The Missing Link Behind Chronic Bloating, Diarrhoea and Fatigue: Bile Acids Explained
If your gut is unpredictable - swinging between bloating, loose stools, greasy toilet bowl dramas, and a persistent lack of energy - you’ve probably been told it’s just IBS, stress, or something vague like “a sensitive tummy.” But beneath these common symptoms could be something far more specific (and fixable): a bile issue.
Bile is one of the most under-discussed players in digestive and metabolic health and when it’s imbalanced, the knock-on effects are anything but subtle. In this blog, I’ll explore the two key ways bile can go wrong:
Bile acid deficiency
and
Bile acid malabsorption (BAM)
I’ll also explain how your gallbladder fits into the picture, and how a nutritional and functional medicine approach can bring things back into balance.
First, What Is Bile and Why we should care?
Bile is a fluid made by the liver and stored in the gallbladder. It’s mostly water, but also contains bile acids (or salts), cholesterol, phospholipids, and waste products like bilirubin.
Its job? It’s essential for:
Breaking down fats in food
Absorbing fat-soluble vitamins (A, D, E, K)
Keeping cholesterol balanced
Helping regulate the gut microbiome
Facilitating detoxification
Modulating inflammation in the small intestine
Without sufficient bile or proper bile acid reabsorption, fat digestion becomes inefficient, which often leads to symptoms like bloating, greasy stools, fatigue, and nutrient deficiencies, even if you’re eating a healthy diet.
The Gallbladder link:
The gallbladder is a small, pear-shaped organ tucked beneath your liver. Its job is to store and concentrate bile, releasing it into the small intestine when you eat -especially when fat is present.
When the gallbladder is sluggish, inflamed, or removed (cholecystectomy), bile delivery becomes less efficient and poorly timed. Instead of being released in a concentrated burst with meals, bile may drip continuously or arrive too late to support digestion properly.
This is why post-gallbladder removal patients often experience:
Loose or urgent stools
Poor fat digestion
Vitamin deficiencies
Chronic bloating or cramping
A sense of fullness or nausea after meals
So while the liver produces bile, the gallbladder’s role is pivotal in regulating its availability. Without it, or when it’s not working well, bile acid imbalance is common.
Bile Acid Deficiency vs. Bile Acid Malabsorption: What’s the Difference?
Though they sound similar, these two issues are functionally different, but both can cause significant gut disruption.
Bile Acid Deficiency:
This means not enough bile acids are being produced or released into the digestive tract. It can stem from:
Poor gallbladder function or removal
Liver dysfunction (bile is made in the liver)
Nutrient insufficiencies (like taurine, glycine, choline)
Low-fat diets over time (bile needs fat to be stimulated)
Gut inflammation disrupting normal bile flow
Key symptoms include:
Pale, greasy, or floating stools
Bloating and belching after meals
Steatorrhoea (fat in stools)
Deficiencies in fat-soluble vitamins
Hormonal imbalance (since fat absorption is compromised)
Feeling worse after fatty meals
Bile Acid Malabsorption (BAM):
Here, bile is being produced - but not reabsorbed properly in the ileum (the last part of the small intestine). Instead, excess bile acids spill into the colon, where they irritate the bowel and draw in water, causing loose stools and urgency.
Common causes include:
Ileal inflammation (from Crohn’s disease, infections, or IBS)
Gallbladder removal
SIBO (small intestinal bacterial overgrowth)
Certain medications
Post-infectious IBS
Key symptoms include:
Chronic watery diarrhoea, especially after eating
Sudden urgency
Bloating and cramping
Fatigue (from malabsorption and nutrient loss)
Feeling ‘drained’ after going to the loo
What Do They Have in Common?
Both bile acid deficiency and malabsorption can lead to:
Malabsorption of fats and fat-soluble vitamins
Disruption of the gut microbiome
Chronic inflammation in the gut
Mood changes (bile acids influence neurotransmitters)
Fatigue and brain fog
But the treatment is very different - so it’s important to identify which one you’re dealing with.
Functional Medicine Approach to Bile Imbalance
Rather than masking symptoms, its my job to ask: Why is bile not flowing or being absorbed properly? Here are the key areas I explore:
1. Gallbladder and Liver Support
Bitters (artichoke, dandelion, gentian) to promote bile flow
Nutrients like choline, taurine, glycine for bile acid synthesis
Phosphatidylcholine to support bile solubility and gallbladder function
Castor oil packs or abdominal massage for sluggish gallbladder
2. Identify SIBO or Gut Inflammation
Test for small intestinal bacterial overgrowth (SIBO), which can damage bile acid transporters
Support gut lining with zinc carnosine, glutamine, aloe vera, quercetin
Use a low-inflammatory, whole foods diet with healthy fats (don’t cut fats entirely!)
3. Replace What’s Missing
If bile acids are deficient, supplementation with ox bile or bile acid formulas may help restore digestion - particularly in those without a gallbladder.
If BAM is diagnosed, medications like bile acid binders from a doctor may be used short term, but functional strategies like reducing ileal inflammation, supporting the microbiome, and removing triggers (like ultra-processed foods) are key.
4. Microbiome Support
Prebiotics and probiotics can help regulate bile acid metabolism
A diverse microbiome helps convert primary bile acids to secondary forms that support gut health
Short-chain fatty acids (SCFAs), especially butyrate, help maintain ileal function and bile reabsorption
So, Should You Get Tested?
Yes - if you’ve been struggling with unexplained digestive symptoms, especially after gallbladder removal or bouts of food poisoning, it’s worth investigating bile acid imbalance with a Gastro specialist.
Tests to consider:
SeHCAT scan (NHS test for bile acid malabsorption)
Stool tests showing steatorrhoea or poor fat digestion
Comprehensive Digestive Stool Analysis (CDSA) for microbiome and bile markers
Liver function and nutrient panels (especially vitamin A, D, E, K, and choline)
We Must Not Underestimate Bile
Bile may be bitter by nature, but its function is sweet! Whether it’s being underproduced, poorly timed due to gallbladder issues, or spilling into the colon when it shouldn’t - bile imbalance can quietly sabotage digestion, mood, immunity, and energy.
And yet, these issues are often missed or misdiagnosed. If you’ve been battling fatigue, bloating, and gut issues that don’t respond to the usual advice, it’s time to give bile its rightful place in the health conversation.