#15 Understanding bile acid diarrhoea / malabsorption in IBD with Professor Julian Walters

Wrestling the Octopus (IBD)

In Episode 15 of Wrestling the Octopus: the IBD Patient Podcast, Nigel and I cover a topic that receives not nearly as much attention as it should: Bile Acid Diarrhoea (BAD) / Bile Acid Malabsorption (BAM) in Crohn's disease. Our expert guest is gastroenterologist, Professor Julian Walters from Imperial College London in the UK.

Through Nigel's story, we also get a candid view of what BAM feels like for inflammatory bowel disease patients who have had their terminal ileum removed.

What You'll Learn In this Episode

What is BAD/BAM? How bile acids normally work versus what happens when they’re not reabsorbed properly, especially in IBD patients with ileal disease or resection.

Updated terminology: Why “bile acid diarrhoea” is now preferred over “bile acid malabsorption,” and what that means for diagnosis and treatment.

Common causes of BAD: Crohn’s disease, gallbladder removal and genetic variants that lead to excess bile acid production.

How to get diagnosed: A breakdown of the SeHCAT scan, C4 blood test and why access to testing varies across the UK.

Treatment options that work: From bile acid sequestrants (like colesevelam and cholestyramine) to loperamide - can combining them help?

Getting the timing right: Why taking sequestrants at night on an empty stomach may be more effective than following cholesterol-lowering instructions.

Diet and lifestyle tips: How fatty meals can trigger symptoms and what you can do to reduce flare-ups.

Emerging treatments: A glimpse into GLP-1 receptor agonists like liraglutide and semaglutide, and their potential role in managing BAD.

Key Points

• BAD affects more people than Crohn’s disease or ulcerative colitis - yet it remains underdiagnosed.
• SeHCAT is the gold standard test, but blood tests like C4 may offer cheaper alternatives soon.
• Don’t rely on loperamide (Imodium) without a formal diagnosis of BAD / BAM.
• If your symptoms fluctuate, track your diet as fatty meals may be the culprit.
• Nighttime dosing of sequestrants might be a game-changer for symptom control.

Follow Professor Julian Walters on Facebook

Follow Rachel at @bottomlineibd

Follow Nigel at @crohnoid