Ep.52 – The possible cause of your IBS-Diarrhoea
19 Jun, 2024

Episode Intro

If you're struggling with diarrhoea predominant IBS, you might be surprised to know that around 34%, that's almost a third of people with IBSD may have something called bile acid diarrhoea or bile acid malabsorption. And that's what I'm going to cover in this episode of the Inside Knowledge podcast. I'll cover what are bile acids, how do we make them, and why would you not be reabsorbing them. I'll also be going through treatment and testing for bile acid diarrhoea, so that you can have a good conversation with your doctor about whether this could be the cause of your IBS.

Podcast transcript

Breathing techniques for IBS

Welcome to episode 52 of the Inside Knowledge podcast. I’m Anna Mappson. The reason I selected bile acid diarrhoea as a topic for this week’s podcast is that I see it quite often linked with SIBO, that is small intestine bacteria overgrowth, that is also a slightly unknown Cause of bloating and gas, but this is one of the consequences of having that SIBO.

So, you know that I’ve recorded previous episodes about SIBO, so you can listen to episode 11, 12, And thirty one about how to treat SIBO. But, let’s go right back to the beginning and talk about what are bile acids. So, bile is made in your liver and then it’s stored in your gallbladder. And when you eat anything, your gallbladder gradually drips out bile.

And this helps with the breakdown of fats in your food. When we can better absorb fats, we can then also absorb fat soluble vitamins, which is vitamin A, E, D, and K, and also just really get the nutrition out of our food that involves fats. As your food then moves through the small intestine, as they get to the end of the small intestine, these bile acids should be reabsorbed back into your bloodstream, and they go back to your liver in the blood as the food waste moves towards the end of the intestine and into your large intestine.

And about Two to five percent of these bile acids will be excreted in the poo, but most of it gets recycled, which is very, very clever. So somewhere like 95 to 98 percent will go back up in the blood and then go to the liver and be used again. Bile acids are actually made from cholesterol as well.

And when we talk about some of the medication that you can take, there is also a link with that, because if you’re taking more bile acids. out. It can also affect your blood lipids, like your cholesterol levels. The reason that this gives you diarrhoea though, when it travels to the large intestine is that these bile salts really irritate the lining of your large intestine, which causes cramps and irritation.

And that’s very hypersensitivity feeling, but also it draws water in and which creates the watery diarrhoea. So this is something that might not be related to your actual food, you know, it’s not necessarily down to what food you’re eating, but it’s down to how your body is processing and digesting it.

And I wanted to talk about it in this episode as well because it is so common. It’s basically one in three people who’ve got IBSD may actually have this problem with their bile salts. And the symptoms are pretty much the same as normal IBSD, so particularly watery diarrhoea. And that is when you know, it’s really urgent and very liquidy.

So I’m not talking about like just mushy stools. And if you go back to the Bristol stool chart and have a look at that, it wouldn’t be if you were getting like type 5 or type 6. I’m talking about literally like, watery very loose stools. Another thing that is commonly linked to bile acid malabsorption is incontinence because of this severe urgency.

So you may even get some leakage or be having more frequent accidents as your body is trying to get rid of this excess bile acids and all this excess liquid. In terms of the type of poo as well, it might be particularly green or yellow. The green is down to the bile colour but also the yellow may be indicating a malabsorption of fats and it can sometimes be quite frothy and certainly quite smelly as well.

Some people have a sort of genetic predisposition to this, and they call it Primary Bile Acid Diarrhoea, or Primary Bile Acid Malabsorption. And that is when your body is just making too much bile acid, so it can’t be reabsorbed. But, a lot of the cases, when It’s not being reabsorbed, so it’s more down to the fact that you’re making the right amount but your body’s just not recycling it properly and then it’s going to the large intestine where it’s causing that irritation and the problems.

 The other things that we know cause it is if you’ve had some damage to your small intestine and that would be Because, your body is stopping the reabsorption process due to some damage in the small intestine. So, maybe you’ve had part of your ileum removed, that’s like the last little bit. Maybe you’ve got an ileostomy bag. Perhaps you’ve got IBD, something like Crohn’s disease or some other abdominal surgery that could have upset your nutrient digestion. Another reason is sometimes people have coeliac disease and again due to Undiagnosed coeliac disease, you may have an issue with absorbing nutrients because the small villi, these are like small finger like protrusions that stick out into the small intestine and help you absorb your nutrients.

In untreated coeliac disease, where you’re constantly exposed to gluten, They can flatten and they can become less able to absorb nutrients. Now, I mentioned at the beginning that the bile is made in the liver, stored in the gallbladder. So some people will have had their gallbladder removed and this could be if you were frequently getting gallstones and that would be making the bile that should be just dripping out as we eat, very sludgy and some little hard stones in there. So if you’ve had the gallbladder removed, what will happen is that your bile will just drip out constantly.

It doesn’t come out only when we eat. It’s not triggered to release on the digestion of food. It will just gradually drip, drip out and this can also really affect people’s digestion and can create some of those really loose stools. And then the other reason why you might have this bile acid absorption problems is down to an overgrowth of bacteria in your small intestine.

And this has also been shown to affect the reabsorption of the bile acids. So SIBO might increase your transit time. So that’s like your digestion gets sped up and that’s because you’re not digesting your carbohydrates properly. And you get drawing water into the small intestine that pushes things through much quicker and therefore that might also be affecting the time allowed for the bile acid malabsorption.

So if this is ringing a few bells for you and you’re thinking, oh, I wonder if this is my problem with diarrhoea, then it’s definitely worth a conversation with your doctor to see if they think your symptoms might be might line up with this kind of profile. The test that they can do is called a SeCAT scan and basically it helps to look at whether you are reabsorbing those bile salts or not or whether they are being excreted into your large intestine.

So it’s slightly strange that you swallow a little capsule with some radioactive material in it. And I know that sounds a bit scary, but it’s not really. It’s just a very, very small amount. You swallow this, uh, and this obviously is done in a hospital. And then, uh, What it does is it’s like a tracer. So it’s this radioactive material that can be shown up inside your body.

So you firstly go and have one scan like a couple of hours after taking this first radioactive tracer. And then you come back in a week and see how much you have been reabsorbing or how much has been excreted in the second scan. This is the way a doctor can diagnose you with problem in reabsorbing your bile salts. The only other way you can look at it is actually looking at the level of bile acids in your poo, which can be done in a stool test. And sometimes it’s done over multiple days. So it’s looking at how much on average is present in the poo. Sometimes I will run a stool test with some of my clients but obviously when I do it, it’s just a private test and it’s just a one off quite expensive test, which is why I don’t do it with most people.

However, some hospitals will do it looking at your stool results over multiple days in order to get a profile of how much is. And that’s another way to do it, just because I think the SeCAT test is very expensive. And obviously it’s not suitable for everybody because it is using, a low level of radiation. I’ll come on to a little bit about treatment and diet, especially in just a minute. Bye. I also wanted to talk about what happens to the bile salts in the large intestine, because I think it’s really interesting. It’s a bit of a two way relationship. We know that having a high level of bile salts in your large intestine can affect the microbiome.

It can affect the ecology, the environment for your gut microbes which can then affect digestion of other carbohydrates and other compounds in your food which can give you other symptoms as well and we know that the bacteria also work on the bile salt so it is really a two way process. And there is some really small bit of interesting research looking at the difference in the gut microbe diversity of people who’ve got bile acid diarrhoea compared to people who’ve got IBSD.

So sometimes you might have diarrhoea predominant IBS, which has nothing to do with your bile salts., and they compared people by diagnosing them with this SeCAT scan first, like I just mentioned, and then they looked at the gut microbes that were in this pool of research people. And people who had bile acid diarrhoea had a lot less diversity in their large intestine blood vessels.

So, as you know, if you’ve listened to my podcast a lot, we want good diversity in our gut microbes because this is better associated with overall health. We also could see from this study that people who had bile acid diarrhoea had different levels of the short chain fatty acids that the gut bacteria make.

When fibre and carbohydrates come to the large intestine, our gut bacteria normally make something, these short chain fatty acids that are really beneficial for our health. And there’s no sense from this, research paper that I’m mentioning that this is bad. It’s just that we could see a different profile of these fermentations.

So these are like the results of the fermentation by our gut bacteria. And that’s probably because there were different gut bacteria there in the first place. Because if you’ve got high levels of bile salts, it affects the types of microbes that want to grow there. So, um, We know that there are slightly different bacteria that love to live in that sort of environment.

Whereas people who don’t have high levels of bile salts will have, again, another set of gut microbes. Now, it’s really difficult when we talk about what is a healthy gut, because there isn’t really a good sense of what we’re looking for, what we’re aiming for.

But we do know that majority of research papers are all pointing in the same direction, saying that More diversity is good and that there are some bacteria that seem to be associated with things like obesity, heart disease, or kind of metabolic conditions. And that’s probably down to the types of food we eat.

So we never really know, again, what is it that comes first? Is it the gut microbes? Is it the food? They’re very, very interlinked and it, I always feel a little bit nervous talking about gut bacteria because there is, So much research about it, but it doesn’t really necessarily tell us that much clinically about what we should be doing, you know, on a day to day basis, what an individual person should be eating or not eating other than, you know, eat lots of fruits and vegetables and whole grains, pulses, nuts and seeds and all of those things that are high in fibre.

It doesn’t necessarily, um, mean, Oh, you’ve got this certain bacteria, therefore you need to eat this food. So I think we’re not really at that sort of level of understanding yet about the gut microbes, but it is a really interesting area. And I’m sure more will come out over the years if you see the amount of research papers that are around the gut microbes and, you know, digestion generally.

It is huge. It’s a hugely, popular research area. Oh, anyway, that was just a little aside about gut bacteria and bile salts. But, if you’re listening to this and thinking, actually, maybe I have got this problem, um, then let’s just talk about what you can do about it. So, firstly, if the reason that you’ve got the bile acid diarrhoea because you’re not absorbing these bile salts, and if it’s down to another condition, like maybe you’ve got Crohn’s or you’ve got coeliac disease, the first line of treatment is to get that condition under control because it may help your overall digestion and reduce down the problems of diarrhoea resulting from bile acid malabsorption.

If your doctor doesn’t know why you’ve got bile acid diarrhoea, sometimes that’s called idiopathic, it means that the cause is unknown, then your doctor might prescribe some medication that helps you to bind the bile acids in the large intestine and stop them causing that irritation to your gut lining.

So then that would stop the loose frequent stools that feel very, very out of control. The most popular brand that I see my clients taking is Colostyramine and this is a cholesterol lowering medication. And that’s why it does need to be doctors who are prescribing it because if your cholesterol is being lowered, you need to have some checks on how your body is coping with that lower level of cholesterol because cholesterol is also used for making your hormones, for your cells.

skin health, all kinds of things.

So that’s the medication you may be offered, and it’s definitely worth a discussion with your doctor. But in terms of diet, there isn’t really that much evidence about how to support bile acid diarrhoea. However, most of the advice that is in research papers and also just that I know sort of clinically that works is two things.

One, increasing fibre in your diet and reducing down your fats. If you’re drinking a lot of coffee as well, do consider Whether you can cut down a little bit on that, because coffee might also be stimulating the release of bile from the gallbladder. So just think about whether you’re having a lot of coffee as well.

And we know that coffee also really does set off diarrhoea anyway in a lot of people. Either by the caffeine or by some of the other compounds in coffee called chlorogenic acid. And that has been shown to trigger a need for bowel movements. So even in Decaf coffee. Some people will get more diarrhoea when they’re drinking a lot of decaf coffee.

 If we were going to look at how to increase your fibre, so the, the way this helps is that higher fibre diets can affect the bile acids, because it’s binding to the bile acids, as well as it’s feeding the good microbes in your large intestine, which supports a healthy gut lining. Particular types of fibre that you can try is like the gel forming fibres.

So things like seaweed and oats, as well as like chickpeas. These are quite good because they’re helping to create, that sort of formed, but softer stool. So if you. aren’t sure about things like chickpeas, you can just start with a very small amount and just testing out your tolerance to them, checking that it’s not going to make things worse, obviously.

Now all of us should be aiming for somewhere between 25 to 30 grams of fibre a day. That can be really challenging if you’re also getting IBS type symptoms like bloating and gas and those things when you eat a high fibre diet. This is where low FODMAPs can be really really helpful, so things like berries, carrots, brown rice and quinoa, potato with their skin on, other fruits like bananas, you can include kiwis, oranges, like just trying to get in as many high fibre but low FODMAP foods as you can.

In order to increase your fibre, some people feel good with supplementing with psyllium husk. And another type of fibre that I sometimes use with people is partially hydrolyzed gua gum or PHGG, which is also low FODMAP. Whereas the psyllium is not necessarily going to be low FODMAP. Now, if you get on well with apples and I know they are high FODMAP and not great for some people, but the good thing about apples is that they’ve got this fibre in them called pectin, which is a very good binding type of fibre.

Stewed apple is sometimes a really good way to get the apples in Test it out a little bit and if you get on well with it just cook up an apple Mash it down You can put it in with a bit of yogurt put it in your porridge or just eat it on its own In terms of the fat reduction. Some people feel better on a low fat diet And it may be really help to reduce down the frequency of your bowel movements, the urgency, as well as , reducing the amount of gas, so flatulence and burping and the kind of like noisy digestion that you often get.

So, because Like I said at the beginning, fat is important in our diet, and we do need some of it. We may need to supplement with some fat soluble nutrients, like vitamin A, E, D, and K. And also, we just want to make sure that a low fat diet is being, um, implemented in a healthy way. Some people feel that, getting less than 40 grams of fat per day is a way of managing bile acid malabsorption.

Now this is a very low fat diet, which means you would need to cut out a lot of fatty meats all butter, like high fat dairy, chocolates, and then things like biscuits and cakes as well. Like I said, it really is best to work with someone who really understands diet overall because you don’t want to go too low with your fats or your calories.

You want to make sure that you are getting some healthy fats in there where you can and also just making sure that your diet is overall giving you everything that you need. But those are the two sort of dietary approaches if you have been diagnosed with bile acid malabsorption. I hope that’s given you a little overview of bile acid diarrhoea and if you want to ask me any questions about it Then please do send me an email And if you’ve got a topic you’d like me to cover in a future episode you can send me an email at info@goodnessme-nutrition.com. And I will get back to you. I’ll leave it there for this week though. Thank you very much for listening to this episode of the Inside Knowledge. For people with IBS., better digestion for everyone.

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