Bile Acid Malabsorption (BAM), also known as Bile Acid Diarrhoea (BAD), can significantly impact an individual's quality of life. This article aims to provide a comprehensive understanding of BAM, its causes, diagnosis, and management strategies, including dietary adjustments, based on NHS guidelines and real-life experiences.
Introduction to Bile Acid Malabsorption
BAM is a condition where the body cannot properly reabsorb bile acids in the small intestine. Bile acids, produced by the liver, are essential for fat digestion. When they are not reabsorbed efficiently, they enter the colon, drawing water into the bowel and causing diarrhoea.
Understanding the Types and Causes of BAM
BAM is categorised into three main types, each with distinct causes:
- Type I: This occurs when there is a problem in the ileum, the part of the small intestine responsible for re-absorption. Conditions such as Crohn’s disease or cancer treatment can cause inflammation or removal of the ileum, leading to BAM.
- Type II: This is known as primary bile acid malabsorption, where no definitive cause can be identified.
- Type III: This type can result from other diseases or conditions within the abdomen, such as gallbladder removal, coeliac disease, chronic pancreatitis, radiotherapy, or small bowel bacterial overgrowth.
Helen's Experience with BAM: A Personal Journey
After undergoing gallbladder removal surgery in March 2022, Helen experienced severe bowel issues that significantly impacted her life. Initially, she believed her consultant's assurance that her symptoms-severe cramping, painful bloating, and chronic diarrhoea-would subside within 12 weeks. However, her condition worsened, leading to a debilitating experience during a family dinner at her son’s house, where she had to repeatedly leave the table to rush to the toilet.
The Road to Diagnosis
Hesitant to self-diagnose, Helen researched her symptoms online and came across Bile Acid Malabsorption (BAM), also known as Bile Acid Diarrhoea (BAD). Her GP suspected BAM as a possible cause and referred her back to her consultant for a SeHCAT scan, the gold standard for diagnosing BAM.
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Treatment and Challenges
Her consultant prescribed cholestyramine, a bile acid sequestrant, to bind to bile acids and prevent diarrhoea. However, it caused severe side effects like nausea, vomiting, and headaches. She was then prescribed Colesevelam, which, while not officially licensed for BAM in the UK, is often used when cholestyramine fails.
Colesevelam also presented challenges, including bloating, gas, and interactions with other medications. Finding the right dosage was difficult, and she experienced a cycle of constipation and diarrhoea, leading to feelings of isolation, anxiety, and depression.
Finding Support and Adjusting Treatment
Helen sought support and found an online group where she learned that the dosage instructions for Colesevelam, designed for high cholesterol, were not ideal for BAM. Taking the medication all at once on an empty stomach made a big difference. She also discovered that a low-fat diet alone was insufficient and that a low-residual fibre diet was beneficial.
Dietary Adjustments and Symptom Improvement
Cutting out fruits with skins, seeds, or high fibre content, avoiding most green vegetables, and eliminating whole grains significantly improved her symptoms. The frequency of diarrhoea dropped dramatically, and the cramps became less severe. Balancing her medication and diet, she reduced her Colesevelam dose and added psyllium husk capsules.
Symptoms of Bile Acid Diarrhoea
Symptoms of Bile Acid Diarrhoea vary significantly from person to person. Common symptoms include:
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- Severe cramping
- Painful bloating
- Chronic diarrhoea
The Importance of Diagnosis
Many individuals experience a mix of emotions upon diagnosis, including relief and shock. It is important to understand the type of BAD (Primary or Secondary) and its severity (mild, moderate, or severe). If unsure, consult your GP or refer to BAD UK’s GP Information leaflets. A SeHCAT scan is essential for determining the severity of symptoms.
Support Groups and Resources
Support groups provide invaluable assistance, offering a platform to learn more about the condition from clinical specialists and connect with others who understand the challenges of living with BAD. BAD UK is a charity dedicated to supporting those who suffer from BAD.
Adjusting to Medications
Adjusting to bile binding medications can take time, with some experiencing quick improvements and others needing up to three months to find the right dose and regime. Discuss any concerns with your GP or consultant's team, who may adjust the dose, change the type of bile binder, prescribe additional medications, or recommend further dietary adjustments.
Medication Timing and Logging Bowel Movements
The timing of medication can be adjusted to suit individual needs, with some preferring one dose a day and others splitting the dose. Keeping a log of bowel motions helps analyse stool frequency and identify when symptoms are worse. It is crucial not to miss doses, and having an emergency supply of bile binders is advisable. Staying well-hydrated is also important for medication effectiveness.
Healthcare Professional Relationships
A widespread lack of awareness among healthcare professionals can impact patient experiences. However, there is growing awareness of BAD across health systems. Taking information from BAD UK web pages can aid discussions with GPs. If issues persist, suggest the GP contacts the consultant or consider seeing a different GP.
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Diet and Eating Out with BAM
A low-fat diet (less than 40g a day) is generally recommended, but individual trigger foods can vary. Smaller, more frequent meals can help. Common trigger foods include gluten, wheat, dairy, high fibre, spices, garlic, and processed foods. A balanced diet of protein, fruit, vegetables, carbohydrate, and calcium is essential. A dietician can help identify trigger foods and support dietary needs.
Practical Dietary Tips
Cooking from scratch makes it easier to control fat content. Utilize reduced or low-fat versions of butter, cheese, crème fraiche, yoghurts, cottage cheese, and quark. Opt for lower fat meats like white meat parts of chicken and turkey, venison, ostrich, kangaroo, and rabbit. Be cautious of hidden fats in ready-prepared foods and the high sugar and laxative content in low-fat processed meals and sweet treats.
Eating Out Strategies
Eating out can be challenging due to hidden fats. Educate friends and family on hidden fats and consider switching to oil sprays at home. Specialist dietary advice is available from resources like Abi Purrington’s blog.
Regular Blood Checks
Regular blood checks are important to monitor B12 and fat-soluble vitamin levels (A, D, E, and K), as well as cholesterol and lipid levels, which can be affected by bile binders.
Managing Flare Ups
Flare ups can occur inexplicably, even with strict adherence to medication and diet. Resting, staying hydrated, and remaining positive are crucial during these periods.
Working with BAD
Managing BAD in the workplace can be challenging. Employers should be aware that BAD is recognised as a disability under the Equality Act, and reasonable adjustments should be considered.
Travel and Social Activities
Regaining confidence to travel and participate in social activities is important. Start with small steps and travel with someone for support. Obtain a toilet card and radar key for priority access to disabled toilets.
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