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.
Table of Contents
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 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
- Increased bowel frequency
- Steatorrhoea (fat in stools)
- Abdominal gurgling
- Lack of control
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).
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
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.
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.
Kirsten Jackson is a UK registered Consultant Gastroenterology Dietitian and founder of The Food Treatment Clinic. She has undergone many qualifications to get where she is today, including a UK BSc Honours Degree in Dietetics and Post-Graduate Certificate in Advanced Dietetics. In addition to this, she has FODMAP Training from Kings College London University. Kirsten set up The Food Treatment Clinic in 2015 after first experiencing digestive problems herself. She felt that the NHS was unable to provide the support individuals needed and went on to specialise in this area before opening a bespoke IBS service. Kirsten also participates in charity work as an Expert Advisor for the IBS Network. In addition, she can be seen in publications such as Cosmopolitan and The Telegraph discussing IBS as an Official Media Spokesperson to the IBS Network.
Julian RF Walters says
Good to raise awareness.
We think that many “IBS-diarrhoea” patients are not malabsorbing bile acids but are actually over-producing them as the intestine is not telling the liver to reduce new synthesis. So we prefer to call it bile acid diarrhoea.
Think about BAD, test and treat with bile acid sequestrants and a low fat diet.
Kirsten Jackson Specialist Dietitian says
Thank you for your feedback Professor!
Can BAM or BAD be treated or cured with Chinese medicine or those type of remedies?
Kirsten Jackson Specialist Dietitian says
Sadly not no.
I have continually diarrehea even medication also takened but after skip medication 5 to 6 letter again condition continue.
Serena Bansal says
Hi Mousa. I am so sorry to hear that you are struggling with this. Please do reach out to us and email on email@example.com if you would like further support with your symptoms 🙂
Hi Kristen, thanks for giving us these other options beyond IBS. I have some kind of fat malabsorption that is unusual. I have had my gall bladder removed. I have lactose intolerance, and when I eat fats I have a floating stool or diarrhea, except when I eat parmesan cheese fat. As you know, Parmesan cheese is aged 2 years so most of the lactose is gone due to the aging. I can eat that cheese with no problems. In fact, when I have a loose stool and I eat parmesan cheese, the loose stool becomes more normal. I eat it every day.
Many thanks for your tips. Best wishes