Dealing with Bile Salt Malabsorption

Bile salts are produced in the liver. They are included in the bile and sent to the gallbladder, where the bile is concentrated and stored. When the stomach empties its contents into the upper intestines (duodenum) for further digestion, the gallbladder releases the bile into the duodenum to aid in the digestion of fats in the food.

If bile salts are not absorbed properly, they are passed into the intestine where they can cause diarrhea. If your gallbladder has been removed, bile constantly trickles into your duodenum and small intestine – while this is not usually a problem, a percentage of people without a gallbladder will have digestive problems – either because of too much bile (causing diarrhea) or too little (causing improper digestion of fats and indigestion – a bile salt supplement is recommended).

The diarrhea may be watery, and frequently occurs after meals. Testing of the diarrhea specimens will reveal excess amounts of bile salts (acids) present. While the disorder is not life-threatening, it can disrupt normal life due to the number of trips to the bathroom.

Causes of Bile Salt Malabsorption

woman stomach ache bile acidBile salt malabsorption is connected to two primary diseases: Crohn’s disease and Irritable Bowel Syndrome. However, it is difficult to determine if the malabsorption causes the diarrhea in those diseases, or if the diseases themselves trigger the malabsorption.

The lower part of the small intestine, called the ileum, is responsible for absorbing bile salts. In patients who have had part of their ileum removed, bile salt malabsorption is common.

Another possible cause of bile salt malabsorption is pancreatic insufficiency. In other words, improper function of the pancreas. This can be the result of alcoholism, but can have other causes as well.

If you have had your gall bladder removed, you may experience this as well – about 5% of patients report painful diarrhea after surgery, which does not abate. Studies show that the liver sometimes produces extra bile salts to compensate for the lack of a storage area for bile. This excess bile overwhelms the small intestine and spills over into the colon, where it acts as a laxative.

How Intestinal Bacteria Relates

Recent studies show that the malabsorption of bile acids may also be due to improper balance of intestinal bacteria. The body normally maintains about 400 types of good bacteria (called probiotics) in the intestinal tract. These flora can be killed off when antibiotics are taken for infection. The resulting imbalance of intestinal bacteria may contribute to failure to properly absorb bile salts. (Whenever I take antibitotics, I always take a probiotic supplement afterward.)

Treatment for Malabsorption

The most common treatment for bile salt malabsorption is bile salt binders, called sequestrants. The most common binders are cholestyramine and colestipol, which are both available by prescription. Even though these drugs are effective at stopping the diarrhea, they are often hard for patients to tolerate. Side effects can include abdominal pain and bloating. Other possible treatments may include:

  • Welchol (Colesevelam) – a newer drug called Welchol – generic name of colesevelam, is said to be 4 times more potent than traditional binders. This drug has shown fewer side effects and greater likelihood of success. It is available by prescription.
  • Medi-Clay – a purified bentonite clay product that adsorbs excess bile salts in a similar way that the drugs do. Although not as potent, every body is different and some may get better results with this.
  • Apple Pectin – also helpful for binding excessive bile acids
  • Probiotics – because some research points to an imbalance of intestinal bacteria, it may be helpful to supplement with probiotics. These supplements are natural, have few, if any side effects, and can be beneficial for dealing with other digestive disorders. They help gas, bloating, and diarrhea in certain cases. Because of their safety, probiotics may be an excellent way to support the digestive process and correct the cause of bile acid malabsorption. (Probiotics are also found in yogurt.)
  • Pancreatic Support – because some bile salt absorption is linked to poor function of the pancreas, treatments that support the pancreas may help the problem. Pancreatic enzymes are readily available over the counter and help the digestion of proteins and fats.

  • Brenda says:

    I was diagnoised recentley with bile salt malabsorbtion. I am finding it very hard to get to grips with it all and wondered if anyone out there has any tips on how to come to terms with it and accept the condition.

    • bob says:

      order cholestrymne from your pharmacy

    • Hemma says:

      I’ve also just been diagnosed with Bile Salt Malabsorption and tryied a liquid medicine which I found very difficult to take,& didn’t help at all and now I’m on Colesevelam and it works most of the time although I’m still getting a lot of the effects e.g tiredness, pain,gagging,nausea,dizziness, some diarrhoea. Some days feel like the meds are not working and other days I feel like I’m finally getting through the worst of it.
      Going to see my consultant agin next week.
      To everyone who has left comments I really feel your pain BSMA is truly life changing.

  • Daisy says:

    I hear you. I had a resection done because of a bowel obstruction/crohn’s disease, and to my disappoinment, I’ve had diarrhea ever since, several times a day, every day for years. The doctor prescribed Questra which does stop the diarrhea, but a day after taking it, I end up with the worst case of bile reflux that ends up in my esophagus and is very painful. I am trying to find natural remedies that will help better than the doctor’s medication.

    • Sandy says:

      Daisy, I too am in the suffering throws of life and am trying to help myself as everything the Dr. has perscribed for me hasn’t even made a dent in my Nausea. 13 months and it still is there. The only thing that helps is if I take a 1/2 an oxycodone. I don’t like or want to take it but after all this time I’m about to scream (which I have done many times). I wish the medical field would tell you what the consequenss are or can be as I did not exspect this.
      Good luck and God help us all.

  • Kathy says:

    I tried Questran (cholystyramine) and although it worked most of the time, I hated trying to time it with other pills, including vitamins, and it was difficult to take if I was out somewhere. By accident, I discovered that Garcinia Cambogia works even better. I wanted to lose a few pounds, and had to choose between the Questran and the Garcinia because of the timing, and after a few days discovered that I was having much less diarrhea. Garcinia works to reduce fat absorption in the liver, and I don’t know why it seems to stop the bile salts diarrhea, but it does. Twice a day, 1/2 hour before meals. Worth a try. Would love to know if it works for anyone else.

    • Annabelle says:

      I had a small bowel resection 2 years ago due to Crohn’s and I have struggled with diarrhea ever since. Tried Questran and at first things were better. It was difficult to be able to take it regularly because of other meds I’m on then I started to get painful trapped wind so I stopped it. I am existing on an Imodium equivalent I buy in bulk but even that is becoming hit and miss. I will have a look at the Garcinia Cambogia, anything is worth a try as long as it is okay with my other meds. I took Yakut every day for a long while but it made no difference. I almost wish I had ended up with a colostomy bag I have felt so desperate at times.

      • Denise says:

        Hi Annabelle

        My situation is the same, I started taking Questran Light two weeks ago and my stomach is completely swollen due to trapped wind, my consultant suggested that I stop taking them, I stopped taking them two days ago and the swelling is slowing starting to go down however I am now visiting the toilet approximately 20 times a day

        I just wanted to ask if you started the Garcinia Cambogia? And if so did it work? and were there any side effect?

        I hope you are feeling better.

  • Cherie Phillips says:

    Goodluck! I have tried everything from Probiotics to total food elimination to resolve my problem spend a absolute fortune on doctors and alternatives. Finally a Colon Rectal Surg. recommended Questran Lite.

    Fantastic, however I have had to adjust the dose to suit my own requirements. I am now only taking 1 sachet per day with my morning juice.

    Finally I can leave my home without wondering if I can find a toilet in time.

    I wish you all the best!

  • Angela Davis says:

    , I’ve had this problem for a year, following resection. I have seen a top nutritional therapist privately. She was excellent and has treated lots of people successfully, but she didn’t seem to be helping me and my problem was getting worse. A few weeks ago she told me to try the meds from the Dr. I was v disappointed, but am trying Colesevelam, which is quite different from questram,/ cholestyramine. It is apparently more successful and better tolerated. I react v strongly to drugs, so am taking a v small dose, but it is working. I still have a very restricted diet but hope to introduce things gradually. I have a small stomach pain from the colesevelam, but I can tolerate it if I don’t have to have the diarrhoea. See if you can get this drug prescribed.

  • Lisa says:

    I had my gallbladder removed a year ago. Within the last month I’ve found myself doubled over in severe pain after every meal. I strictly changed my diet back to no fats- plant based only. I’ve done this for a month now. I found relief for 3-4 weeks then the pain came back even with a no fat diet. I tried pro-biotics as well. No change, possibly worse. On a whim I took some cholacol from Standard Process thinking “Well things can’t get any worse.” And actually it got better. I am able to eat without severe pain. I still don’t feel completely ‘right’ and I’m still on a plant based diet. Going to a gastroenterologist soon to hopefully get some answers. Otherwise- looks like bile salts are a fix.

  • Anne says:

    I have a gallbladder – but had gallbladder attacks during pregnancy 30 years ago.
    I have many health problems now…including psoriasis and arthritis. A friend who is a Registered Nutitionist suggested I take Bile salts and eat fermented foods (probiotics). Even before I started eating fermented foods, the psoriasis started to clear up quickly – (3 weeks for a 75% improvement), I also always had diarrhea (was afraid to mention it to the doctor as I didn’t want to be told I have Crohns also). Ironically taking bile salts ended my diarrhea.
    BUT…a homeopath, and a MD say my liver is not working…(I do not drink alcohol – never drank more than 4 – 6 a month, but took prednisone for 2 years when I was 16). The homeopath says that when your liver is not functioning you get twitcy pain in the left side just under the rib cage and you get pain between the shoulder blades and tingling fingers in the right hand. All three of those symptoms have returned since I started to take Bile Salts……why? What may help? (I can’t ask the homeopath – as he would not approve of me taking the Bile Salts – I have quit going to him because he doesn’t want his patients to take anything EXCEPT meds he makes.

  • Dawn says:

    I had a bowel disection over two years ago and have been suffering with diarrhoea ever since . now found out I have very low bile salt absorption. Being forwarded to a gastroenteritis.

  • Liz says:

    Cholacol from standard process. you can get it on Amazon.

  • Jenn says:

    I just got diagnosed with BAM.. I am on questran.. Mixed with orange juice does make it tolerable.. It’s not a fix all.. But I’m not running to the bathroom every hour. I go to see a liver specialist at Cleveland clinic and between him and my gastro…. They figured it out on my first visit…

  • Margaret says:

    I was diagnosed with bile salt malabsorption two years ago and have been on Colesevelam ever since. I had radiation treatment to my pelvis for cervical cancer in 1991 and have suffered with diarrhoea on a daily basis for years. The medication has helped with the watery diarrhoea, but I still have big problems with finding a loo in time and also leakage. I also suffer from attacks of stomach cramps and sickness. I have tried altering my diet, but nothing seems to help. All these problems make life very difficult, travelling on public transport or going on holiday is stressful.

  • Katie says:

    I started taking Pancreatic Enzymes from Pure Encapsulations and it stopped the attacks of pain in my sternum after Gallbladder surgery in 2012 and the chronic diarrhea. I strongly suggest to give this a try.

  • Jerry says:

    I had a small kidney stone about a year ago. After a round of anti-biotics, my anus began to itch and/or burn. I’ve been examined:no hmroids, no fizures…colonscopy is clear, CT Scan clear…

    Nothing seems to be helping, including probiotics. I’ve even had a PT working on my pelvic floor.

    I use wipes with witch hazel and aloe which sometimes provides relief.

    Any suggestions? (I want my life back)

  • Dawn says:

    I have been battling chronic diarrhoea for 13 months in July tested strongly positive for bile acid malabsorption started me on question powders then coleveslam tablets but still not right. Had to return to my conultant who ordered me to have another colonoscopy still waiting on the results but have been put on steroids in the mean time. It is looking like I have Chron’s disease as well. If any of you are not happy with your medication keep on at doctors otherwise you will be left as long as I am for a diagnosis. Last 13 months have been hell given up work temporary, have been a recluse due to urgent toilet needs.

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