Hello, it's Jo again and instead of my usual scrummy recipes and bakes, I'd like to talk to you about Bile Acid Malabsorption instead today. Because truth be told, I have been so poorly over the past six months that I have barely been eating! I've managed to keep up with Insta and Facebook, but apart from the odd recipe I've made for there, I really haven't been able to face blogging properly. I have so little energy that my poor old blog has definitely been finishing last in the race.
I'll talk more about Bile Acid Malabsorption in a moment but if you are here because you are struggling with IBS, PLEASE read my story. If it is starting to sound familiar, please go and get an appointment with a gastroenterologist because it could be a condition which has IBS as one of it's symptoms, rather than IBS alone. I don't mean to scare you, there's no need to worry but do go and get checked out - I don't want you to leave it as long as I did before getting some help!
I have had IBS A for twelve years now and like so many people, it got worse as the years rolled on until it finally reached crisis point. For about 8 years I have had at least two tummy bugs a year and struggle with urgent diarrhoea. A few years ago I discovered that gluten was a huge trigger food for me and things got a little calmer after I cut it out. Then... last year I had a whopping fourteen courses of antibiotics and needless to say I've been at crisis point ever since. Things have got so desperate that I have to wear an adult nappy when I'm out now or I'd be too frightened to go out at all!
After a week in hospital last October because I could not stop vomiting, I discovered that alongside gastritis and IBS, my Bile Duct was unusually swollen (swollen Ampulla of Vater). Six months on I have lost 2.5 stone in weight and we are still trying to find out the exact cause of my severe symptoms so I'm going to link to Benenden Health Insurance here. By paying £10.25 per month to Benenden, I have been able to see a private gastroenterologist four months quicker than an NHS one- so if you are struggling , please do sign up with them.
So far, my consultant has diagnosed Coeliac Disease because of my history and frequent nutritional deficiencies (though I've never been able to tolerate enough gluten to get a positive blood test). And at the moment, our working hypothesis for what is causing all the trouble is Bile Acid Malabsorption - also known as Bile Salt Malabsorption and Bile Acid Diarrhoea.
What is Bile Acid Diarrhoea/ Bile Acid Malabsorption?
It is thought that up to 1 in 3 patients who suffer from IBS actually suffer from BAM instead and it can be caused by Coeliac Disease. When we eat, Bile salts are released to help food process in our digestive tract and once they have been used, they are re- absorbed back into our system ready for next time. If you have BAM, these salts aren't re-absorbed properly and irritate the lining of your colon- causing water to flood to the area and create diarrhoea. BAM is a lifelong condition that requires a certain type of medication, but can be managed successfully.
* Urgent diarrhoea (up to or more than 10 times a day)
* Foul smelling wind
* Diarrhoea that is pale, greasy, or unusually coloured such as green or orange
* Diarrhoea that is hard to flush away
* Diarrhoea during the night
* Vitamin B12 Deficiency
* Weight loss
* Gastritis or Acid reflux as a result of ongoing IBS
There are three main types of BAM:
* Type 1: Bile acid malabsorption that is caused by ileal surgery, or ileal inflammation (Crohn’s disease)
* Type 2: Idiopathic / primary bile acid malabsorption - this is when Bile Acid Malabsorption is a separate condition, not caused by any other illness or disease
* Type 3: Secondary to various gastrointestinal diseases such as cholecystectomy, small intestinal bacterial overgrowth (SIBO), post radiation, coeliac disease or chronic pancreatitis
BAM is usually diagnosed by having a Sehcat scan which is a series of scans taken one week apart. On your first appointment, you will be given a tablet containing Bile Salts and a small amount of radioactive dye. You will be asked to return for a CT scan after three hours which will measure the amount of salts you currently have. One week later you will need a second CT scan which will show how many salts have been processed and re-absorbed. The scans, bile salts and dye are all painless and should not cause any adverse effects. If you experience any unusual side effects after taking the tablet, consult your doctor immediately.
If you are diagnosed with BAM, your consultant will start you on a group of medicines called Bile acid sequestrants. Originally used to help lower cholesterol, bile acid sequestrants work by binding bile salts together in the small bowel, allowing them to be passed instead of causing irritation.
There are three main types of bile acid sequestrants - Colestyramine and Colestipol come as a powder and Colesevelam comes as a tablet. All three medications can cause constipation if the dose is too high so it's important to work with your consultant to find the right dose. Your doctor may also prescribe an anti-diarrhoea medication called Loperamide (Immodium) as a short term aid.
Diet can play an important part in lowering the effects of Bile Acid Malabsorption and it is generally recommended that you eat a low fat diet (less than 40g per day). Some people find that the low fat diet is enough, but others need to avoid some of the classic IBS triggers such as Gluten, Dairy or foods high in Fodmaps too. It is very much a case of trial and error, learning what you can and can't tolerate once the medication has started to take effect.
If you would like some more information on Bile Acid Diarrhoea please feel free to explore the articles that I used to inform this blog post. Although BAM is still a largely specialised subject, more research is sure to happen as the rates of diagnosis increase. For now, here is the best of current research:
Bile Acid Diarrhoea Support are a charity who help sufferers of BAM. They have lots of information about the condition and how to manage it : https://www.bad-uk.org/
Guts UK are a charity who support people that have a number of 'gut conditions'. If after reading this article, you decide that you probably don't have BAM - the Guts UK site has useful information about a range of other conditions: https://gutscharity.org.uk/
What the NHS says about BAM: https://www.uhcw.nhs.uk/bam/what-is-bam/
You can find more information about Bile Acid Diarrhoea medications through the NICE guidelines site: https://www.nice.org.uk/advice/esuom22/ifp/chapter/About-colesevelam