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Bile Acid Malabsorption: Causes, Symptoms & Treatment

Bile acid malabsorption occurs when the intestine fails to reabsorb bile acids properly, leading to chronic diarrhea and impaired fat digestion.

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Things worth knowing about "Bile Acid Malabsorption"

Bile acid malabsorption occurs when the intestine fails to reabsorb bile acids properly, leading to chronic diarrhea and impaired fat digestion.

What is Bile Acid Malabsorption?

Bile acid malabsorption (BAM), also referred to as bile salt malabsorption or bile acid loss syndrome, is a condition in which the body loses an excessive amount of bile acids through the stool. Under normal circumstances, bile acids produced by the liver are released into the small intestine to help digest dietary fats. Around 95% of these bile acids are reabsorbed in the terminal ileum (the last section of the small intestine) and recycled back to the liver via the enterohepatic circulation.

When this recycling process is disrupted, excess bile acids reach the colon, where they stimulate fluid secretion and cause chronic diarrhea. At the same time, insufficient bile acids in the small intestine impair fat and fat-soluble vitamin absorption.

Causes

Bile acid malabsorption can be caused by a variety of underlying conditions and procedures:

Surgical removal of the terminal ileum (e.g., due to Crohn's disease or colorectal cancer)
Crohn's disease affecting the terminal ileum
Short bowel syndrome
Idiopathic bile acid malabsorption (no identifiable cause, also called primary BAM)
Radiation enteritis following abdominal radiotherapy
Small intestinal bacterial overgrowth
Cholecystectomy (gallbladder removal), which can accelerate bile acid delivery to the colon in some patients

Symptoms

Symptoms arise from two main mechanisms: irritation of the colon lining by excess bile acids, and impaired absorption of fats and fat-soluble vitamins in the small intestine.

Chronic watery diarrhea (cholerheic or bile acid diarrhea)
Steatorrhea – pale, greasy, foul-smelling stools caused by fat malabsorption
Abdominal bloating and cramping
Unintentional weight loss in severe or prolonged cases
Deficiency of fat-soluble vitamins (A, D, E, K) in advanced stages

Diagnosis

Several diagnostic approaches are used to confirm bile acid malabsorption:

SeHCAT test (selenium homocholic acid taurine test): A nuclear medicine scan considered the gold standard. A radiolabelled bile acid is swallowed and its retention in the body is measured after 7 days.
Serum C4 (7-alpha-hydroxy-4-cholesten-3-one): A blood marker that is elevated when bile acid synthesis is increased due to malabsorption.
Serum FGF19 levels: Low levels may indicate impaired ileal reabsorption of bile acids.
Stool bile acid measurement: Direct quantification of bile acids in fecal samples.
Therapeutic trial: A positive response to bile acid sequestrants such as colestyramine strongly supports the diagnosis.

Treatment

Treatment is tailored to the underlying cause and severity of the condition:

Bile Acid Sequestrants

Medications such as colestyramine or colesevelam bind excess bile acids in the colon, reducing mucosal irritation and improving diarrhea. They are often the first-line treatment for symptomatic relief.

Dietary Modifications

A low-fat diet can significantly reduce symptoms. In cases of severe fat malabsorption, medium-chain triglycerides (MCT) may be recommended, as they are absorbed without requiring bile acid emulsification.

Treatment of Underlying Conditions

Managing the underlying cause -- such as controlling inflammation in Crohn's disease -- is essential to minimize ongoing bile acid loss.

Fat-Soluble Vitamin Supplementation

Patients with prolonged bile acid malabsorption may require supplementation of vitamins A, D, E, and K to prevent deficiency-related complications.

References

Walters JR, Arasaradnam R, Andreyev HJ. Bile acid malabsorption - a missed diagnosis? Frontline Gastroenterology. 2020;11(1):40-45. PubMed PMID: 31885833.
Camilleri M. Bile Acid diarrhea: prevalence, pathogenesis, and therapy. Gut and Liver. 2015;9(3):332-339. PubMed PMID: 25918264.
Aldini R, Roda A, Festi D, et al. Bile acid malabsorption and bile acid diarrhea in intestinal diseases. Digestive Diseases and Sciences. 1982;27(6):495-502.

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