Introduction to Bile Acid Loss Syndrome

The bile acid loss syndrome develops from a physiologically significant loss of bile acids in the intestine. It manifests itself as stubborn diarrhea that cannot be treated even with the usual medication. Whether curative or merely symptomatic therapies are possible depends on the cause of the bile acid loss syndrome.

What is Bile Acid Loss Syndrome?

In bile acid loss syndrome, as the name suggests, there is a significant loss of bile acids in the intestine. Bile acids are necessary to emulsify dietary fats so that they can then be absorbed in the small intestine. At the same time, with the absorption of fats and fatty acids, fat-soluble vitamins are also absorbed there.

The bile acids get from the liver via the bile ducts into the duodenum (duodenum), where they perform their functions and are usually reabsorbed in the ileum (lower section of the small intestine). The re-absorbed bile acid is now returned to the liver via the enterohepatic circulation.

Only a small part of the bile (around five percent) is broken down in the intestine. Among other things, the breakdown product bilirubin is created, which gives the faeces its brown color. The bile acids recycled via the enterohepatic cycle are in turn used for the same process.

Their small loss through degradation in the intestine is compensated for in the liver through new synthesis from cholesterol. However, if certain processes lead to a significant loss of bile acids, these have to be synthesized again to a greater extent in order to maintain normal fat digestion and the supply of vitamins to the organism.

Loss of bile acids is caused by the fact that they get into the large intestine and are broken down there. This leads to a compensated or, in more severe cases, a decompensated bile acid loss syndrome.

In the case of a compensated bile acid loss syndrome, the capacity for new bile acid formation is sufficient to ensure normal fat digestion, while the decompensated form can lead to malabsorption of fats and fat-soluble vitamins with the symptoms of malnutrition.


The causes of a bile acid loss syndrome are both the disturbance of the absorption of bile acids in the lower part of the small intestine (ileum) and their increased breakdown in the small intestine due to incorrect colonization with bacteria. Bile acid absorption does not apply, for example, when the ileum is removed as part of an intestinal operation for Crohn’s disease.

Even with Crohn’s disease itself, the reuptake of bile acids is disturbed. An increased breakdown of bile acids in the small intestine takes place in the so-called blindsack syndrome. The blind sack syndrome is characterized by a sack-like protuberance on the small intestine. The main cause of this syndrome is surgery on the small intestine.

In this protuberance, remnants of the intestinal contents and bile acids collect, which are broken down with intensive bacterial formation. This leads to a considerable loss of bile, which can lead to a massive disruption of fat digestion, a vitamin B12 deficiency and severe anemia. It was previously believed that these two causes were mainly responsible for bile acid loss syndrome.

According to more recent findings, however, a significant proportion of irritable bowel patients also suffer from this syndrome. No recognizable causes for the resorption disturbances could be established here. Nevertheless, this so-called idiopathic form of the bile acid loss syndrome is now estimated at around 33 percent.

Symptoms, ailments & signs

Bile acid loss syndrome manifests itself as persistent chologene diarrhea. This diarrhea is caused by the osmotic effects of the bile acids. They are associated with severe abdominal cramps. The diarrhea can cause weight loss and dehydration.

In the anus region, eczema often forms due to the irritation of the bile acids. With no food, the symptoms improve. In the decompensated cases of the bile acid loss syndrome, fatty stools (steatorrhea) occur, which are noticeable through real fat films on the water.

Since the bile acid loss is very great, the bile acid concentration in the gallbladder also drops. As a result, gallstones and urinary stones can develop. The gallstones represent salt-like precipitations of bile acids, while the urinary stones consist of oxalates, as oxalic acid is absorbed to a greater extent in the intestine. If fatty acid absorption is permanently impaired, there is a deficiency in vitamins B12, A, D and F. A vitamin B12 deficiency can lead to pernicious anemia in the long term.


There are several ways to test for bile acid loss syndrome. One possibility is a stool test for bile acids. The 15SeHCAT test is more meaningful. Another test, the 4C glycocholate breath test, is rarely performed. The administration of the exchange resin colestyramine has proven to be the best. If the symptoms improve in this case, the diagnosis of bile acid loss syndrome is confirmed.


In most cases, the bile acid loss syndrome causes discomfort in the stomach and abdomen. Those affected suffer from severe diarrhea and pain in these regions. Diarrhea also causes dehydration if people do not drink enough fluids. There is also weight loss, which is generally a very unhealthy condition for the body.

Eczema and other inflammations in the stomach also occur frequently. As the disease progresses, gallstones and urinary stones can occur, which usually lead to severe pain. The symptoms often lead to psychological stress. The patient is no longer able to exercise or do sports.

The quality of life is therefore severely restricted by the bile acid loss syndrome. The treatment of bile acid loss syndrome is usually causal and depends on the underlying disease. This rarely leads to complications. In many cases, an operation is necessary, after which the symptoms and complaints disappear again. There are no further complications and the patient’s life expectancy remains unchanged.

When should you go to the doctor?

If the symptoms of diarrhea are repeated and persistent, a doctor should be consulted. If the diarrhea cannot be stopped despite all efforts and a change in diet, the person affected needs medical support. In the case of general weakness, exhaustion, the loss of the usual level of performance and lack of strength, a doctor is required. If you can no longer cope with everyday life due to the symptoms, a doctor’s visit is necessary.

If there are deficiencies in the body, there is cause for concern and a doctor should be consulted. The patient is threatened with an insufficient supply of the organs and thus functional disorders that are often painful. Help is needed in the case of dizziness, unusual bowel noises, internal restlessness, irritability and skin changes on the anus. The patient should undergo extensive examination and treatment so that no further diseases can develop.

Persistent stress, noticeable changes in behavior or changes in personality should be discussed with a doctor. If there is a feeling of dryness in the organism, a doctor should be consulted. Dehydration threatens, which is a medical emergency. If there is severe weight loss, there may be malnutrition, which must be treated medically to avoid further complications. If you have cramps in your stomach or intestines, if your body temperature rises, or if you have blood in your stool, you need to see a doctor.

Treatment & Therapy

The best therapy for bile acid loss syndrome is the treatment of the underlying disease. However, this is often no longer possible. For example, if the lower part of the small intestine (ileum) had to be removed as part of an intestinal operation, only symptomatic treatments can be carried out to improve the symptoms.

In this sense, the exchange resin cholestyramine has proven itself best against diarrhea. It is ingested with food and absorbs the bile acids. This means that they can no longer exert their osmotic effect against the intestinal walls and the diarrhea comes to a standstill.

However, the resin should not be used on fatty stools, because the deficiency symptoms would be exacerbated here. Vitamin deficiencies must be treated with vitamin substitution.

Outlook & forecast

The prognosis and the course of the disease depend on the curability of the diagnosed underlying disease. In many cases, freedom from symptoms is not possible because the causal disease is irreparable. If parts of the intestine had to be removed, the patient with bile acid loss syndrome can no longer fully recover.

The focus of treatment for these patients is on alleviating the existing symptoms and improving the current quality of life. In the case of malnutrition, a change in diet and an adequate supply of vitamins can lead to a significant improvement in health.

Relapses are documented as soon as food intake does not take place optimally in the further course of life and is adapted to the needs of the organism. If the lack of vitamins can be permanently and stably compensated for, the patient will normally be free of symptoms. Even with irreparable underlying diseases, a balanced and healthy diet can alleviate the symptoms.

Well-being is strengthened, although no healing occurs. In these cases, dealing with the disease is made easier for the patient. In addition, strengthening the psyche and an optimistic attitude towards life are elementary for a good prognosis of the bile acid loss syndrome. This enables an improvement in the general state of health and the handling of the complaints is easier for the patient to bear.


Since the bile acid loss syndrome mainly occurs after intestinal operations in severe intestinal diseases or is caused by unclear causes, no specific recommendation for prevention can be given.

However, those affected can help improve symptoms by eating a healthy, varied and low-fat diet. Food supplements with medium-chain fatty acids and fat-soluble vitamins are recommended.


In most cases, the patient with bile acid loss syndrome does not have any special follow-up options. The patient himself is primarily dependent on medical treatment for this complaint in order not to reduce life expectancy. Early detection and treatment of this syndrome has a positive effect on the further course and can prevent further damage.

Sometimes life expectancy is reduced due to the bile acid loss syndrome. In most cases, bile acid loss syndrome is treated with surgery on the bowel. The patient should definitely rest after such an operation and take care of his body.

You should therefore refrain from exertion or other stressful activities. Likewise, only light and low-fat food may be consumed in order not to overwhelm the intestines and stomach. With the help of supplements, deficiencies in vitamins and other nutrients are treated, so that the person concerned makes sure that they are taken regularly and that the dosage is correct.

Only after successful treatment of the bile acid loss syndrome should you switch to a normal diet. In this syndrome, the support and care of one’s own family also has a positive effect on the course of the disease.

You can do that yourself

It is not possible to treat bile acid loss syndrome directly through self-help. Those affected are always dependent on medical treatment, which is usually carried out with an operation to completely combat the disease.

By means of self-help, only the individual symptoms can be weakened. Since bile acid loss syndrome often leads to diarrhea, those affected should ensure that they drink more fluids to avoid dehydration.

Supplements can also be used here to counteract deficiency symptoms. However, the use of these agents should always be discussed with a doctor. This can also determine which deficiencies are currently occurring through a blood test. Vitamins in particular often have to be substituted.

Furthermore, a low-fat and varied diet can have a positive effect on the course of the bile acid loss syndrome and alleviate the symptoms. The diet should be healthy and follow a healthy lifestyle. The use of cholestyramine can also have a positive effect on the course of the disease. This also alleviates the symptoms.

Bile Acid Loss Syndrome