Could My IBS Be Bile Acid Malabsorption

Bile Acid Malabsorption (BAM) is a condition which is often misdiagnosed as IBS.

It is thought that at least 1 in 100 people have BAM – pretty common! (1). If you have IBS which is sensitive to fat then you may BAM.

In this article I will explain what BAM is and the common symptoms. I will also guide you on how to get a diagnosis and what treatment options there are for BAM.

What Is Bile Acid Malabsorption?

In normal digestion, your liver produces bile acids which are used to break down fat. After use,  bile acids are directed back to your liver by your small intestine.

The recycling of bile acid can happen several times a day.

Bile acid malabsorption occurs when the small intestine does not send these bile acids back to your liver. This results in poor digestion (2).

Symptoms

Symptoms of bile acid malabsorption vary in type and severity .

Here are some common symptoms which you may experience (3);

• Chronic diarrhoea (2)
• Urgency to open bowels
• Abdominal pain
• Bloating
• Increased bowel frequency
• Steatorrhoea (fat in stools)
• Abdominal gurgling
• Lack of control
• Flatulence

Causes

Bile acid malabsorption can be caused for multiple reasons.

If you have had certain surgeries such as gall bladder removal, bowel resections or upper gastro-intestinal surgery this can be a trigger (4, 5).

If you have a condition or treatment that affects the very end part of your small bowel, this may cause BAM. Examples would be Chron’s disease or having radiotherapy in that area of your body (4, 5).

Conditions such as diabetes and pancreatitis have also been linked (4, 5).

Diagnosis

To find out if your IBS symptoms are caused by bile acid malabsorption you will need further testing.

There is only 1 test currently available for BAM called SeHCAT.

When you have the SeHCAT test you will swallow a radioactive version of bile acid. The doctor will then be able to use a machine to detect how well the substance is retained or lost in your bowel (3).

Here are the ranges your doctor will use to diagnose BAM (6);

• 10–15% retention = mild bile acid malabsorption
• 5–10% retention = moderate bile acid malabsorption
• 0–5% retention = severe bile acid malabsorption

Treatment

There are several ways to treat bile acid malabsorption. The method used will depend on what stage you are at (3).

15-20% SeHCAT scan result

This is the least severe BAM level.

If you have this level then you may not require any medication. Instead, you will be advised on a low fat diet trial by a dietitian.

Your symptoms will be closely monitored whilst you trial the diet. Further medication may be required.

10-15% SeHCAT scan result

If you have this level of BAM, you may also be able to manage it through diet alone. Again you will be asked to trial a low fat diet.

Your dietitian may or may not recommend a multivitamin and additional, combined calcium /vitamin D supplement.

Again, your symptoms will be closely monitored whilst you trial the diet. Further medication may be required.

5-10% SeHCAT scan result

Your dietitian will immediately start you on a multivitamin and combined calcium / vitamin D supplement.

The reason you may need nutritional supplements are because you are not absorbing fats. Some vitamins are fat soluble and you will be at risk of certain nutritional deficiencies.

At this level you will be given a choice over your treatment. You will be given both the option of a low fat diet trial or medications.

0-5% SeHCAT scan result

This is the most severe stage of bile acid malabsorption.

If you are at this level then your doctor will immediately commence you on medications as well as the multivitamin and calcium / vitamin D combination.

You may or may not be required to start a low fat diet at this stage. This will depend on how your body reacts to medications.

The low Fat Diet

You will find that a diet at 42g of fat / day will improve your symptoms of BAM (3).

This diet is a medical therapy and needs to be done under the careful supervision of a trained dietitian.

The dietitian will also guide you on the use of additional nutritional supplements due to the risk of malabsorption.

Bottom Line

If you are experiencing the above symptoms then you may have bile acid malabsorption and not IBS.

Please see your doctor for further assessment to determine whether you need to go for testing.

BAM can often be managed through dietary changes alone. In severe cases you may require medications also.

If you do not manage bile salt malabsorption correctly then you will be at risk of certain nutritional deficiencies which could affect your long-term help.