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By Dr Raghuram Y.S. MD (Ay) & Dr Manasa, B.A.M.S

When your intestines cannot absorb bile acids properly you suffer from a condition called Bile Acid Malabsorption (BAM). Since the bile acids are not absorbed from the intestines, extra bile acids are left over in the intestines. This causes irritation of the small intestine and causes watery diarrhea. It is also called as bile acid diarrhea (BAD). Experts report that roughly 1 out of 100 people may have BAM. (Read more)

Bile is a natural fluid made in the liver. It is needed for digestion. Bile contains acids, proteins, salts and other products. The bile formed in the liver moves to the gallbladder through the common bile duct. The bile is stored in the gallbladder until the food is consumed. When you eat food, your gallbladder contracts and release this bile into your intestine. The acids in the bile help to break down the food and nutrients so that the body can absorb them efficiently. The bile acids are reabsorbed back into the bloodstream in your colon so that they can be reused again.

When these bile acids are not reabsorbed in the colon from time to time, it leads to BAM. Too much bile acid in the colon can lead to diarrhea and watery stools. This is the reason BAM is also called as bile acid diarrhea.
Read – 37 Ayurveda Home Remedies For Diarrhea And Dysentery

Symptoms of Bile Acid Malabsorption

Diarrhea – the main symptom of BAM is diarrhea. Presence of salt and water from bile acid in the colon prevents proper formation of stools. This leads to diarrhea. Diarrhea might happen daily or occasionally.

Stools may be –

  • Painful
  • Watery
  • Urgent
  • Yellow
  • Smelly

Other symptoms –

Causes of BAM

Non re-absorption of bile acids in the colon is the main cause for BAM. We often don’t find a precise explanation so as to why this condition occurs in some people.

One third of people with irritable bowel syndrome and diarrhea (IBS-D) have BAM.

Secondary BAM – is when BAM is a symptom of another condition. Conditions that may cause secondary BAM include –

  • Crohn’s disease
  • Celiac disease
  • Small intestinal diseases
  • Pancreatic diseases
  • Small intestinal bacterial overgrowth

Note – side effects of medications can also cause BAM.
Read – IBS: Ayurvedic Treatment, Home Remedies, Lifestyle Tips

Classification

There are three kinds of BAM based on what causes the condition

Type 1 – can happen after surgical removal of part of small intestine. Inflammatory bowel conditions such as Crohn’s disease can also cause type 1 BAM.

Type 2 – also called primary or idiopathic BAM, doesn’t have obvious cause.

Type 3 – develops as a result of other conditions such as chronic diseases, radiation treatment or celiac disease. (Read more)

Diagnosis of BAM

Two tests are available, one for research purpose and the other for clinical use (Mayo Clinic)

  • Fasting Serum C4 (for research only)
  • Fecal bile acid test – involves collecting samples over 48 hours and examining them for signs of bile acid.

Treatment

Treatment principles for BAM include focus on medication and dietary changes. Both are skillfully combined to provide good results. Treatment of secondary BAM includes treating the underlying conditions.

The main medication to treat this condition is called bile acid binder. By binding with the bile acids in your digestive tract, it reduces their impact on the colon. They also effectively treat BAM associated diarrhea. Examples – Cholestyramine, Colestipol, Colesevelam etc
Read – GERD, Heartburn: Causes, Symptoms, Ayurvedic Treatment, Tips, Remedies

Diet, Home remedies, Prevention

Dietary changes also help in reducing episodes of BAM associated diarrhea. Bile is needed for fat digestion. When you take fat rich foods your body has to release more bile and bile acids. Following a low fat diet can reduce the amount of bile acid your body produces. Thus less bile acids move into colon. When the bile acid level in the colon is lower, the chances of diarrhea are less.

You may reduce the below mentioned foods which are fat rich –

  • Fried or breaded foods
  • Mayonnaise
  • Butter and margarine
  • Full fat dairy products (whipping cream, sour cream etc)
  • Lunch meats, hot dogs, sausage, bacon or other processed meats
  • Baked goods – cookies, pastries, croissants etc

Take foods with healthier fats like –

  • Avocados
  • Nuts including cashews and almonds
  • Fatty fish such as salmon and sardines

These fats are good but should still be consumed in moderation if you have BAM.

Most people with BAM respond well to treatment and are able to prevent or manage their symptoms with medications and lifestyle changes.
Read – Importance Of Diet (Pathya) For Specific Diseases

Prevention

Avoiding fatty foods and taking healthier fats with caution forms the most important preventive measure.

Eating spicy foods can trigger BAM symptoms, therefore they shall be avoided.

Eating less than 40 grams of fat a day in small, separate portions can be helpful.

Most reported trigger foods are as mentioned below. They shall be avoided if found to cause or trigger symptoms of BAM –

  • Gluten
  • Garlic
  • Processed foods
  • Spices and spicy foods
  • Dairy products
  • High fiber foods

Trigger foods may be different for different individuals. People with BAM can track both what they eat and when their symptoms are worse to identify their own trigger foods and keep them away.

Cooking at home is a great way to be sure that what one eats is made up of safe to use ingredients.

Speaking to a nutritionist and planning ideal diets so as to get all essential nutrients and also helpful for healthy gut is essential.

Ayurveda Concept

Pitta and Bile – Bile is a body fluid which takes part in digestion of food, mainly fat predominant foods. Pitta, one among the tridoshas too takes part in digestion, assimilation and absorption of food owing to its hot, intense, corrosive, and minute qualities. Bile comes under the broad spectrum of pitta.

Pachaka Pitta and Bile – Since bile digests the food, the pitta subtype pachaka pitta located in the stomach and upper intestine can be functionally correlated to it.

Ranjaka Pitta and Bile – Since bile is produced in the liver, it can also be compared to another subtype of pitta i.e. ranjaka pitta produced in the liver and stomach. The functions of ranjaka pitta are different from that of bile. It colors the juice formed from digestion of food (rasa) which passes through the liver and spleen and converts it into blood. But the counterpart of ranjaka pitta located in the stomach can be said to participate in the digestive activities. The intrinsic factor located in the stomach which enables the body to absorb vitamin B12 is often compared to the ranjaka pitta located in the stomach. Its deficit production leads to vitamin B12 deficiency which in turn leads to pernicious anemia.

Bile Acid Malabsorption In Ayurveda terms

Excess bile acids in the intestine can be correlated to excessive pitta in the gut. This also pertains to increased or imbalanced qualities of pitta. This enhances an acidic, hot and corrosive environment in the small intestines & colon.

Increase of unctuous quality of pitta makes it incapable of digesting the fats.

Increase of intense / sharpness / harshness quality makes the pitta irritate the intestine and increases the peristalsis.

Increased liquidity and subsequently decreased hotness dilutes the pitta and makes it difficult to digest the food. The food is improperly digested. The improperly digested food becomes ama i.e. immature digestive juices which are toxic for the stomach, intestines and tissues (post absorption).

Increased ‘free flow’ or ‘purging’ quality of pitta pushes the indigested liquid food towards the colon. In the colon the re-absorption of liquids does not take place and the stools are formed in immature and liquid form. This leads to diarrhea of pitta origin.

The increased in foul smell of pitta gives the liquid stools foul odor.

The whole process can be compared to bile acid malabsorption and bile acid diarrhea, which closely resembles pittaja atisara i.e. diarrhea of pitta origin.
Read – Fruitful Ayurvedic Remedies For Gastritis

Treatment

Bile Acid Malabsorption and Bile Acid Diarrhea are treated on the basis of –

  • Treatment of excessive pitta
  • Treatment of pittaja atisara i.e. diarrhea of pitta origin
  • Treatment of pittaja grahani i.e. pitta type of inflammatory bowel disease, mainly Crohn’s disease / irritable bowel / celiac disease / small intestine disorders
  • Treatment of Krimi – intestinal infections

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