How should I manage a patient diagnosed with bile acid malabsorption, including dietary recommendations?

The provided UK guidelines do not contain specific recommendations for the management of bile acid malabsorption (BAM) ¹,²,³. However, they do offer general dietary and lifestyle advice for managing gastrointestinal symptoms such as diarrhoea and bloating, often in the context of Irritable Bowel Syndrome (IBS), which may be relevant for symptom management ¹,².

General Management and Dietary Advice (from IBS Guidelines):

• Referral to a Dietitian: If general lifestyle and dietary advice for gastrointestinal symptoms has not been helpful, referral to a dietitian is recommended for further dietary management ¹,². This is particularly important for single food avoidance or exclusion diets, such as a low-FODMAP diet, which should only be undertaken under specialist supervision to ensure nutritional balance and avoid deficiencies ¹,².
• Regular Meals and Fluid Intake: Patients should be advised to eat regular meals, take time to eat, and avoid missing meals or long gaps between eating ². Drinking at least 8 cups of fluid per day, especially water or non-caffeinated drinks like herbal teas, is recommended ². Tea and coffee intake should be restricted to 3 cups per day, and alcohol and fizzy drinks should be reduced ².
• Fibre Adjustment: Fibre intake should be adjusted according to symptoms ¹. For predominant symptoms of diarrhoea and/or bloating, patients should reduce their intake of insoluble fibre (e.g., wholemeal or high-fibre flour and breads, cereals high in bran, brown rice) ¹,². Soluble fibre (e.g., oats, linseed, ispaghula powder) may be helpful for constipation-predominant symptoms and should be increased gradually ¹,².
• Food Avoidance: Patients with diarrhoea should avoid sorbitol, an artificial sweetener found in sugar-free sweets, chewing gum, and some diabetic/slimming products ². It may also be helpful to limit intake of 'resistant starch' found in processed or re-cooked foods ². Consideration should be given to reducing foods that may exacerbate symptoms, such as caffeine, alcohol, carbonated drinks, and gas-producing foods ¹.
• Probiotics: If a patient chooses to try a probiotic supplement, they should be advised to take it for at least 4 to 12 weeks and discontinue if there is no symptom improvement ¹,².
• Lifestyle: General lifestyle advice includes identifying and making the most of leisure time, creating relaxation time, and increasing physical activity levels ². Managing associated stress, anxiety, and depression is also important ¹.

The guidelines also mention malabsorption in the context of cystic fibrosis, where pancreatic enzyme replacement therapy is used to minimise symptoms of malabsorption due to exocrine pancreatic insufficiency ³.