From Dr. Lauren Deville - Naturopathic Doctor

Image by Alicia Harper from Pixabay

Bile is the yellowish-green substance produced in the liver and stored in the gallbladder that enables the body to absorb fat and fat-soluble vitamins, as well as excrete various different types of toxins via the bowels. It is comprised of bile acids (breakdown products of cholesterol), bile salts, a breakdown product of red blood cells called bilirubin, cholesterol itself, and water (about 85% is water actually).

Bile Acids vs Bile Salts vs Conjugated Bile Salts The first step in bile production is the breakdown of cholesterol into the primary bile acids, cholic acid and chenodeoxycholic acid. This is how the body breaks down cholesterol, so that you can maintain normal levels of it (and you don’t want too little of it, by the way, for a wide variety of reasons. This is just one of them).

Once bile is secreted into the small intestine, the bacteria there should modify some of them into secondary bile acids, deoxycholic acid and lithocholic acid.

Incidentally, bile acids and the microbiome maintain a symbiotic relationship—while the gut flora participate in production of these secondary bile acids, the bile acids also help to curb the small intestinal bacterial population, inhibiting overgrowth of SIBO.

The liver then adds an amino acid side group to both primary and secondary bile acids (either glycine or taurine), at which point they become conjugated bile acids, or bile salts. These are the component of bile most useful for fat breakdown and absorption. Because everything in the body functions via feedback mechanisms, the presence of bile salts actually inhibits the rate-limiting enzyme leading to production of more bile acids (cholesterol 7 alpha-hydroxylase), signaling, “slow down, we’ve already got plenty.”

Why You Might Be Low in Bile Acids or Bile Salts If your cholesterol is low (perhaps because you’re on a statin—which I’d definitely discourage pretty much across the board), you might be low in bile acids.

Those with a genetic condition called hypobetalipoproteinemia, or abetalipoproteinemia will have very low cholesterol, which will also mean deficiency in bile acids.

If your cholesterol levels are not too low, then in theory you shouldn’t have a deficiency of bile acids, unless you have a genetic mutation in the gene encoding for the rate-limiting enzyme in the breakdown process (called cholesterol 7 alpha-hydroxylase).

If you have enough bile acids being produced, you might still have low levels of bile salts, if you’re low in glycine (which is surprisingly common), or taurine (which might be over-utilized elsewhere, such as in modulating adrenaline levels or calming hyper-excitable membranes).

If you have SIBO, even if you’re producing both bile acids and bile salts just fine, the bacteria don’t like the fact that bile is antimicrobial—so they’ll deconjugate the bile acids, rendering them far less effective.

Symptoms of Low Bile Acids or Bile Salts The most obvious, but least specific symptoms of low bile salts are gut distress, due to poorly absorbed fats and possibly bacterial overgrowth in the small intestine, leading to gas, bloating, diarrhea (especially with floating stools), or constipation (as bile salts tend to have a natural laxative effect).

Bile also stimulates the secretion of bicarbonate (which is alkaline) to neutralize the acidic chyme that comes from the stomach into the small intestine, so heartburn may be a symptom as well. And of course, while there are other reasons for gallstones besides low bile salts (just as there are other reason for the other listed symptoms), this can certainly result as well. Bile acids can in some cases even break down gallstones.

Low levels of bile salts may also result in poor absorption of fat-soluble vitamins A, E, D, and K, low essential fatty acids, low omega-9 fatty acids, and low phospholipids. All of these latter deficiencies may lead to unhealthy cell membranes.

Low bile salts will also mean low levels of anything built from fat, which would include all of your adrenal hormones (cortisol, aldosterone, DHEA), and the rest of your sex hormones (estradiol, progesterone, and testosterone).

It also turns out that, at least in men, inadequate bile salts inhibit the conversion of the thyroid hormone conversion of T4 into the more metabolically active T3—resulting in functional hypothyroidism. (This is a bit of a catch-22, since hypothyroidism also slows all metabolic activities, including the liver’s breakdown of cholesterol, too.)

Because bile acids help with fat absorption and utilization, they’ll keep fat from accumulating in the liver, as in NAFLD. So NAFLD or even liver fibrosis can be an indication of low bile acids.

As NAFLD is nearly always related to insulin resistance, this may be why adequate bile acids will help to improve insulin and glucose sensitivity, and decrease cardiovascular disease too. Elevated blood sugar is very often a cause of heart disease, which may be why this is connected.

Some giveaways of a gallbladder issue on labs might be elevated bilirubin levels, as bilirubin is secreted in bile. This is what turns feces dark brown, and it’s the reason why gallbladder issues can result in pale stools. Of course, if this progresses far enough, increased circulating bilirubin levels can result in jaundice.

The UpshotIf you have any of the above symptoms, depending upon severity and what you’ve already ruled out, consider checking a lipid panel (make sure cholesterol levels are adequate—total levels at least over 170, if not higher), a CMP (make sure bilirubin isn’t elevated), SIBO testing, and potentially consider micronutrient testing to see whether there are any deficiency patterns that might suggest a fat absorption issue.

It’s also worth considering whether the low-hanging fruit might be insufficient glycine, given all its many functions, or not enough taurine to go around, if you’ve been super stressed out lately, especially.

Bile Salts, Bile Acids, and Gallbladder Support