Did you know that a hidden cause of persistent diarrhea in people with inflammatory bowel disease may be something called bile acid malabsorption (BAM)? Bile plays an important role in digesting and absorbing fats. When the gut can’t properly reabsorb bile acids, they accumulate in the colon instead of being recycled, disrupting digestion and leading to symptoms like diarrhea, also known as bile acid diarrhea.
Bile acid malabsorption appears more often in people with Crohn’s disease than in those with ulcerative colitis. It is also not limited to ileal involvement or those who have undergone ileal resection as it can also occur during periods of clinical remission and even in people without ileal disease.
Despite its significant impact on quality of life, this condition frequently goes unrecognized in both clinical practice and everyday care. That is why we are taking a deeper dive into this topic today with Gina Giebner to raise awareness and help ensure people living with this challenging condition feel seen, heard, and better supported.
Gina Giebner is an advanced and registered specialist gastrointestinal and oncology dietitian with over 20 years of experience in dietetics, director of The Rehab Dietitian and Macmillan specialist dietitian at The Beatson West of Scotland Cancer Centre, Glasglow. Gina supports patients with medical and surgical IBD, as well as other gastrointestinal conditions and oncology patients.
What are the symptoms in daily life and clinical practice?
Identifying symptoms of BAM is an important first step. BAM can be diagnosed through tests such as SeHCAT (Selenium-75-homocholic acid taurine) and Serum C4. SeHCAT is considered the gold standard, although it isn’t available in many countries.
Gina explains that, in clinical practice, she often observes increased urgency and stool frequency. For some people, their bowels can open overnight and many times during the day. In addition, there can be abdominal cramps and discomfort. Other important changes in bowel habits include liquid, mushy, or oily stools. The color can change to a paler, more orange or yellow color.
“Some people say they feel like acid is passing out of them. Others can get indigestion and heartburn (pain just below the breastbone). Wind and bloating can also happen. For those who are on medications that constipate them, like painkillers, these symptoms can be masked, but often unpredictability, discomfort, and urgency remain,” she says.
Gina supports patients by not only creating personalized diet plans tailored to their needs, but also by recognizing symptoms early and monitoring them, helping to provide more responsive and effective care.
Read more about the causes of BAM here explained by GUTS UK, a national charity for digestive conditions.
Why is it important to distinguish between BAM and IBS?
BAM can often present with symptoms similar to irritable bowel syndrome (IBS), highlighting the need for careful clinical assessment to ensure appropriate treatment.
Gina highlights how she carefully reviews whether a person has been labelled as having IBS if any of the following occur:
- They have IBD
- They have had their gallbladder removed, have kidney stones or gallstones
- They have had a bowel operation
- They have had cancer treatment
“Frequent urgent diarrhea that is ongoing means BAM should be ruled out before giving an IBS diagnosis. It can be difficult to distinguish, but IBS is a diagnosis of exclusion, and BAM should be ruled out first if first-line lifestyle and diet changes have not helped” she mentions.
What are debilitating challenges to living with BAM?
Living with this condition can bring serious, often invisible challenges. Gina observes that many patients experience significant day-to-day limitations. People can feel the stress of explaining themselves, and due to a lack of awareness, other people may not understand when plans are canceled. These moments can ripple outward, straining relationships and disrupting important life events. On top of that, anxiety around bowel habits and the toll on physical health, especially when exercise becomes difficult, add a constant layer of pressure and limitation.
“Unfortunately it is common but underrecognized, and trying to get help and support is often hard.”
What are dietary interventions for BAM and how can nutritional adequacy be ensured?
Treatment for BAM often includes medications known as bile acid sequestrants. In addition, dietary interventions can play an important role in improving symptoms.
While further research on dietary interventions in IBD is still needed, several approaches may already be considered. It is essential that patients have access to, and guidance from, a dietitian to make safe dietary changes.
Gina first assesses a patient’s overall eating patterns, including meal timing, portion sizes, and eating pace. Another key consideration is avoiding overstimulation of the bowels or bile acid production. She also emphasizes the importance of stress, lifestyle factors, and adequate hydration. Additionally, she is mindful of intake of caffeine, alcohol, and spicy foods, although some individuals may tolerate small amounts without issue.
A central component of dietary management for people with BAM is being mindful of high-fat foods, as these can trigger symptoms. While the underlying mechanisms in IBD are not yet fully understood and require further research, moderating fat intake is often considered a practical strategy.
“Fatty rich foods can be triggering, so I would usually recommend a lower fat diet while ensuring that total calories and protein remain optimal for the person and recover. We all need some fat and it is still important for those with IBD and BAM to meet their essential fatty acid needs. It is good to try and do this by having small portions of oily fish and or nuts/nut butter in the day” Gina explains.
An interesting aspect of nutrition is the potential role of soluble fiber, which has bile-binding properties. Some examples include oats, beans and bananas. However, further research into specific food types in IBD is needed and could build on findings from previous studies. For example, a study by McKenzie et al. (2023), although not conducted in patients with IBD and per fiber source, identified certain foods as less likely to trigger symptoms.
Gina mentions that fiber tolerance is very individual and can depend on factors such as anatomy, inflammation, stool consistency, and fluid intake. A dietitian can support patients in identifying the most appropriate type and amount of fiber for their specific needs.
Additional supplementing, if necessary, should always be discussed with a healthcare provider.
What are the risks and barriers contributing to delayed diagnosis and its impact on disease management and outcomes?
A delayed diagnosis can place a significant burden on people living with this condition, limiting access to appropriate care and the support they need. It may also negatively affect disease management and overall outcomes.
Gina highlights several important considerations for clinicians, noting that BAM is often underrecognized and its symptoms can be mistaken for active IBD, post-surgical changes, or short bowel syndrome. As a result, patients may have their IBD medications unnecessarily escalated or restarted, or be treated with agents such as loperamide instead of receiving appropriate management for BAM.
“The barrier is therefore lack of knowledge or awareness. It can impact on care due to the physical, psychological and nutritional impacts mentioned already. In my practice I support my clients and communicate with their doctors to explain that BAM is a possibility. I will also encourage self-advocacy and give advice on how to do this” she says. Gina adds that the lack of awareness and the scale of the problem is not only in IBD but occurs unfortunately in other conditions as well.
Greater investment in research on bile acid malabsorption is crucial. Encouragingly, researchers are actively advancing understanding in this area, including professor Julian Walters, a leading expert in the field.
We hope that more patients will receive timely diagnoses and the treatment they need. Continued research, greater awareness and action will be key to making that possible.
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Gina Giebner currently works part time as an NHS Macmillan dietitian and has a private freelance practice (The Rehab Dietitian) seeing people for medical and surgical IBD as well as other gastrointestinal conditions and oncology. She is also a MDT contributor/co-author on the 2025, British Society of Gastroenterology practice guidance on the management of acute and chronic gastrointestinal symptoms, and complications as a result of treatment for cancer. In addition, she serves as an expert volunteer advisor for PRDA (Pelvic radiotherapy disease association). For more information about her work, visit her website www.therehabdietitian.com.
The information in this article is for informational purposes only and is not intended as medical advice. Please consult with your healthcare provider before making any decisions regarding your health or treatment.
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