Bile Acid Malabsorption & FXR

BAM or bile acid malabsorption happens when bile acids are not reabsorbed in the colon. There is a theory that this is either due to excessive bile production or inadequate bile reabsorption in the colon. Most of the medical information and research is chasing a symptom only approach is not logical in its mechanisms and logic. 

This article is designed for the lay person, aka patient, to understand why they may have bile acid malabsorption and more importantly to understand emerging research that may or may not help them.

The symptoms of bile acid malabsorption are usually unformed or loose stools with visible discoloration due to bile and increased frequency. Extreme urgency or near bowel incontinence usually later develops as the condition worsens. 

In this article I only speak of primary or idiopathic BAD, which means you have it but we don’t know why. This may or may not apply to someone with colon surgery, gallbladder removal, ulcerative colitis, etc. Those are individual cases that need to be discussed individually. 

If you look at systematic reviews on diarrhea, we know that bile acid diarrhea is currently highly underdiagnosed. 

It is estimated that 25 to 30 percent of diarrhea patients actually have bile acid diarrhea. 

Or up to 1% of the population. (Thus making it much more prevalent than Crohn’s disease or Ulcerative Colitis.) 

It is actually as prevalent as true Celiac Disease! Imagine if the grocery stores were lined with bile acid diarrhea safe foods as they are with gluten free. So definitely a serious concern in health.

There is a HUGE need for improved bile acid diarrhea treatment that is currently not being met by traditional gastroenterology.

The Gallbladder and Bile Acid Diarrhea

When you eat, drink or even smell, the gallbladder is stimulated to contract. (In order for this to occur you need proper CCK levels in the small intestine.) When the gallbladder contracts and releases bile, up to 95% of the bile is reabsorbed in the ileum. (See picture. A part of the small intestine.) This process is usually VERY efficient and the cycle repeats itself up to 6 times a day.  Your body only makes around 30 ounces of bile per day. 

FXR And Bile Acid Diarrhea SIMPLIFIED

First we have to accept that the mechanisms of bile reabsorption and production are not fully understood. Thus any explanation provided by “research” at this time is just theory not fact.  Also we have to acknowledge that most drugs are developed without a full working knowledge of why they work and it is more common than ever to use “off label” prescriptions, or drugs for things they weren’t intended for. 

Let me just use this opportunity to tangent really quickly into the fact that everyone thinks their doctors office is scientific though science always meets its maker at some point. Meaning at some level everything is experimental. If drugs work on 30% of the population then it can be approved. Placebo rate for many trials is 30%. Point being, while many doctors shame complimentary and alternative medicine, traditional medicine also tries to treat beyond the research and yet their model is often much more dangerous in chronic illnesses.

Back to what is FXR? Long story short, FXR is a bile acid receptor in the large intestine. When the FXR is stimulated it creates a reaction that then turns down bile acid production in the liver. A feedback loop. 

So now to the hypothesis. What has been found is that there is decreased FGF19 in idiopathic bile acid diarrhea. We are all on board here….

The leap of faith…

The scientific leap of faith gastroenterologist are taking here is that because the FGF19 is low, it is dysfunctional. Because it is dysfunctional, the stopping of bile production is not being happening and thus you have overproduction of bile. 

Unfortunately in my opinion this leap of faith is not scientific at all. 

There are definitely studies that show that if you knock out FGF, then watery diarrhea occurs, but it doesn’t say that this is the pathogenesis or start of bile acid diarrhea. The root cause still needs to be determined!

In fact, I would suggest that FGF is low for a reason. I know medicine doesn’t think that the body can dysfunction for a good reason, but in holistic medicine we believe that the body often has a symptoms for a reason. So bile clears toxins, eliminates waste, etc. Much like if you have the stomach flu you may vomit, rapid bile elimination in your stool can be a GOOD thing for your body! (Just bad for your lifestyle.)  

FXR and Bile Acid Diarrhea

The FXR hypothesis is the new idea that a FXR defect causes malabsorption in the intestines. Thus developing a drug to simulate FXR would then help. We are probably 10 years or more away from that medication and thus it doesn’t benefit most people at this time. 

Does Bile Cause Diarrhea?

We definitely know that there are certain ways in which bile causes diarrhea. But, did you know bile can also can STOP diarrhea? In low quantities bile actually can slow down your response that make you need to urgently go.


Bile acid malabsorption is being suggested that it is a problem with enzymes and receptors. It is my experience that this is not true. In another article I will elucidate the mechanisms of most bile acid malabsorption that have proven to benefit patients without having to suffer forever. 

Read more about natural bile acid malabsorption HERE

Take Dr. Anderson’s Bile Acid Malabsorption Course at

DISCLAIMER: Houston C. Anderson is NOT a licensed Medical Doctor (MD).He is a licensed Chiropractic Physician and Applied Kinesiologist in the state of Arizona. Information on this website is provided for general educational purposes only and is NOT intended to constitute (i) medical advice or counseling, (ii) the practice of medicine including psychiatry, psychology, psychotherapy or the provision of health care diagnosis or treatment, (iii) the creation of a physician patient or clinical relationship, or (iv) an endorsement, recommendation or sponsorship of any third party product or service by the Sponsor or any of the Sponsor's affiliates, agents, employees, consultants or service providers. These statements have not been evaluated by the Food and Drug Administration. These products are not intended to diagnose, treat, cure, or prevent any diseases. If you have or suspect that you have a medical problem, contact your health care provider promptly.

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