Struggling with IBS-D? Did you know it could be related to bile acid diarrhoea (BAD)? You might not have heard of this, but some studies show that around 34% of people with Diarrhoea predominant IBS may have BAD.

In this episode I'll cover

• What are bile acids, and how do we make them?
• What conditions could lead to issues with bile acid reabsorption?
• How would a doctor test for bile acid malabsorption, and what medication is available?
• Diet suggestions for bile acid diarrhoea

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If you're struggling with diarrhoea

predominant IBS, you might be surprised

2

to know that around 34%, that's

almost a third of people with IBSD

3

may have something called bile acid

diarrhoea or bile acid malabsorption.

4

And that's what I'm going to cover in this

episode of the Inside Knowledge podcast.

5

I'll cover what are bile acids,

how do we make them, and why

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would you not be reabsorbing them.

7

I'll also be going through treatment

and testing for bile acid diarrhoea,

8

so that you can have a good

conversation with your doctor about

9

whether this could be the cause of

10

Welcome to episode 52 of the

Inside Knowledge podcast.

11

I'm Anna Mappson.

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The reason I selected bile acid

diarrhoea as a topic for this week's

13

podcast is that I see it quite often

linked with SIBO, that is small

14

intestine bacteria overgrowth, that

is also a slightly unknown Cause of

15

bloating and gas, but this is one of

the consequences of having that SIBO.

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So, you know that I've recorded

previous episodes about SIBO, so you

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can listen to episode 11, 12, And

thirty one about how to treat SIBO.

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But, let's go right back to the beginning

and talk about what are bile acids.

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So, bile is made in your liver and

then it's stored in your gallbladder.

20

And when you eat anything, your

gallbladder gradually drips out bile.

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And this helps with the

breakdown of fats in your food.

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When we can better absorb fats, we can

then also absorb fat soluble vitamins,

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which is vitamin A, E, D, and K, and

also just really get the nutrition

24

out of our food that involves fats.

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As your food then moves through the

small intestine, as they get to the

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end of the small intestine, these bile

acids should be reabsorbed back into

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your bloodstream, and they go back to

your liver in the blood as the food

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waste moves towards the end of the

intestine and into your large intestine.

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And about Two to five percent of

these bile acids will be excreted

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in the poo, but most of it gets

recycled, which is very, very clever.

31

So somewhere like 95 to 98 percent

will go back up in the blood and then

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go to the liver and be used again.

33

Bile acids are actually made

from cholesterol as well.

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And when we talk about some of the

medication that you can take, there

35

is also a link with that, because

if you're taking more bile acids.

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out.

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It can also affect your blood

lipids, like your cholesterol levels.

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The reason that this gives you

diarrhoea though, when it travels

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to the large intestine is that

these bile salts really irritate

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the lining of your large intestine,

which causes cramps and irritation.

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And that's very hypersensitivity

feeling, but also it draws water in

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and which creates the watery diarrhoea.

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So this is something that might not be

related to your actual food, you know,

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it's not necessarily down to what food

you're eating, but it's down to how your

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body is processing and digesting it.

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And I wanted to talk about it in this

episode as well because it is so common.

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It's basically one in three people

who've got IBSD may actually have

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this problem with their bile salts.

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And the symptoms are pretty

much the same as normal IBSD, so

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particularly watery diarrhoea.

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And that is when you know, it's

really urgent and very liquidy.

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So I'm not talking about

like just mushy stools.

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And if you go back to the Bristol

stool chart and have a look at

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that, it wouldn't be if you were

getting like type 5 or type 6.

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I'm talking about literally

like, watery very loose stools.

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Another thing that is commonly linked to

bile acid malabsorption is incontinence

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because of this severe urgency.

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So you may even get some leakage or be

having more frequent accidents as your

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body is trying to get rid of this excess

bile acids and all this excess liquid.

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In terms of the type of poo as well, it

might be particularly green or yellow.

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The green is down to the bile

colour but also the yellow may be

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indicating a malabsorption of fats

and it can sometimes be quite frothy

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and certainly quite smelly as well.

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Some people have a sort of genetic

predisposition to this, and they

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call it Primary Bile Acid Diarrhoea,

or Primary Bile Acid Malabsorption.

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And that is when your body is

just making too much bile acid,

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so it can't be reabsorbed.

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But, a lot of the cases, when It's not

being reabsorbed, so it's more down

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to the fact that you're making the

right amount but your body's just not

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recycling it properly and then it's

going to the large intestine where it's

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causing that irritation and the problems.

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The other things that we know cause it is

if you've had some damage to your small

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intestine and that would be Because, your

body is stopping the reabsorption process

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due to some damage in the small intestine.

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So, maybe you've had part of your ileum

removed, that's like the last little bit.

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Maybe you've got an ileostomy bag.

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Perhaps you've got IBD, something

like Crohn's disease or some other

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abdominal surgery that could have

upset your nutrient digestion.

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Another reason is sometimes people

have coeliac disease and again due to

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Undiagnosed coeliac disease, you may

have an issue with absorbing nutrients

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because the small villi, these are

like small finger like protrusions

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that stick out into the small intestine

and help you absorb your nutrients.

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In untreated coeliac disease, where

you're constantly exposed to gluten,

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They can flatten and they can become

less able to absorb nutrients.

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Now, I mentioned at the beginning

that the bile is made in the

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liver, stored in the gallbladder.

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So some people will have had their

gallbladder removed and this could

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be if you were frequently getting

gallstones and that would be making

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the bile that should be just dripping

out as we eat, very sludgy and

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some little hard stones in there.

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So if you've had the gallbladder

removed, what will happen is that your

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bile will just drip out constantly.

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It doesn't come out only when we eat.

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It's not triggered to release

on the digestion of food.

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It will just gradually drip, drip

out and this can also really affect

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people's digestion and can create

some of those really loose stools.

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And then the other reason why you

might have this bile acid absorption

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problems is down to an overgrowth

of bacteria in your small intestine.

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And this has also been shown to affect

the reabsorption of the bile acids.

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So SIBO might increase your transit time.

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So that's like your digestion gets

sped up and that's because you're not

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digesting your carbohydrates properly.

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And you get drawing water into the

small intestine that pushes things

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through much quicker and therefore

that might also be affecting the time

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allowed for the bile acid malabsorption.

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So if this is ringing a few bells

for you and you're thinking, oh, I

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wonder if this is my problem with

diarrhoea, then it's definitely worth

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a conversation with your doctor to see

if they think your symptoms might be

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might line up with this kind of profile.

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The test that they can do is called a

SeCAT scan and basically it helps to

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look at whether you are reabsorbing those

bile salts or not or whether they are

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being excreted into your large intestine.

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So it's slightly strange that

you swallow a little capsule with

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some radioactive material in it.

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And I know that sounds a bit

scary, but it's not really.

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It's just a very, very small amount.

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You swallow this, uh, and this

obviously is done in a hospital.

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And then, uh, What it does

is it's like a tracer.

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So it's this radioactive material

that can be shown up inside your body.

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So you firstly go and have one scan

like a couple of hours after taking

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this first radioactive tracer.

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And then you come back in a week and see

how much you have been reabsorbing or how

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much has been excreted in the second scan.

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This is the way a doctor can

diagnose you with problem in

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reabsorbing your bile salts.

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The only other way you can look

at it is actually looking at the

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level of bile acids in your poo,

which can be done in a stool test.

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And sometimes it's done

over multiple days.

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So it's looking at how much on

average is present in the poo.

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Sometimes I will run a stool test with

some of my clients but obviously when I

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do it, it's just a private test and it's

just a one off quite expensive test, which

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is why I don't do it with most people.

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However, some hospitals will do it looking

at your stool results over multiple days

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in order to get a profile of how much is.

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And that's another way to do

it, just because I think the

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SeCAT test is very expensive.

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And obviously it's not suitable

for everybody because it is

138

using, a low level of radiation.

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I'll come on to a little bit

about treatment and diet,

140

especially in just a minute.

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Bye.

142

I also wanted to talk about what happens

to the bile salts in the large intestine,

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because I think it's really interesting.

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It's a bit of a two way relationship.

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We know that having a high level

of bile salts in your large

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intestine can affect the microbiome.

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It can affect the ecology, the

environment for your gut microbes which

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can then affect digestion of other

carbohydrates and other compounds in

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your food which can give you other

symptoms as well and we know that the

150

bacteria also work on the bile salt

so it is really a two way process.

151

And there is some really small bit of

interesting research looking at the

152

difference in the gut microbe diversity

of people who've got bile acid diarrhoea

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compared to people who've got IBSD.

154

So sometimes you might have diarrhoea

predominant IBS, which has nothing to do

155

with your bile salts., and they compared

people by diagnosing them with this SeCAT

156

scan first, like I just mentioned, and

then they looked at the gut microbes that

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were in this pool of research people.

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And people who had bile acid diarrhoea

had a lot less diversity in their

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large intestine blood vessels.

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So, as you know, if you've listened to

my podcast a lot, we want good diversity

161

in our gut microbes because this is

better associated with overall health.

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We also could see from this study that

people who had bile acid diarrhoea had

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different levels of the short chain

fatty acids that the gut bacteria make.

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When fibre and carbohydrates come

to the large intestine, our gut

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bacteria normally make something,

these short chain fatty acids that

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are really beneficial for our health.

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And there's no sense from

this, research paper that I'm

168

mentioning that this is bad.

169

It's just that we could see a different

profile of these fermentations.

170

So these are like the results of the

fermentation by our gut bacteria.

171

And that's probably because

there were different gut bacteria

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there in the first place.

173

Because if you've got high levels

of bile salts, it affects the types

174

of microbes that want to grow there.

175

So, um, We know that there are

slightly different bacteria that love

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to live in that sort of environment.

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Whereas people who don't have high

levels of bile salts will have,

178

again, another set of gut microbes.

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Now, it's really difficult when we talk

about what is a healthy gut, because

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there isn't really a good sense of what

we're looking for, what we're aiming for.

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But we do know that majority of

research papers are all pointing in

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the same direction, saying that More

diversity is good and that there are

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some bacteria that seem to be associated

with things like obesity, heart disease,

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or kind of metabolic conditions.

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And that's probably down to

the types of food we eat.

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So we never really know, again,

what is it that comes first?

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Is it the gut microbes?

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Is it the food?

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They're very, very interlinked and it, I

always feel a little bit nervous talking

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about gut bacteria because there is, So

much research about it, but it doesn't

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really necessarily tell us that much

clinically about what we should be doing,

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you know, on a day to day basis, what

an individual person should be eating

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or not eating other than, you know, eat

lots of fruits and vegetables and whole

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grains, pulses, nuts and seeds and all

of those things that are high in fibre.

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It doesn't necessarily, um, mean,

Oh, you've got this certain bacteria,

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therefore you need to eat this food.

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So I think we're not really at

that sort of level of understanding

198

yet about the gut microbes, but

it is a really interesting area.

199

And I'm sure more will come out over the

years if you see the amount of research

200

papers that are around the gut microbes

and, you know, digestion generally.

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It is huge.

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It's a hugely, popular research area.

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Oh, anyway, that was just a little

aside about gut bacteria and bile salts.

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But, if you're listening to this and

thinking, actually, maybe I have got

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this problem, um, then let's just

talk about what you can do about it.

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So, firstly, if the reason that you've

got the bile acid diarrhoea because you're

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not absorbing these bile salts, and if

it's down to another condition, like maybe

208

you've got Crohn's or you've got coeliac

disease, the first line of treatment is to

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get that condition under control because

it may help your overall digestion and

210

reduce down the problems of diarrhoea

resulting from bile acid malabsorption.

211

If your doctor doesn't know why you've

got bile acid diarrhoea, sometimes

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that's called idiopathic, it means that

the cause is unknown, then your doctor

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might prescribe some medication that

helps you to bind the bile acids in the

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large intestine and stop them causing

that irritation to your gut lining.

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So then that would stop the

loose frequent stools that

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feel very, very out of control.

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The most popular brand that I see my

clients taking is Colostyramine and this

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is a cholesterol lowering medication.

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And that's why it does need to

be doctors who are prescribing it

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because if your cholesterol is being

lowered, you need to have some checks

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on how your body is coping with that

lower level of cholesterol because

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cholesterol is also used for making

your hormones, for your cells.

223

skin health, all kinds of things.

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So that's the medication you may

be offered, and it's definitely

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worth a discussion with your doctor.

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But in terms of diet, there isn't

really that much evidence about

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how to support bile acid diarrhoea.

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However, most of the advice

that is in research papers and

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also just that I know sort of

clinically that works is two things.

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One, increasing fibre in your

diet and reducing down your fats.

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If you're drinking a lot of coffee as

well, do consider Whether you can cut

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down a little bit on that, because

coffee might also be stimulating the

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release of bile from the gallbladder.

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So just think about whether you're

having a lot of coffee as well.

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And we know that coffee also

really does set off diarrhoea

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anyway in a lot of people.

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Either by the caffeine or by

some of the other compounds in

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coffee called chlorogenic acid.

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And that has been shown to trigger

a need for bowel movements.

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So even in Decaf coffee.

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Some people will get more diarrhoea when

they're drinking a lot of decaf coffee.

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If we were going to look at how to

increase your fibre, so the, the way

243

this helps is that higher fibre diets

can affect the bile acids, because

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it's binding to the bile acids,

as well as it's feeding the good

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microbes in your large intestine,

which supports a healthy gut lining.

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Particular types of fibre that you can

try is like the gel forming fibres.

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So things like seaweed and

oats, as well as like chickpeas.

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These are quite good because

they're helping to create, that

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sort of formed, but softer stool.

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So if you.

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aren't sure about things like chickpeas,

you can just start with a very small

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amount and just testing out your

tolerance to them, checking that it's not

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going to make things worse, obviously.

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Now all of us should be aiming

for somewhere between 25

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to 30 grams of fibre a day.

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That can be really challenging if

you're also getting IBS type symptoms

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like bloating and gas and those

things when you eat a high fibre diet.

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This is where low FODMAPs can be really

really helpful, so things like berries,

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carrots, brown rice and quinoa, potato

with their skin on, other fruits like

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bananas, you can include kiwis, oranges,

like just trying to get in as many high

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fibre but low FODMAP foods as you can.

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In order to increase your fibre,

some people feel good with

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supplementing with psyllium husk.

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And another type of fibre that I sometimes

use with people is partially hydrolyzed

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gua gum or PHGG, which is also low FODMAP.

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Whereas the psyllium is not

necessarily going to be low FODMAP.

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Now, if you get on well with apples

and I know they are high FODMAP and

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not great for some people, but the good

thing about apples is that they've got

269

this fibre in them called pectin, which

is a very good binding type of fibre.

270

Stewed apple is sometimes a really good

way to get the apples in Test it out a

271

little bit and if you get on well with

it just cook up an apple Mash it down

272

You can put it in with a bit of yogurt

put it in your porridge or just eat it

273

on its own In terms of the fat reduction.

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Some people feel better on a low fat

diet And it may be really help to

275

reduce down the frequency of your

bowel movements, the urgency, as well

276

as , reducing the amount of gas, so

flatulence and burping and the kind of

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like noisy digestion that you often get.

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So, because Like I said at the

beginning, fat is important in our

279

diet, and we do need some of it.

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We may need to supplement with

some fat soluble nutrients,

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like vitamin A, E, D, and K.

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And also, we just want to make

sure that a low fat diet is being,

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um, implemented in a healthy way.

284

Some people feel that, getting less

than 40 grams of fat per day is a way

285

of managing bile acid malabsorption.

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Now this is a very low fat diet, which

means you would need to cut out a

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lot of fatty meats all butter, like

high fat dairy, chocolates, and then

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things like biscuits and cakes as well.

289

Like I said, it really is best to work

with someone who really understands diet

290

overall because you don't want to go

too low with your fats or your calories.

291

You want to make sure that you are

getting some healthy fats in there

292

where you can and also just making

sure that your diet is overall

293

giving you everything that you need.

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But those are the two sort of dietary

approaches if you have been diagnosed

295

with bile acid malabsorption.

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I hope that's given you a little overview

of bile acid diarrhoea and if you want

297

to ask me any questions about it Then

please do send me an email And if you've

298

got a topic you'd like me to cover in

a future episode you can send me an

299

email at info@goodnessme-nutrition.com.

300

And I will get back to you.

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I'll leave it there for this week though.

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Thank you very much for listening to

this episode of the Inside Knowledge.

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For people with IBS., better

digestion for everyone.