Bile Salt Supplementation and Bile Acid Diarrhea

There is no question about the countless benefits of bile salt supplements for digestion, gut health, and bile circulation. Bile salts support detoxification and stimulate fat burning, according to numerous research studies. Despite the overwhelming advantages, there are some people apprehensive about taking bile salts simply because they are afraid of bile acid diarrhea (BAD). But the truth is – bile salt supplements are not the cause of bile acid diarrhea!

Having loose stools or more frequent bowel movement over a short period of time is very different from chronic diarrhea and BAD. And although it is true that taking bile salt supplements may alter the enterohepatic circulation (bile circulation) and may change the schedule or frequency of elimination in some individuals, BAD is much worse and more complicated.

Bile Acids: The Basics

Before we discuss the details of bile acid diarrhea, we need to first have at least a basic understanding of what bile acids are and what they do for us.

Bile acids are products of cholesterol emulsification and utilization and are synthesized in the liver, stored in the gallbladder, and reabsorbed in the small intestine. Bile acids induce the secretion of water and electrolytes, accelerate the transit of food and waste in the colon by stimulating contractions, and ultimately supports better digestion and metabolism.

Bile acids are considered “detergent molecules” because they break down fatty acids and monotriglycerides, making them crucial components of digestion and metabolism.

Below is the average bile acid kinetics in adults:

  • Bile acid secretion 12 g/day
  • Bile acid pool size 2-3 g
  • Cycling frequency 4-6x/day
  • Amount reabsorbed per cycle 95%
  • Fecal bile acid loss <0.5 g/day
  • Average half-life 3 days

Significant alterations of those quantities may cause irregularities in the frequency, quantity, and quality of elimination.

Symptoms of Bile Acid Diarrhea

There are a lot of possible reasons for diarrhea ranging from bad food to intestinal diseases. You don’t usually to go to the emergency room at the first feeling of discomfort, but if your diarrhea is severe, frequent, and long-term, then maybe it’s time for a check-up. Below are some symptoms of bile acid diarrhea, also referred sometimes as bile acid malabsorption. Many of these symptoms mimic those of irritable bowel syndrome (IBS) and other related conditions so it is really not advisable to self-diagnose chronic diarrhea.

  • Pale and greasy stools
  • Up to ten episodes of diarrhea during the day, sometimes also at night
  • Bloating
  • Cramping
  • Abdominal Pain
  • Excessive Gas

Diagnosis of Bile Acid Diarrhea

There are a number of different diagnostic tests that can confirm if there is abnormal bile acid amounts lost in the feces. However, before any test is done, a thorough examination of the patient’s medical history should be done to rule out all other possible causes of the diarrhea. Past procedures done like cholecystectomy, radiotherapy, or ileal resection definitely increase the risk of BAD. Patients with Chron’s Disease and IBD are also at greater risk of suffering from BAD.

Initially, what diagnosis aims to determine is whether the chronic diarrhea has been caused by inflammation, the ingestion of an active substance that interferes with the normal function of the digestive system or the body as a whole, or if it is secretory diarrhea (the type of loose bowel elimination wherein electrolyte absorption is impaired). In cases where patients are suspected to have bile salt-induced diarrhea, a distinction must be made if it is a fatty type of elimination or if the electrolyte absorption is impaired.

Once other possible diarrhea causes have been eliminated, a number of tests may be administered. Until new and more advanced methods are developed, the SeHCAT test remains to be the gold standard bile acid diarrhea diagnosis.

Causes of Bile Acid Diarrhea

There are various causes of bile acid diarrhea:

  1. Chlorgenic diarrhea – This type is also called chlorgenic enteropathy, the type of diarrhea caused by ileal dysfuction such as in individuals with Chron’s disease.
  2. Ideopathic diarrhea – This is also called primary BAD. Unlike the first type, there is no clear explanation in idiopathic diarrhea as to why the colon does not fully reabsorb the circulating bile acids.
  3. BAD caused by gastrointestinal disorders that affect absorption of bile acids in the body like small intestinal bacterial overgrowth (SIBO), Celiac Disease, Chronic Pancreatitis, etc.
  4. Excessive bile acid synthesis in the liver – There is no definitive cause for excessive bile acid production. Some studies associate it with some hypoglycemic drugs like metformin but there is also a plausible theory on the role of genetics and hormonal dysfunction with bile acid synthesis. Some studies show that it is due to the impaired negative feedback by the ileal (small intestine) hormone called fibroblast growth factor 19 (FGF19). The theories state that the bile acid absorption in the cells of the small intestine is not enough to generate the sufficient level of FGF19. FGF19’s function is to repress bile acid synthesis as it signals through receptors in the liver.

Treatment of Bile Acid Diarrhea

Once BAD has been diagnosed, then various treatments may be recommended by the doctor coupled with dietary changes. If there are underlying conditions causing the BAD such as in idiopathic diarrhea, then those gastrointestinal, pancreatic, or hepatic conditions must be addressed first. The following bile acid sequestrant medications may then be prescribed:

  1. Colestyramine and Colestipol
  2. Colesevelam

Bile acid sequestrants act by absorbing grabbing the excessive bile and removing it via bowel secretion. In general, these drugs work only on the bile and are not systemic drugs. Ask your doctor for the proper dosage and frequency of the medication.

Dietary Changes

If you have a confirmed case of BAD, dietary changes are a must. The body synthesizes and releases more bile acids when we eat lots of foods, especially fatty and greasy ones. Therefore, to lessen the amount of bile acids available, a low-fat diet is recommended. Low levels of bile acids in the colon decreases the chances of having diarrhea. And since fats are still required by the body, don’t waste your limited allotment on unhealthy choices.  Use good fats such as the following:

  • Omega 3 Oils like fish, flax or hemp
  • Olive oil
  • Avocado
  • Cold water fish – like salmon and trout

And you can also try C8 and C10 oils which are two type of medium chain triglycerides isolated from coconut oil which do not require bile for digestion. Therefore, not only are they readily absorbed, but may not affect the bowel. Note that you need to start extremely slowly as they commonly cause bowel issues if not taken in very small doses while your body acclimates.


Bile acid diarrhea or bile acid malabsorption is a condition; it is not caused by supplemental bile salts. You can get loose stools or diarrhea by taking too high doses of bile salts, but this can be easily modified to your comfort if you buy small capsules with lower milligrams. The ability of bile salts to move the bowel is one of its virtues and appreciated by many people.  Just use your common sense, and start slowly.