If I am understanding correctly, BAD is not an overproduction of bile in the stomach, it's excess bile entering the small intestine. Would Cholestyramine reduce only the bile entering the small intestine or also reduce bile (acid) in the stomach?
I am concerned that my stomach acid is low and I don't want to reduce it more. I am wondering if the pancreas is trying to kick in a little extra to make up for a stomach acid deficiency.
I am considering a short trial of Cholestyramine to learn if my intestinal spasms, gurgling, and D would slow down, but I don't want to reduce my stomach acid.
Anatomy of BAD ..... Cholestyramine
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Hi DJ,
A little anatomy refresher is in order. Bile salts produced by the liver are stored in the gallbladder, and they are introduced into the digestive tract through the common bile duct located near the top end of the duodenum (the duodenum constitutes approximately the upper third of the small intestine). The only way that bile can enter the stomach is if reflux is allowed back up from the duodenum through the pyloric sphincter (the valve located between the stomach and the duodenum). This sometimes happens, but it is a malfunction, not a normal occurrence. There are basically 3 ways that bile reflux can occur:
1. complications resulting from surgery that interfere with the proper operation of the pyloric valve
2. Peptic ulcers that block the pyloric valve to prevent proper closing
3. Cholecystectomy (gallbladder surgery) resulting in the presence of relatively high levels of bile salts flowing through the common bile duct at all times (rather than only when it is needed to emulsify fats)
And yet misinformation is all over the internet suggesting that bile salts are normally found in the stomach. Even the National Institutes of Health makes that mistake when discussing how bile acid sequestrants can help to lower cholesterol levels:
Well duh! Apparently the NIH thinks that the word "stomach" is synonymous with the digestive system in general. Actually bile acid sequestrants work by binding bile in the small intestine (downstream of the common bile duct) before it can reach the terminal ileum where it may be reabsorbed for normal recycling.
The presence of bile in the small intestine should normally not be a problem, because it is needed there to emulsify fats so that pancreatic lypase (which is also introduced through the common bile duct) can then hydrolyze the globules of fat emulsified by the bile to convert the fats into monoglycerides and free fatty acids. Obviously exceptions can occur if the gallbladder has been surgically removed, because in that situation bile may flow continuously, even when it is not needed. However, the digestive system is designed so that the leftover (unused) bile can be reabsorbed in the terminal ileum (at the distal end of the small intestine) for recycling. Unfortunately when the terminal ileum is inflamed (which is very often the case with MC), reabsorption of leftover bile salts is compromised, and they pass into the colon, where they can cause D.
It appears that most types of D originate in the small intestine, because of elevated levels of electrolytes in the fecal stream, and/or a compromised ability to absorb electrolytes in the small intestine. But since bile acid malabsorption (BAM) occurs in the terminal ileum, the fecal flow has only a few centimeters to go before it reaches the colon, so really what happens upstream from there is sort of a moot point, because the you-know-what hits the fan when the bile-laden flow reaches the colon (separated from the ileum by only the cecum). So while the cause of the D associated with BAM occurs in the terminal ileum, the D is apparently actually generated in the colon.
In view of all this, unless I'm overlooking something, theoretically at least, bile acid sequestrants should have no significant effect on stomach acidity. But to address your question directly, if you happen to have bile acid reflux, and you actually have bile salts in your stomach, then yes, a bile acid sequestrant should bind those bile salts so that they cannot emulsify fats. But I doubt that this would lower your stomach acidity significantly because bile acids and gastric acid are 2 entirely different entities. Bile fatty acids actually have rather minimal (and specific) digestive capabilities. Basically, they emulsify fats (they break fat up into tiny globules so that more surface area will be available to allow the pancreatic lypase to work more efficiently).
Believe it or not, bile is actually alkaline, not acidic. The pH of bile stored in the gallbladder is typically in the range of 6.8 to 7.65, and the pH commonly increases to about 7.5 to 8.05 in the common bile duct. So getting rid of any bile that happened to be in the stomach certainly should not decrease the overall stomach acidity.
I hope this is helpful.
Tex
A little anatomy refresher is in order. Bile salts produced by the liver are stored in the gallbladder, and they are introduced into the digestive tract through the common bile duct located near the top end of the duodenum (the duodenum constitutes approximately the upper third of the small intestine). The only way that bile can enter the stomach is if reflux is allowed back up from the duodenum through the pyloric sphincter (the valve located between the stomach and the duodenum). This sometimes happens, but it is a malfunction, not a normal occurrence. There are basically 3 ways that bile reflux can occur:
1. complications resulting from surgery that interfere with the proper operation of the pyloric valve
2. Peptic ulcers that block the pyloric valve to prevent proper closing
3. Cholecystectomy (gallbladder surgery) resulting in the presence of relatively high levels of bile salts flowing through the common bile duct at all times (rather than only when it is needed to emulsify fats)
And yet misinformation is all over the internet suggesting that bile salts are normally found in the stomach. Even the National Institutes of Health makes that mistake when discussing how bile acid sequestrants can help to lower cholesterol levels:
https://www.nlm.nih.gov/medlineplus/enc ... 000787.htmThese medicines work by blocking bile acid in your stomach from being absorbed in your blood. Your liver then needs the cholesterol from your blood to make more bile acid. This reduces your cholesterol level.
Well duh! Apparently the NIH thinks that the word "stomach" is synonymous with the digestive system in general. Actually bile acid sequestrants work by binding bile in the small intestine (downstream of the common bile duct) before it can reach the terminal ileum where it may be reabsorbed for normal recycling.
The presence of bile in the small intestine should normally not be a problem, because it is needed there to emulsify fats so that pancreatic lypase (which is also introduced through the common bile duct) can then hydrolyze the globules of fat emulsified by the bile to convert the fats into monoglycerides and free fatty acids. Obviously exceptions can occur if the gallbladder has been surgically removed, because in that situation bile may flow continuously, even when it is not needed. However, the digestive system is designed so that the leftover (unused) bile can be reabsorbed in the terminal ileum (at the distal end of the small intestine) for recycling. Unfortunately when the terminal ileum is inflamed (which is very often the case with MC), reabsorption of leftover bile salts is compromised, and they pass into the colon, where they can cause D.
It appears that most types of D originate in the small intestine, because of elevated levels of electrolytes in the fecal stream, and/or a compromised ability to absorb electrolytes in the small intestine. But since bile acid malabsorption (BAM) occurs in the terminal ileum, the fecal flow has only a few centimeters to go before it reaches the colon, so really what happens upstream from there is sort of a moot point, because the you-know-what hits the fan when the bile-laden flow reaches the colon (separated from the ileum by only the cecum). So while the cause of the D associated with BAM occurs in the terminal ileum, the D is apparently actually generated in the colon.
In view of all this, unless I'm overlooking something, theoretically at least, bile acid sequestrants should have no significant effect on stomach acidity. But to address your question directly, if you happen to have bile acid reflux, and you actually have bile salts in your stomach, then yes, a bile acid sequestrant should bind those bile salts so that they cannot emulsify fats. But I doubt that this would lower your stomach acidity significantly because bile acids and gastric acid are 2 entirely different entities. Bile fatty acids actually have rather minimal (and specific) digestive capabilities. Basically, they emulsify fats (they break fat up into tiny globules so that more surface area will be available to allow the pancreatic lypase to work more efficiently).
Believe it or not, bile is actually alkaline, not acidic. The pH of bile stored in the gallbladder is typically in the range of 6.8 to 7.65, and the pH commonly increases to about 7.5 to 8.05 in the common bile duct. So getting rid of any bile that happened to be in the stomach certainly should not decrease the overall stomach acidity.
I hope this is helpful.
Tex
It is suspected that some of the hardest material known to science can be found in the skulls of GI specialists who insist that diet has nothing to do with the treatment of microscopic colitis.
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robinc2525
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- Joined: Sat Jun 08, 2013 7:29 am
Tex, My gastro prescribed cholestyramine for me at my request and it helps me more than anything else I have ever taken (including Uceris, Lialda, Apriso etc). I don't have to take a lot either, just one packet in a day if at all. I told this to my PCP at a recent physical and she said I don't have a problem with bile, the cholestyramine just slows things down (like immodium). Do you think that could be true?
Hi Robin,
That's great news that the cholestyramine is working so well for you. Frankly, I seriously doubt that cholestyramine slows motility enough to make any significant difference in stool consistency. But cholestyramine has other properties that your PCP is probably overlooking. Bile salts are not the only substances that can be sequestered by cholestyramine. It is prescribed, for example, along with antibiotics for treating a C. diff infection, because it turns out that bile acid sequestrants can also bind many toxins produced by pathogenic bacteria. So it's possible for bile acid sequestrants to be beneficial in cases where D might be due to various unidentified agents that happen to be present in the fecal stream.
When nothing else is working right, cholestyramine is certainly worth a try.
Thanks for sharing,
Tex
That's great news that the cholestyramine is working so well for you. Frankly, I seriously doubt that cholestyramine slows motility enough to make any significant difference in stool consistency. But cholestyramine has other properties that your PCP is probably overlooking. Bile salts are not the only substances that can be sequestered by cholestyramine. It is prescribed, for example, along with antibiotics for treating a C. diff infection, because it turns out that bile acid sequestrants can also bind many toxins produced by pathogenic bacteria. So it's possible for bile acid sequestrants to be beneficial in cases where D might be due to various unidentified agents that happen to be present in the fecal stream.
When nothing else is working right, cholestyramine is certainly worth a try.
Thanks for sharing,
Tex
It is suspected that some of the hardest material known to science can be found in the skulls of GI specialists who insist that diet has nothing to do with the treatment of microscopic colitis.
Tex,
Thanks for the anatomy refresher.....really good info.
As you know, I am considering Cholestrymine next (since I had side effects with Welchol tabs)...do you think it would be best to try this before Budesonide?
Also, when going GF/DF and cutting back on soy and sugar, does your body go through withdrawal? I feel crappy and achy.....I still have back/muscle pain really bad (which I was attributing to the Welchol)....but the blurry vision is better. It could be that it is all having an effect on my Fibromyalgia.
Thanks,
Terre
Thanks for the anatomy refresher.....really good info.
As you know, I am considering Cholestrymine next (since I had side effects with Welchol tabs)...do you think it would be best to try this before Budesonide?
Also, when going GF/DF and cutting back on soy and sugar, does your body go through withdrawal? I feel crappy and achy.....I still have back/muscle pain really bad (which I was attributing to the Welchol)....but the blurry vision is better. It could be that it is all having an effect on my Fibromyalgia.
Thanks,
Terre
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robinc2525
- Adélie Penguin
- Posts: 75
- Joined: Sat Jun 08, 2013 7:29 am
Thank you! Very interesting especially since I repeatedly test positive for SIBO (hydrogen and methane positive) despite measures to get rid of it. Maybe the cholestyramine is actually helping soak up some of their toxins. I had stopped taking it since it contains sugar and I thought it would complicate matters while I try to erradicate SIBO.
Thanks again Tex,
Robin
Thanks again Tex,
Robin
I would try it first, because it's a relatively simple remedy (compared with a corticosteroid), if it works.do you think it would be best to try this before Budesonide?
Many people crave gluten and dairy after cutting them out of their diet because when they are digested they produce peptides that attach to opiate receptors in the brain, so they can be somewhat addictive. But most people do not experience aches and pains as withdrawal symptoms. It's probably possible though, in some cases. Those are sometimes residual effects of gluten, because it takes a while before the immune system slows down its production of antibodies against gluten. But if the Welchol caused blurry vision, then it may well have also caused the aches and pains, and it may take a bit longer for all that to clear your body. And fibromyalgia could certainly be causing some or all of the aches and pains, also. Your fibromyalgia should become less of a problem as the diet changes begin to reduce the inflammation.
You're very welcome,
Tex
It is suspected that some of the hardest material known to science can be found in the skulls of GI specialists who insist that diet has nothing to do with the treatment of microscopic colitis.
Robin,
I suspect that most of us probably have SIBO at various times while we are reacting, because the poor digestion that results from the inflammation that causes MC is bound to create an environment of partially-digested food that attracts various undesirable bacteria. But as our intestines heal, and our digestion improves, the bacteria that thrive on poor digestion are slowly starved out, and they are automatically replaced by a more normal gut bacteria population.
You're very welcome,
Tex
I suspect that most of us probably have SIBO at various times while we are reacting, because the poor digestion that results from the inflammation that causes MC is bound to create an environment of partially-digested food that attracts various undesirable bacteria. But as our intestines heal, and our digestion improves, the bacteria that thrive on poor digestion are slowly starved out, and they are automatically replaced by a more normal gut bacteria population.
You're very welcome,
Tex
It is suspected that some of the hardest material known to science can be found in the skulls of GI specialists who insist that diet has nothing to do with the treatment of microscopic colitis.
Hi Tex,
I can't see my original response to your post so maybe I didn't hit send.Thank you so much for your detailed, helpful response.
I would love to learn if something is not right in my small intestine without reducing my stomach acid. I have a chronic gas location (repeatedly seen on ultrasound, etc.) just below my stomach, leading me to believe that something isn't right in that area. I twist and turn my rib cage until I burp like a cartoon character and that usually reduces my coughing and gagging. I am also back to the point of pooping WD and undigested food. Work is difficult right now and as my stress level increases, so do my symptoms of WD. Fortunately, I will soon retire.
Tex, You are much appreciated.
DJ
I can't see my original response to your post so maybe I didn't hit send.Thank you so much for your detailed, helpful response.
I would love to learn if something is not right in my small intestine without reducing my stomach acid. I have a chronic gas location (repeatedly seen on ultrasound, etc.) just below my stomach, leading me to believe that something isn't right in that area. I twist and turn my rib cage until I burp like a cartoon character and that usually reduces my coughing and gagging. I am also back to the point of pooping WD and undigested food. Work is difficult right now and as my stress level increases, so do my symptoms of WD. Fortunately, I will soon retire.
Tex, You are much appreciated.
DJ
DJ,
You're most welcome. That's odd that such an air pocket would be a chronic problem. But my own experience tells me that persistent gas can not only be aggravating, but it can upset my digestion.
Best of luck to you if you try the cholestyramine.
Tex
You're most welcome. That's odd that such an air pocket would be a chronic problem. But my own experience tells me that persistent gas can not only be aggravating, but it can upset my digestion.
Best of luck to you if you try the cholestyramine.
Tex
It is suspected that some of the hardest material known to science can be found in the skulls of GI specialists who insist that diet has nothing to do with the treatment of microscopic colitis.
