The Liver Flush Is Soap | The Angry Gut, Chapter 28

Bile acid malabsorption · gallbladder surgery

Bile Acid Malabsorption After Gallbladder Surgery: What to Measure

After gallbladder surgery, the measurement to ask for is a bile acid test, arranged by your physician or a gastroenterologist, because bile acid diarrhea is one of the most common causes of urgent, loose stools and one of the least often tested. A positive breath test belongs before any antibiotic for overgrowth.

Loose stools and fat intolerance years after gallbladder surgery often get treated as a bacterial problem. The real cause is frequently bile arriving at the wrong time, and it is rarely measured.

Bile acid malabsorption, called bile acid diarrhea in most of the research, means bile acids are reaching the colon, and the colon answers by flooding the bowel with water. After gallbladder removal it is one of the most common explanations for urgent, loose stools, and one of the least often tested. The video above, The Liver Flush Is Soap, presents Chapter 28 of The Angry Gut by Dr. Gurpreet Singh Padda, MD, MBA, MHP, and Ami Michelle Grimes. It follows a woman of fifty-nine who spent eleven years after her surgery unable to face a fatty meal, and who received four courses of antibiotics for a bacterial overgrowth her breath tests never confirmed.

The gap in her care was a missing measurement. Nobody asked where her bile was going. What follows is what a routine visit tends to check, what it skips, and which numbers are worth having before anyone writes a fifth prescription.

What happens to bile after gallbladder removal?

A gallbladder holds bile between meals and squeezes it out when fat arrives. Once it is removed, bile drips into the gut around the clock, with or without food. Two problems follow. Fat that bile never breaks into droplets is not absorbed, and the vitamins that ride along with fat are lost too, a supply problem that starts before the intestine ever gets a chance. Bile also acts as a guard. In people whose bile duct is completely blocked, bacterial endotoxin from the gut crosses into the blood, and in a small surgical series, giving a bile salt by mouth before the operation kept it out.

That guard matters beyond digestion. The Angry Gut calls the gut the first brain and the skull the second brain, and bacterial debris slipping past a weak defense feeds metaflammation, the steady, low-grade metabolic inflammation underneath insulin resistance and chronic pain. A bowel that misfires all day is not a private nuisance. It belongs to the metabolic picture.

Why is SIBO blamed so often after gallbladder surgery?

Dr. Padda expected the missing organ to be what lets bacteria climb upward, and he would have told this patient exactly that. The surgical data corrected him. In a prospective study of people after abdominal surgery, overgrowth ran 37.6% against 13.3% in healthy controls, but gallbladder removal carried the smallest risk of the operations compared, 17.1%, while stomach surgery reached 96.2%. In a second study of gallbladder disease, the group most likely to test positive was people who still had their gallbladder and their stones, at 40.5%.

So a sluggish gallbladder is worse than an absent one, and bile that sits still is the real fault. The antibiotics kept coming anyway. Part of the reason is the clock: ordering a breath test means preparation instructions and a second appointment, while writing a prescription fits inside the visit already underway. Antibiotics for overgrowth have a legitimate trigger, and that trigger is a positive test. Four courses without one describe a habit, not a diagnosis.

How common is bile acid diarrhea?

A teaching hospital scanned 1,071 people in a row who had been sent in for chronic diarrhea. Bile acid diarrhea turned up in 42.7% of them, and having had the gallbladder removed ranked among three features that predicted an abnormal result. The more surprising figure: 61.0% of those referred had no known risk factor, and 35.7% of that group had the condition anyway. Severity among positive results was mild in 31.7%, moderate in 34.4% and severe in 33.9%.

That particular scan is not offered in the United States, so the numbers travel but the exact route to a diagnosis does not; a gastroenterologist picks the method available here. For a patient the takeaway is simpler. Chronic loose stools after gallbladder surgery have a name, a test and a treatment, and it is fair to ask whether anyone has looked.

Does a liver flush remove gallstones?

The internet fix for bile trouble is an olive oil and citrus flush, which produces green, stone-shaped lumps in the toilet. In the one case where someone sent them to a laboratory, they held no cholesterol, bilirubin or calcium, the building blocks of a real gallstone, and they melted into oil after ten minutes at 40 degrees. They were soap, made in the gut from the drink itself, and the woman still had her gallstones. Something you can see in a toilet bowl has not been measured.

Do TUDCA or milk thistle improve bile flow?

The same standard applies to bottles. Tauroursodeoxycholic acid, sold as TUDCA, borrows its reputation from a prescription relative, ursodeoxycholic acid, whose pooled trials in its own liver disease shifted blood tests without reducing deaths. The best metabolic trial of TUDCA itself gave obese men and women 1,750 mg daily; after four weeks, liver and muscle insulin sensitivity were up by about 30%, and nothing in the gut or the bile was measured. Milk thistle lowered two liver enzymes in pooled trials, with no effect at a BMI of 30 or above. No product sold to boost bile flow has been shown to raise measured bile flow in a person.

None of that is a reason to start or stop anything on your own. It is a reason to ask, for anything you take, which number is supposed to move and when it will be checked. Every change to a prescription or a supplement belongs in a plan made with your physician.

Bile acid malabsorption: what Measura measures and what it does not

Measura [Cardiometabolic and Autonomic Health Analysis] does not test bile, the gallbladder or gut bacteria. Bile acid tests, gallbladder imaging and breath tests for overgrowth are different tests, arranged elsewhere by your physician or a gastroenterologist. What Measura can add is the metabolic terrain that gallbladder trouble keeps company with. In the study of 265 people with gallbladder disease, the disease was independently linked to fatty liver and metabolic syndrome as well as overgrowth.

Laboratory panels, chosen with your physician, can show the blood sugar, insulin and lipid patterns of insulin resistance long before a diabetes diagnosis. Insulin resistance and metabolic health explains why those early numbers matter.
Bioimpedance body composition splits your weight into fat, muscle and water, something a bathroom scale cannot do. See body composition, not BMI.

Every result goes to the physician who ordered it. Measura measures; it does not diagnose bile acid diarrhea or treat it.

Questions to bring to your physician

Could my symptoms be bile acid diarrhea, and how would we test for it here?
Did a positive breath test come before every antibiotic course I was given?
Gallbladder disease keeps company with fatty liver and metabolic syndrome. Have mine been checked?
For each supplement I take, which number should change, and when do we look again?

Why bile works as a signal is covered in the earlier post on bile, and once drainage works the gut wall still has to close, which is where the next post on healing time picks up. Every study named here, with its limits, is in the Chapter 28 book companion. Unmeasured is unmanaged: the woman in the video ate a restaurant meal at four months, her first since the surgery, once someone measured the right thing.

Frequently asked questions

What are the symptoms of bile acid malabsorption?

In the case behind the video, the pattern was chronic loose stools, bloating by mid-afternoon and trouble with fatty meals, years after gallbladder surgery. Bile acids reaching the colon draw water into the bowel. Those symptoms overlap with other conditions, which is why a test matters more than a guess. For making sense of any flagged value, see understanding your results.

Is SIBO common after gallbladder removal?

Less common than many people assume. After abdominal surgery, overgrowth was least frequent after gallbladder removal, at 17.1%, and most frequent after stomach surgery. People with gallstones still in place tested positive more often than people who had the organ removed. A positive breath test should come before antibiotics. The limits of any single result are laid out in what a test result can and cannot tell you.

Does Measura test for bile acid malabsorption?

No. Bile acid tests, gallbladder studies and breath tests are not in the Measura library and are arranged elsewhere. Measura measures the metabolic and body composition picture that gallbladder disease tends to travel with, and every finding goes to your physician. For the full list of tests, read what Measura actually measures.

Why would gallbladder problems matter for metabolic health?

Researchers who followed 265 people with gallbladder trouble found it tied, on its own, to fatty liver and to metabolic syndrome. A gallbladder that will not empty is often a sign of a wider metabolic problem, not a lone plumbing fault. Checking insulin resistance and body composition answers that question directly. See insulin resistance before diabetes.

What are the green stones after a liver cleanse?

In the one published case where a laboratory examined them, the lumps lacked every ingredient of a true gallstone and consisted largely of fatty acids. Investigators then produced identical lumps by mixing lemon juice, oleic acid and potassium hydroxide, a recipe for soap. The woman who passed them still needed surgery for her real stones. Worth raising at your next visit: questions worth asking your doctor.

How is bile acid malabsorption diagnosed?

With a bile acid test, arranged by your physician or a gastroenterologist. In the largest study on this page, a hospital scan found the condition in 42.7% of people sent in for chronic diarrhea, but that scan is not offered in the United States, so a gastroenterologist picks the method available here. Measura does not perform bile acid, gallbladder or breath tests.

What can be mistaken for bile acid malabsorption?

Bacterial overgrowth is the usual stand-in. After gallbladder surgery, loose stools and trouble with fatty meals often get treated as a bacterial problem, sometimes with repeated antibiotics and no positive breath test. Yet overgrowth was least common after gallbladder removal, at 17.1%. Because the symptoms overlap, a test settles it: a bile acid test for bile, and a breath test before any antibiotic for overgrowth.

How do you fix bile acid malabsorption?

The fix starts with a diagnosis. Bile acid diarrhea has a name, a test and a treatment, and the treatment is chosen by your physician or gastroenterologist once a bile acid test confirms it. In the case behind the video, the woman ate her first restaurant meal since surgery four months after someone measured the right thing. Products sold to boost bile flow have not been shown to raise measured bile flow.

Measure the terrain behind the symptoms

Request Measura testing to see your metabolic and body composition numbers, and bring your bile and breath test questions to the physician who receives the results.

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References

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