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
Bile 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.
- 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.