Bile Acid Malabsorption – Causes, Symptoms and Treatment
Bile acid malabsorption is a digestive disorder in which bile acids are not properly reabsorbed in the small intestine, leading to chronic diarrhoea and digestive discomfort.
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Bile acid malabsorption is a digestive disorder in which bile acids are not properly reabsorbed in the small intestine, leading to chronic diarrhoea and digestive discomfort.
What is Bile Acid Malabsorption?
Bile acid malabsorption (BAM), also known as bile salt malabsorption, is a condition of the digestive tract in which bile acids are not adequately reabsorbed in the small intestine. Under normal circumstances, bile acids are almost completely recaptured in the final section of the small intestine, known as the terminal ileum, and recycled back to the liver via the bloodstream. When this process is disrupted, excess bile acids pass into the colon, where they stimulate water secretion and cause chronic, watery diarrhoea.
Causes
Bile acid malabsorption is classified into three types:
- Type 1 (secondary form): Results from a disease or surgical procedure affecting the terminal ileum, such as Crohn's disease, ileal resection, or radiation enteritis.
- Type 2 (idiopathic form): Occurs without an identifiable underlying cause. It is the most common form and is frequently misdiagnosed as irritable bowel syndrome (diarrhoea-predominant type).
- Type 3 (associated form): Occurs alongside other conditions, including chronic pancreatitis, coeliac disease, cholecystectomy (gallbladder removal), or gastric surgery.
Symptoms
The typical symptoms of bile acid malabsorption include:
- Chronic, watery or loose diarrhoea (often multiple times per day)
- Abdominal cramps and bloating
- Urgency to defecate
- Steatorrhoea (fatty stools) in severe cases
- Weight loss with prolonged illness
- Deficiency in fat-soluble vitamins (A, D, E, K) over time
Diagnosis
Diagnosing bile acid malabsorption can be challenging, as its symptoms overlap with other gastrointestinal conditions. The following diagnostic approaches are used:
- SeHCAT test (75Se-homocholic acid taurine test): Considered the gold standard. A radioactively labelled synthetic bile acid is ingested, and retention is measured after 7 days. A retention below 15% is considered abnormal.
- Serum 7-alpha-hydroxy-4-cholesten-3-one (C4): A blood marker that rises when bile acid synthesis is increased, offering a cost-effective alternative to the SeHCAT test.
- Stool tests: Measurement of bile acid excretion in the stool.
- Exclusion of other conditions (colonoscopy, coeliac serology, pancreatic imaging)
Treatment
Treatment of bile acid malabsorption aims to bind excess bile acids in the intestine and relieve symptoms.
Pharmacological Therapy
- Bile acid sequestrants (anion exchange resins): First-line treatments include cholestyramine and colesevelam. These agents bind bile acids in the gut and prevent them from irritating the colonic mucosa.
- Colesevelam is generally better tolerated than cholestyramine and has fewer drug interactions.
Dietary Adjustments
- Reducing dietary fat intake can decrease bile acid production and help alleviate symptoms.
- Adequate supplementation of fat-soluble vitamins (A, D, E, K) and vitamin B12 should be ensured to prevent deficiencies.
Treatment of Underlying Conditions
In secondary forms (Type 1 and Type 3), managing the underlying condition is a priority -- for example, anti-inflammatory therapy for Crohn's disease.
References
- Camilleri M. et al. - Advances in the management of lower functional gastrointestinal disorders and pelvic floor dysfunction. Gastroenterology, 2022.
- Walters JR. - Bile acid diarrhoea and FGF19: new views on diagnosis, pathogenesis and therapy. Nature Reviews Gastroenterology and Hepatology, 2014.
- National Institute for Health and Care Excellence (NICE) - Diarrhoea and vomiting caused by gastroenteritis in under 5s: diagnosis and management. Clinical Guideline, 2023.
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Related search terms: Bile Acid Malabsorption + Bile Salt Malabsorption + BAM