Bile is a dark greenish-yellowish-brownish liquid composed of acids, salts, proteins, and other substances. It’s produced and secreted by the liver and stored in the gallbladder. The acid in it, what we’ll refer to as bile acid in this article, is necessary for the digestion of fats in the small intestine. Bile moves from the liver to the gallbladder through bile ducts, and then gets released from the gallbladder into the stomach when you eat.
The bile acid in bile helps break down the food, releasing the nutrients in it so that your body can absorb them. It then moves from the stomach and small intestines to the large intestine where it is reabsorbed for recycling.
When this process is going smoothly, digestion is easy and there are no problems with the reabsorption of the acids. In some cases, however, one or more aspects of this process are disrupted, and symptoms begin to surface.
For example, if bile acid is not reabsorbed properly, leaving too much of it in the large intestine and colon, the stools become watery and, you can get diarrhea, bloating, and sudden urges to use the bathroom. This condition is called Bile Acid Malabsorption (BAM).
In some cases, the cause is understood – it’s part of another gastrointestinal (GI) tract disorder. Many people, an estimated 30%, with diarrhea-dominant Irritable Bowel Syndrome (IBS-D), also have this issue. This is what’s called secondary Bile Acid Malabsorption (BAM). In other cases, the cause is not found, and this is referred to as primary BAM.
Other GI tract disorders related to BAM include Celiac disease, Crohn’s disease, Small Intestinal Bacterial Overgrowth (SIBO), issues with the pancreas, and issues with the small intestines.
In this article, we will focus on IBS, as it is a growing health concern that is often not properly identified and managed, and it has the strongest links to bile acid issues compared to all the other GI tract disorders.
IBS is a very common GI tract condition that affects the large intestine in varying severity. Its symptoms include:
Even if there is alternation between diarrhea and constipation, some cases of IBS are diarrhea-dominant (IBS-D), while other cases are constipation-dominant (IBS-C). IBS symptoms usually come in cycles, where for a period of time your symptoms are mild or even gone completely, and then for a period of time, there is a flare-up.
Generally speaking, IBS is not a sign of serious structural or health issues with the GI tract, such as colorectal cancer. If managed properly, it also doesn’t need to become a debilitating daily struggle. In some situations, if the symptoms are severe enough, it may be a sign of something more serious and may need stronger interventions.
There is one factor, however, that can be addressed, that is at the root of IBS and many other GI tract disorders and health issues - a factor you should be aware of.
Although your system can handle stress – through the NeuroEndoMetabolic (NEM) stress response, which is your body’s global response to stress – it is not made to deal with chronic stress. When the six circuits of your NEM are under constant pressure, they eventually dysregulate. Some will be more susceptible than others, depending on which organs and systems are under more pressure. But even if only one circuit dysregulates at first, the rest often follow.
These six circuits are the hormone, the bioenergetic, the neuroaffect, the cardionomic, the inflammation, and the detoxification circuits. Your GI tract is part of the inflammation circuit, although it affects and is affected by all the other organs and systems in your NEM. Closely linked to the GI tract is your microbiome – the ecosystem of different flora in your gut. The microbiome is also involved in the inflammation circuit, as well as the neuroaffect circuit.
This is indicative of the close connection between the gut and the nervous system, which is becoming more and more apparent with new research. In fact, the gut-brain connection is being used by functional medicine doctors to diagnose and support patients with anxiety and depression. Studies are starting to show that those with increased markers of stress – such as high cortisol levels, the activation of the autonomic nervous system, and the rise of proinflammatory cytokines – also have a weakened gut lining and the translocation of gut bacteria.
This translocation of gut bacteria – a condition called dysbiosis – is only now being seen as a serious factor in GI tract disorders, chronic inflammation, and many other health problems. When the gut’s lining is weak, particles enter through it into the bloodstream, which triggers an immune response. This immune response creates inflammation in the area that can then spread to other parts of the body if it is not dealt with properly.
Chronic low-grade inflammation that spreads to the nervous system and brain has been shown to be a major factor in anxiety, depression, and brain fog. That is one of the reasons why SSRIs work for some people – they are anti-inflammatory and so reduce the inflammation that has affected the brain and nervous system. But the gut-brain connection goes the other way as well, for those undergoing a lot of mental/emotional stress tend to also get gastrointestinal issues. This is why in a meta-analysis of those with anxiety and depression showed them to have a higher risk of developing IBS.
Inflammation, though a necessary part of the immune response, is a huge stressor on the body. It requires a mechanism to be neutralized once it has completed its job. That is partly the role of cortisol, the body’s main anti-stress hormone, which is secreted by the adrenal glands.
But, if inflammation is chronic, that means the adrenals have to work beyond their normal capacity in order to produce more cortisol. This marks the beginning stages of Adrenal Fatigue Syndrome (AFS), where cortisol levels are higher than average. But after a while, the adrenals inevitably become exhausted and their cortisol output drops, marking the more advanced stages of AFS and leaving the body to fight stress in other ways.
Symptoms of AFS include fatigue, weight gain, insomnia, brain fog, anxiety, mild depression, hair loss, loss of libido, PMS, infertility, hypoglycemia, constipation, heart palpitations, food and drug sensitivities, frequent colds and flus, an inability to handle stress, and waking up in the middle of the night. Weak adrenals also have a significant effect on digestion and the GI tract.
In the more advanced stages of AFS, the body begins to slow down its metabolism and many of its functions in an effort to conserve its depleting energy stores. This also slows down the movement of the gut, which means food moves through the system more slowly. This is why people with AFS commonly complain of constipation. This lack of timeliness in elimination irritates the GI tract and can worsen the symptoms of IBS.
Bile acid also has a big effect on gut motility, though in most cases it has the opposite effect as AFS. In patients with IBS, bile acid was found to increase colonic transit time and to alter fecal weight, causing more diarrhea than constipation. This is seen in patients with and without overt bile acid malabsorption.
So what happens when if you have both AFS and IBS?
This situation is actually more common than you’d think. These two conditions come together quite frequently and tend to aggravate each other. But if one condition leans more towards constipation and the other more towards diarrhea, the result is that you experience alternating phases. The more common situation is that you get constipation more often, with bouts of diarrhea once in a while.
But there are cases where IBS is more constipation dominant (IBS-C), which can add to the already frustrating constipation that comes with AFS. The type of IBS you get is largely determined by the type of bacteria in your microbiome. In those with IBS-C, Bacteroides bacteria are more prominent in the microbiome, while in those with IBS-D, Escherichia coli are more prominent in the microbiome.
Until recently, IBS has been diagnosed by a process of elimination, where tests will come out negative for different conditions, such as celiac disease or infection. Once all other possibilities with similar symptoms are excluded, the conclusion is that you have irritable bowel syndrome.
But testing for an increase in bile acid, about 10% above average, may become a new diagnostic tool to check for IBS. Also, finding out which type of bacteria is prominent in the microbiome can help with designing a recovery plan that is suited to your specific condition and needs.
Similarly, AFS is also usually determined by a process of elimination. Chronic fatigue syndrome, thyroid disorders, and other conditions that have symptoms in common with AFS are looked at and ruled out. In many cases, because AFS is not yet accepted in the general medical community, if your tests come out negative, you are sent home without a diagnosis or treatment plan.
Many people have had this happen to them, only for their adrenal fatigue to progress to adrenal exhaustion before they found a medical professional who understood what was going on. And this is what IBS patients also went through before the general medical community accepted IBS as not only a possibility, but a very common condition. Hopefully, this will happen with AFS very soon too.
Excess bile acid is usually treated with medications called acid binders, such as colestipol, cholestyramine, and colesevelam. But that doesn’t get rid of the underlying issue. It is always better to approach recovery holistically, looking at diet and lifestyle changes first before using medication, or in conjunction with medication in the hope that after a while it will no longer be needed.
With BAM, a low-fat diet seems to help a lot. This includes animal-based and plant-based fats. So try reducing or cutting out foods like butter, mayonnaise, avocados, fatty fish, full-fat dairy, pastries made with a lot of butter and oil, nuts, fried foods, and processed meats.
Out of all the above, fatty fish, nuts, and avocados are considered healthy, so if you choose to incorporate them later, you can try small amounts at a time. Raw and organic dairy is also a possibility later on. The adrenal fatigue diet is a great choice for recovering from both adrenal fatigue and IBS. Just use less fat than what is usually recommended and then see how you feel.
Because bile acid, IBS and AFS are all aggravated by stress, stress management is essential for recovery. Get enough rest and sleep. Try meditation, gentle yoga, and taking time off. Lighten your workload for a while as you recover. If you need therapy or group support, that can also be a great way to help you deal with psychological and relational stress.
There are also some supplements that can be useful. Adaptogens like ashwagandha and rhodiola help your body adapt to stress when the time is right and if your body is strong enough to handle herbs. Those who are weak should stay away. Omega-3 fatty acids and vitamin D-3 also have a positive effect on mental health, and since you might cut down on omega-3 rich foods like fatty fish and walnuts for a while, you may need to supplement. Glutamine, pantethine, and DHEA in combination has been well received.
What’s important to understand is that improving one condition will automatically start to improve the other. So don’t feel overwhelmed, and get the right medical guidance to help you determine the best plan for your unique situation.
© Copyright 2020 Michael Lam, M.D. All Rights Reserved.
Excess bile acid, sometimes due to malabsorption in the intestines, can create a lot of problems in the gastrointestinal tract. If you have IBS, one cause of it might be too much bile acid in your gut. And if that’s the case, new research has made you closer to recovery than before.