids, proteins, salts, and other products.
The common bile duct moves it from your liver to your gallbladder, where it’s stored and concentrated until you eat. When you eat, your gallbladder contracts and releases this bile into the first part of your small intestine, the duodenum. Sometimes the bile can get into the stomach and if this happens, it usually results in vomiting.
Once the bile is in your small intestine, the acids in the bile help break down food and nutrients so your body can absorb them efficiently. These bile acids aid in absorbing fat and fat-soluble vitamins like vitamins A, E, D, & K. Bile also acts as a natural anti-bacterial agent in your small intestine.
What are the symptoms of BAM?
- Diarrhoea: this is the main symptom. When bile acids are not properly re-absorbed from the ileum (small intestine), they pass instead into the large intestine, irritating the lining of the colon and stimulating salt and water secretion. Diarrhoea is usually frequent during the day and sometimes at night. It may be pale, greasy and hard to flush away, or unusually coloured – often green or yellowy-orange.
- Stomach problems: these include bloating, cramping, abdominal pain and excessive wind. Unfortunately, many symptoms of bile acid malabsorption mimic those of Irritable Bowel Syndrome (IBS) and some IBS patients may actually have undiagnosed bile acid malabsorption. If you are having multiple episodes of diarrhoea daily (more than 10), please go and see your GP and get properly tested for BAM.
Why does BAM occur?
BAM can occur either because too much bile is being released – this is known as primary Bile Acid Malabsorption or not enough is absorbed – secondary Bile Acid Malabsorption.
When the gallbladder is removed, it results in bile seeping into the small intestine constantly. One of the functions of bile is to increase transit time in the bowel, so many people who’ve had their gallbladder removed find that their bowel movements speed up!
In some people, more bile ends up in the intestines than can be reabsorbed. Ideally, should all be reabsorbed at the end of the small intestine, the ileum. If it gets through the ileocecal valve into the first part of the large intestine, it can cause diarrhea.
When SIBO, coeliac disease or an inflammatory bowel disease is present, there could also be impaired absorption.
SIBO can cause the bile acid to become disrupted by the bacteria, making it much more difficult for the gut to reabsorb. This can lead to bile getting into the large intestine, which causes diarrhoea. And, in the case of IBD, the terminal ileum is affected due to potential lesions from the disease. Again reducing the body’s ability to reabsorb bile, meaning it can get into the large intestine.
Types of Bile Acid Diarrhoea
There are 3 types of bile acid diarrhoea:
Type 1 – is structural – meaning something structurally has changed that has impaired the reabsorption of bile acids
Type 2 – is idiopathic (with an unknown cause). It may be due to overproduction of bile acids.
Type 3 – is impaired absorption due to other diagnoses, for example, colitis or conditions causing fast motility.
How is BAM diagnosed?
The main investigation for a definitive diagnosis of Bile Acid Malabsorption is a nuclear medicine test called the SeHCAT scan. An artificial bile acid, SeHCAT is swallowed via a capsule or drink and a first scan is carried out on the same day to establish how much artificial bile acid is in the body – the starting amount.
One week later, a second scan is performed to show how much of the artificial bile has been retained. The overall result is then used to establish how much bile acid is lost from the body and whether malabsorption is taking place.
What is the treatment for BAM?
Treatment includes medication and dietary changes. If there is an underlying condition (type 1 or 3), treatment of the underlying condition can lead to improvement of symptoms.
The main type of medication used to treat BAM is called a bile acid binder. It binds with the bile acids in your digestive tract, which reduces their impact on your colon, slowing it down, giving welcome relief from the constant trips to the toilet.
They will affect the absorption of other drugs, however, so must be taken four hours before or after other medications.
The most common bile acid binders include:
- Colestyramine and colestipol – these medications only come in powder form. Unfortunately, some people may find them unpalatable. It’s also important to adjust the dose according to your symptoms as if it’s too high it can cause constipation. Talk to your practitioner about this.
- Colesevelam – this is a newer medication and comes in a tablet form. Some patients find it easier to take than colestyramine. Due to current cost and drug licensing, colesevelam may not be widely available.
- Consuming high soluble fibre foods and/or soluble fibre supplements, such as psyllium husk. Fibre supplements are a natural bile acid binder, helping to reduce the amount of water being pulled into the bowel
- A lower FODMAP diet may work well for certain individuals
- Make sure you are getting enough of your fat-soluble vitamins. Taking these in an emulsified form can be beneficial to aid absorption.
- B12 may also be implicated as it is absorbed into the body at the end of the small bowel. If this area of the bowel is damaged, people with Bile Acid Malabsorption may also become deficient in vitamin B12. This can make them feel tired and short of breath.
- Natural agents like guggul, propolis, and Boswellia – many of these compounds are known to lower cholesterol and they do so by being bile binders. Digestive enzymes can also be useful as they help with the digestion of proteins, carbohydrates and fat, so taking the strain off the intestines. Digestive enzymes can be particularly useful if you get bloating, cramps and diarrhoea after eating fats or anything oily and greasy.
- Where fats are not tolerated, use MCT oils from coconut products as they do not require bile acids for digestion. To ensure you get enough fats in your diet, it’s advisable to cook with coconut oil and eat coconut-based yoghurts.
- Eat more healthy fats (avocados, olives, coconut products, nuts, seeds etc) and fewer processed trans fats. Some vegetable oils tend to be problematic after gallbladder removal because they can promote inflammatory processes inside your body. This can make recovery after surgery even more difficult.
Oils that may worsen inflammation in your body are those that are rich in omega-6 fatty acids. These oils include:
- sunflower oil
- safflower oil
- corn oil
- cottonseed oil
- grapeseed oil
- soybean oil
Instead opt for oils rich in omega-3 fatty acids, e.g. extra virgin olive oil or coconut oil.
Note: store-bought products made with these oils can also be problematic, such as mayonnaise and salad dressing. There are other options out there though. One of my favourites is the mayo that Hunter & Gather make using solely avocado. It’s absolutely delicious.
- Eat smaller meals – don’t overload your stomach; eat smaller portions. Simple, smaller meals are always easier for your stomach to digest and can reduce the number and severity of your digestive problems.
Take home message:
Try to establish the underlying/root causes
- SIBO could be one of them. Once the SIBO infection is dealt with, the severity of BAM should reduce, if not disappear completely. If a case of SIBO is suspected, a SIBO test is recommended to confirm this. You would then need to work with a Nutritional Therapy Practitioner to help you to eradicate the SIBO infection.
As stated earlier, if you have been diagnosed with IBS (D) and the multiple trips to the loo are keeping you prisoner in your own home for fear of not being near a toilet when needed, then go see your GP and talk about BAM and having the SeHCAT scan. If it is BAM, and not IBS (D), the medication can be life-changing.
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