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Bile Acid Malabsorption Syndrome – Causes and Treatment

Bile acid malabsorption syndrome is a digestive disorder in which excess bile acids reach the colon, causing chronic diarrhea. It often occurs after bowel surgery or in association with chronic intestinal diseases.

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Things worth knowing about "Bile Acid Malabsorption Syndrome"

Bile acid malabsorption syndrome is a digestive disorder in which excess bile acids reach the colon, causing chronic diarrhea. It often occurs after bowel surgery or in association with chronic intestinal diseases.

What is Bile Acid Malabsorption Syndrome?

Bile acid malabsorption syndrome (BAM), also referred to as bile acid diarrhea (BAD), is a condition in which bile acids are not adequately reabsorbed in the small intestine. Under normal circumstances, bile acids are almost entirely recirculated from the terminal ileum back to the liver via the enterohepatic circulation. When this process is disrupted, surplus bile acids enter the colon, where they irritate the mucosal lining and trigger chronic watery diarrhea.

Causes

Bile acid malabsorption syndrome is classified into three types based on its underlying cause:

Type 1 (secondary BAM): Results from structural damage to the terminal ileum, such as that caused by Crohn's disease, ileal resection, or radiation-induced enteritis.
Type 2 (idiopathic BAM): No identifiable organic cause; thought to be related to reduced levels of FGF-19, a hormone that regulates bile acid synthesis in the liver.
Type 3 (associated BAM): Occurs alongside other gastrointestinal or systemic conditions, including chronic pancreatitis, coeliac disease, cholecystectomy, or diabetes mellitus.

Symptoms

The symptoms of bile acid malabsorption syndrome are often non-specific and can be easily confused with irritable bowel syndrome (IBS). Common symptoms include:

Chronic, watery diarrhea (often occurring after meals)
Abdominal cramps and bloating
Urgency to defecate
Fatty stools (steatorrhea) in more severe cases
Weight loss in prolonged malabsorption
Deficiency in fat-soluble vitamins (A, D, E, K) in chronic cases

Diagnosis

Diagnosing bile acid malabsorption syndrome can be challenging, as there is no single widely available standard test. The following diagnostic approaches are used:

SeHCAT test (selenium-75 homocholic acid taurine test): Considered the gold standard in countries where it is available; measures the retention of radiolabelled bile acids over 7 days. A retention rate below 15% indicates bile acid malabsorption.
Serum FGF-19 measurement: Low FGF-19 levels may indicate impaired bile acid reabsorption and increased hepatic synthesis.
C4 measurement (7-alpha-hydroxy-4-cholesten-3-one): Elevated blood levels indicate increased bile acid synthesis, consistent with malabsorption.
Stool tests and exclusion of other causes (e.g., colonoscopy, blood tests)

Treatment

Treatment of bile acid malabsorption syndrome depends on the underlying cause and the severity of the condition.

Pharmacological Treatment

Bile acid sequestrants (anion exchange resins) are the primary treatment option. They bind excess bile acids in the intestine, preventing their irritating effect on the colon. Commonly used agents include:

Cholestyramine (older agent, less well tolerated)
Colesevelam (newer agent, generally better tolerated)

Dietary Modifications

A low-fat diet can help alleviate symptoms, since dietary fat stimulates bile acid secretion. Medium-chain triglycerides (MCT fats) are better tolerated as a fat source, because they can be absorbed without the need for bile acids.

Micronutrient Supplementation

In severe or prolonged cases, deficiencies in fat-soluble vitamins (A, D, E, K) and vitamin B12 should be assessed and corrected through appropriate supplementation.

Treatment of Underlying Conditions

When a treatable underlying condition is present -- such as Crohn's disease or coeliac disease -- optimal management of that condition is essential for controlling bile acid malabsorption syndrome.

References

Camilleri M. et al. - Bile Acid Diarrhea: Prevalence, Pathogenesis, and Therapy. Gut and Liver, 2015; 9(3):332-339.
Walters J.R. - Bile acid diarrhoea and FGF19: new views on mechanism, diagnosis and treatment. Nature Reviews Gastroenterology and Hepatology, 2014; 11(7):426-434.
National Institute for Health and Care Excellence (NICE) - Bile acid malabsorption: diagnosis and management. NICE Guideline, 2023.

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