Not producing enough bile


Bile Deficiency: Heartburn, Poor Digestion, Toxicity

Author: Michael McEvoy

Of your liver’s 500 functions, its production of bile is one of the most important. Bile is an essential “de-greaser” and “emulsifier” of dietary fats. Bile is also essential for the utilization of the fat soluble vitamins A, D, E and K. The bile that is produced by your liver also contains conjugated “already used” hormones, toxins, foreign chemicals and heavy metals.

An insufficient amount of bile salts can prevent proper dietary fat utilization, cause acid indigestion as well as a backup of toxicity.

Bile insufficiency can also cause poor hormone synthesis because of the fact that all hormones are made from lipids.

Functions Of Bile

Bile is produced by the hepatocyte cells of the liver from cholesterol. When acidified food enters into the small intestine from the stomach, bile salts alkalinize the food, preparing nutrients for assimilation in the small intestine.

Bile emulsifies fat, increasing fat absorption. Bile also contains the conjugated toxins from the 2 phases of liver detoxification. These toxins may include carcinogens, xenobiotic chemicals, pharmaceuticals and heavy metals like mercury, aluminum and lead. When hemoglobin is broken down in the liver, bilirubin is conjugated and excreted through the bile.

Problems When There Is Inadequate Bile

Heartburn can directly be caused if there is a bile salt insufficiency. One of the functions of the alkaline bile salts is to neutralize the food that has been acidified in the stomach by hydrochloric acid. Stomach acid that has not been neutralized is likely to cause heartburn.

A person who complains of feeling abdominal tightness, bloating and having a difficulty digesting fats may very well have a bile insufficiency.

Inadequate levels of bile can cause a build-up of toxins in the liver because of the fact that bile conjugates and carries out the body’s burden of toxicity. Liver congestion can result in gall bladder stones and stagnation. If a person’s cholesterol production is low, bile production is also likely to be low.

Another important component to fat digestion and utilization is hormone synthesis. ALL hormones are synthesized from fat. Endocrine dysfunction may improve greatly with improving liver function.

Helping The Liver To Detoxify & Produce Adequate Bile

In order for the liver to function properly, adequate protein is essential. Amino acids are primary constituents of phase I and II of liver detoxification. The amino acid L-Taurine is critical for bile formation, while the sulphur-bearing amino acid L-Methionine is the primary methylating agent in the liver. Cysteine, another sulphur-bearing amino acid is a precursor to the antioxidant Glutathione, the body’s most ubiquitous antioxidant. Glutathione scavenges free radicals and toxins, which end up excreted through bile.

Proper cellular hydration is also essential for liver detoxification. Approximately 85% of bile is made from water.
The nutrient Betaine, also known as trimethylglycine is one of the most powerful liver detoxificants. Betain is found in the highest concentrations in beets and beet greens.

Individuals with bile acid insufficiency can also benefit from taking bile salts derived from either ox bile or bovine bile salts.

Identifying Bile Insufficiency

On a blood test, if blood cholesterol levels are lower than 170, it is possible there is a bile acid insufficiency. Increases or decreases in the liver enzymes ALT (>30, <10) or AST (>30, <10), GGTP (>30) can indicate dysfunction and/or congestion in the liver.

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Genetic Roots of Bile Acid Deficiency Disease

Though bile acid may sound like a substance you’d want to avoid, it’s not. Your body actually needs bile acid to help digest certain vitamins — specifically fat-soluble vitamins such as vitamins A, D, E, and K.

The liver makes bile acid from cholesterol through a complex process which involves about 17 enzymes and multiple steps. Interruptions in the process can lead to bile acid deficiencies and more. Research published in Gastroenterology in May 2013 pointed to genetics as a potential cause of these interruptions and alterations.

Understanding Bile Acid Deficiency

Bile acid deficiency can result from the body being genetically predisposed to produce faulty or impaired bile acid. Genetic researchers have found that there are moments along the pathway of creating and releasing bile acid when the body’s genetic coding is disrupted, altering the process and resulting in deficiency and possibly, harmful chemical byproducts that damage the liver.

“We’ve defined at least three bile acid defects that clearly have fat-soluble vitamin deficiency, and all are autosomal recessive genes,” noted James E. Heubi, MD, co-director of the Cincinnati Center for Clinical and Translational Research and Training at the University of Cincinnati College of Medicine. These genetic diseases are rare, affecting between one in 60,000 and one in 200,000 people.

Dr. Heubi is among the researchers interested in exploring the genetic risk for bile acid deficiency and the potential for treatment with the right bile acid replacement therapy.

Warning Signs of Bile Acid Deficiency

People with a bile acid deficiency may exhibit various signs or symptoms, including:

  • Vitamin deficiencies, specifically of fat-soluble vitamins such as A, D, E, and K
  • Jaundice, the classic yellowing of the skin and whites of the eyes
  • Stunted or abnormal growth
  • Diarrhea
  • Loss of liver function
  • Liver failure

Bile acid deficiency with a genetic cause can lead to a wide range of effects, from relatively mild to those requiring early medical intervention.

“Patients who would likely be deficient because of bile acid defect would be ones that have identifiable liver disease and also some have a history of chronic diarrhea,” Heubi said. “They may or may not have much liver disease, but they don’t complete the cycle for making complete bile acids.”

In severe cases, he said, children may die before age 5 if the condition is not identified and treated in time. Others can face liver failure or need a liver transplant.

Vitamin D and Bile Acids

Of the fat-soluble vitamins that can be affected by bile acid, vitamin D seems to have attracted the most attention.

Vitamin D plays a leading role in helping the body use calcium to build bones, which is why children with bile acid deficiency may have stunted growth. And, new research suggests that women with osteoporosis and vitamin D deficiency might have some degree of bile acid impairment, according to a study published in Nuclear Medicine Communications in June 2013. Whether the study participants’ bile acid deficiencies had genetic roots, though, was not part of the study.

If you’re concerned that your vitamin D deficiency could be due to a lack of bile acid, stay calm. “It really only accounts for a small fraction of vitamin D deficiency,” Heubi said. Close to

60 percent of the general population is vitamin D deficient, he explained, but that’s most often related to a lack of sun exposure or a lack of vitamin D in the diet. Also, he added, anyone with a bile acid deficiency would probably be low in all fat-soluble vitamins, not just D.

Treating a Bile Acid Deficiency

Bile acid deficiencies are sometimes referred to as “orphan diseases” — conditions that occur so rarely that major research groups and pharmaceutical companies have yet to adopt them for study — so few treatments have been developed. Nonetheless, two investigational treatments exist, said Heubi, who’s part of a national network hoping to create research centers that will focus on orphan diseases, including bile acid deficiency diseases.

“We are in the process of getting a bile acid, called cholic acid, approved by the European Medicines Agency (EMA) and ultimately the FDA (U.S. Food and Drug Administration) so people could get this by prescription,” he said. The other potential treatment is glycocholic acid, another bile acid replacement therapy that Heubi and his colleagues are testing in eligible patients. That treatment is complicated, he explained, because taking action at the wrong point in the body’s bile acid-making process could actually be harmful, not helpful.

A third bile acid, ursodeoxycholic acid, can be prescribed for people with primary biliary cirrhosis and also to treat gallstones, but it’s not appropriate for other bile deficiency diseases, Heubi said.

About the only option remaining is to take vitamin supplements to address a vitamin deficiency, he said, but that’s generally not as effective as addressing the bile acid impairment directly.

However, as researchers continue to explore the genetic risks for bile acid deficiency, what they learn could point the way toward more effective treatments.

How to Keep Your Bile Thin and Moving?

Why is it so important to take care of your liver and gallbladder? The liver produces bile, which is stored in the gallbladder. When we eat, the gallbladder squirts bile into the duodenum (the beginning of the small intestine) as part of the digestive process. Bile is essential for breaking down fats—not only from food, but also fat-soluble toxins, fatty hormones such as estrogen, and more. When we consistently eat fatty, hard-to-digest foods, the gallbladder becomes sluggish and begins to accumulate a thick, gluey sludge that can lead to thickened bile, gallstones, gallbladder inflammation, and other issues.

Congested bile lowers digestive fire and slows down fat metabolism. You may feel:

  • indigestion (bloating, gas, acid reflux, belching)
  • constipation
  • sluggishness
  • nausea
  • pain under the rib cage, on the right side
  • headaches

Indigestion produces excessive ama (poorly or semi-digested food) in your body and ama creates a vicious cycle of more digestive clogging and even stiffness in the muscles and joints. Long-term bile issues can lead to high cholesterol, weight gain, gallstones, reabsorption of toxins and hormones, thyroid imbalance, and more. Sadly, removal of the gallbladder (cholecystectomy) is one of the most common surgical procedures in the United States today.

What Can Cause Bile Sludge?

The foods listed below are hard to digest and can cause gallbladder and bile issues:

  • Frozen/ice-cold foods and beverages: The cold causes the fats in the bile to thicken and congeal.
  • Deep-fried foods
  • Hard-to-digest oils and oil supplements: Vegetable oils, hydrogenated fats and margarines, fish oil, flaxseed oil, and other oils rich in omega-3s and fat-soluble vitamins (A, D, E, K) can overwhelm the gallbladder’s ability to break down fat.
  • Cold dairy—especially Greek yogurt, cold milk, ice cream, frozen yogurt
  • Aged cheeses
  • Nut butters
  • Red meats
  • Refined flours and sugars

Some Foods That Support Healthy Bile Production

  • To thin bile: cooked beets, artichokes, sunchokes, carrots, apples
  • To flush the liver and gallbladder of congested bile: cooked leafy greens, arugula, fresh lime/lemon juice, aloe vera juice, grapefruit
  • To supply soluble fiber: whole grains, lentils, cooked cabbage, Brussels sprouts and leafy greens; daikon radish, celery, berries, powdered psyllium husk
  • To stimulate the release of bile: healthy oils in small quantities, such as cultured ghee, olive oil, coconut oil
  • To help move stagnation: hot water
  • Herbs: Triphala, shilajit, guduchi, hibiscus
  • Spices: fenugreek seeds, cinnamon stick, turmeric, ginger

To Learn More on This Topic:

Dr. John Douillard, Ayurvedic Herbs for Bile Sludge & Gallbladder Health

Dr. John Immel, Diet and Herbs for Healthy Bile Production

Dr. Marianne Teitelbaum, Healing the Thyroid with Ayurveda, Chapter 6: Gallbladder Function and the Thyroid Gland (Healing Arts Press, March 19, 2019).

Dr. John Douillard, Eat Wheat, (Morgan James Publishing, 2017)


Cooked Apple-Beet Smoothie

Sautéed Broccoli Rabe and Beets with Saffron Almonds

Rare Disease Database

Although researchers have been able to establish clear syndromes with characteristic or “core” symptoms, much about bile acid synthesis disorders is not fully understood. Several factors including the small number of identified cases, the lack of large clinical studies, and the possibility of other genes influencing these disorders prevent physicians from developing a complete picture of associated symptoms and prognosis. Therefore, it is important to note that affected individuals may not have all of the symptoms discussed below. Parents should talk to their children’s physician and medical team about their specific case, associated symptoms and overall prognosis.

The age of onset, specific symptoms, and rate of progression can vary greatly from one individual to another depending, in part, on the specific underlying defect. Although BASDs are usually detected in newborns or infants, milder forms of these disorders with later onset exist including cases with onset during adulthood.

Cholestasis in these disorders is intrahepatic, which means it occurs due to defects in the bile ducts within the liver rather than in the bile ducts outside the liver (extrahepatic). Features of cholestasis may include yellowing of the skin, mucous membranes and whites of the eyes (jaundice), failure to thrive, and growth deficiency. Enlargement of the liver (hepatomegaly) and/or spleen (splenomegaly) may also occur. Persistent, severe itchiness (pruritus) is common to other disorders that cause cholestasis, but rarely occurs in individuals with BASDs. Affected individuals may also exhibit diarrhea, excess fats in the stools (steatorrhea), and pale or clay-colored stools due to the suppression of bile flow (acholic stools).

Some of the symptoms of cholestasis result from impairment of the digestive system to properly absorb fat, fat-soluble vitamins, and other nutrients (malabsorption). Malabsorption leads to vitamin deficiency and can result is various symptoms including rickets, a condition marked by softened, weakened bones (vitamin D deficiency), vision problems (vitamin A deficiency), poor coordination and development delays (vitamin E deficiency), and blood clotting problems leading to easy bleeding and bruising (vitamin K deficiency).

In some cases, progressive neurological disease has been described that develops later during childhood or during adulthood. Vitamin E deficiency from undiagnosed liver disease may contribute to neurological disease. In other cases, the cause of neurological disease may be different. For example, in CTX neurological disease results from the accumulation or storage of cholesterol-like, fatty substances in nerve cells and the brain.

In some cases, without treatment liver abnormalities can progress to cause serious life-threatening complications such as the formation of fibrous, scar tissue (fibrosis) and liver regeneration with scarring (cirrhosis), high blood pressure of the main vein of the liver (portal hypertension), and abnormal fluid retention and swelling in the abdomen (ascites). Eventually, liver disease can progress to cause liver failure.

This disorder is sometimes referred to as 3HSD deficiency or bile acid synthesis defect 1. It is believed to be the most common form of BASDs. The clinical picture of this disorder can vary greatly. Generally, affected individuals will develop cholestasis and fat-soluble vitamin malabsorption (and various abnormalities secondary to vitamin deficiency) during infancy. If untreated, progressive liver disease occurs.

In recent years, cases of idiopathic cholestasis that develop during adulthood (late onset liver disease) have been attributed to 3beta-dehydrogenase deficiency. Some of these individuals presented with jaundice during infancy, but improved and were not diagnosed with 3beta-dehydrogenase deficiency until later during life.

This disorder is sometimes referred to as 5beta-reductase deficiency or bile acid synthesis defect 2. The clinical picture of this disorder is similar to that of 3beta-dehyddrogenase deficiency, but generally is more severe and, if untreated, can rapidly progress to cirrhosis and liver failure. 5beta-reductase deficiency can present as neonatal cholestasis or as liver failure that resembles liver disease seen in neonatal hemochromatosis (for more information, choose “neonatal hemochromatosis” as your search term in the Rare Disease Database.)

This disorder is sometimes referred to as bile acid synthesis defect 3. Only a few cases have been reported in the medical literature. Affected infants have exhibited severe neonatal cholestasis, disease affecting the blood’s ability to clot (coagulopathy), hepatosplenomegaly, and, if untreated, cirrhosis and liver failure early in life. Researchers speculate that due to the severity most cases of this disorder prove fatal before birth or shortly after birth.

This disorder is sometimes referred to as 2-methylacyl-CoA racemase deficiency or bile acid synthesis defect 4. The disorder was first reported in three adults presenting with sensory motor neuropathy, a condition in which there is disease of the peripheral nerves (those outside the central nervous system) that control response to pain and temperature and muscle coordination. Sensory motor neuropathy may cause abnormal sensations such as numbness or a feeling of pins and needles in the arms and legs, weakness of the muscles, and problems with balance and coordination. Adults with this disorder may lack symptoms (asymptomatic) until sensory motor neuropathy develops or they may have mild liver disease during childhood. It is not known if asymptomatic adults who develop neurological disease had mild, undiagnosed liver disease that led to fat-soluble vitamin deficiency that eventually caused the neurological findings. This disorder has also been reported in infants who present with severe fat and fat-soluble vitamin deficiencies and mild cholestasis. Fewer than 10 cases have been reported in the medical literature.

This disorder is also known as cerebrotendinous xanthomatosis (CTX). CTX is highly variable and is associated with a wide range of potential abnormalities. Originally, the disorder was believed only to be a neurological disorder of abnormal fat (lipid) storage not associated with liver disease. It is now know that CTX can present in childhood with cholestatic liver disease that can be severe or can be mild and resolve on its own in individuals who may later develop other complications of the disorder such as neurological disease. Patients with CTX not infrequently also have diarrhea.

In CTX, cholestanol deposits accumulate in nerve cells and membranes, causing damage to the brain, spinal cord, tendons, lens of the eyes and arteries. Affected individuals may develop cataracts during childhood and benign, fatty tumors (xanthomas) of the tendons during adolescence. If untreated, progressive neurological problems develop in adulthood potentially causing paralysis, ataxia, and dementia. Coronary heart disease is also common. Many individuals with the adult symptoms of CTX experienced prolonged cholestatic jaundice during infancy.

NORD has an individual report on CTX. For more information, choose “cerebrotendinous xanthomatosis” as your search term in the Rare Disease Database.

This form has been reported in several individuals and is characterized primarily by neurological findings including ataxia, which often became apparent by 3 and half years of age. Liver disease has not been described in this form of BSAD.

This form of BASD is distinct from most other forms because liver disease is usually absent. Affected individuals often develop markedly elevated levels of total and low-density lipoproteins (LDL), premature gallstones, and premature coronary and peripheral vascular disease.

The final step in bile acid synthesis involves the joining together (conjugation) of two amino acids, glycine and taurine. Disorders involving this step are known as “defective bile acid amidation due to failure to conjugate with glycine and/or taurine” or more simply amidation defects. Two disorders in this subcategory have been identified.

Bile Acid CoA Ligase Deficiency
This disorder is characterized by neonatal cholestasis, fat and fat-soluble vitamin malabsorption and growth failure. Fewer than 10 cases have been reported in the medical literature.

Amino Acid N-Acyltransferase Deficiency
This disorder was initially described in several individuals within a large Amish kindred. Affected individuals developed pruritus, variable growth deficiency, and fat malabsorption (familial hypercholanemia). More recently a report has appeared that included description of 10 affected patients with only one from an Amish kindred. The presentation was quite varied in this case series with one family member having liver failure in infancy; however, most patients presented with poor growth and fat soluble vitamin deficiencies.

Are you suffering from gas, bloating, abdominal pain and yellowing of the skin? You may be dealing with a bile or bile salts deficiency. A bile dysfunction can alter the health of your liver, gallbladder, colon and skin — leading to inflammation and the buildup of fats and toxins.

But what exactly is bile, and why are bile salts so important? It’s a complicated and multifaceted question, but this article is meant to simplify the answer so you can determine whether or not bite salts supplements are a good option for you.

Bile is a digestive liquid that’s produced in the liver and contains bile salts and other substances that help to break down fats from our diet. Each day, the liver produces approximately 500–600 milliliters of bile, which consists primarily of water and electrolytes, but also contains organic compounds like bile salts, cholesterol, phospholipids, bilirubin and ingested compounds, such as proteins. (1)

Bile, which is a greenish-yellow secretion, is in charge of aiding the digestion of fats in the duodenum, the first region of the small intestine. Waste products are also eliminated from the body when they are secreted into bile.

Bile is continually secreted from the cells of the liver and then passed to the gallbladder, which is attacked to the liver and rests on top of the small bowel. In the gallbladder, bile is stored and concentrated by the absorption of water and small electrolytes. The body will store bile and other secretions until they are needed to perform digestion. After we eat, our bile duct opens and allows bile, enzymes and secretions to do their jobs.

Bile salts are the main organic component found in bile. They allow the body to excrete cholesterol and potentially toxic compounds, like bilirubin and drug metabolites. Bile salts are synthesized in liver cells that are called hepatocytes, then stored in the gallbladder and secreted into the first part of the small intestine. Then they are reabsorbed and returned to the liver, where they are recycled and used by the body again.

9 Benefits of Bile Salts

  1. Eliminate Cholesterol and Toxic Compounds
  2. Fight Infectious Agents
  3. Promote Gallbladder and Liver Function
  4. Help Dissolve Gallstones
  5. Allow for the Digestion and Absorption of Fats and Nutrients
  6. Affect Bacteria in the Gut
  7. Help Control Blood Sugar Levels
  8. Trigger the Release of Glutathione
  9. Eliminate Bilirubin

1. Eliminate Cholesterol and Toxic Compounds

Bile salts are amphipathic, which means that they have both a water- and fat-soluble region. This allows them to bind to fats and oils and emulsify them in the gut, which is a water-based environment, so they can be broken down by digestive enzymes. This is how bile salts play a role in cholesterol regulation and help get rid of wastes and toxins through bile.

About 500 milligrams of cholesterol are converted into bile acids and eliminated in our bile every day. Cholesterol is secreted into bile, which allows it to be eliminated from the body. Free cholesterol is insoluble in water-based solutions, but when it’s in bile, it’s made soluble by bile salts and lipids like lecithin. In this state, cholesterol can be transported and removed from the body through digestion. (2)

2. Fight Infectious Agents

Bile acids also work as a defense mechanism to fight infectious agents and toxins that can lead to a number of diseases, including sepsis, herpes, psoriasis and parvovirus infection. Bile works as a detoxifying detergent that protects us from “big viruses” that have an outer lipoprotein structure, according to research published in the journal Pathophysiology. This is called a “physico-chemical defense system,” and it wouldn’t be able to protect us properly if there weren’t enough bile salts present in the body. (3)

3. Promote Gallbladder and Liver Function

Bile salts can help to improve gallbladder function by reducing inflammation of the bile ducts and helping normalize blood flow. They also help relieve gas and bloating that can be caused by gallbladder dysfunction.

Bile salts can also improve the symptoms of diseases affecting the liver. They improve liver function by assisting in the process that removes toxic substances and pathogens from the body. If you have a bile salt insufficiency, taking supplements may help improve conditions of the liver like cystic fibrosis, non-alcoholic fatty liver disease and primary biliary cirrhosis. (4, 5)

4. Help Dissolve Gallstones

Gallstones, which are composed mostly of cholesterol particles, occur when cholesterol and other matter that are within bile bind together and become solid. As a result, they become lodged in the inner lining of the gallbladder and grow into cholesterol gallstones over time.

Bile salts help dissolve gallstones that have formed in the gallbladder, and they help to prevent them from forming in the first place by breaking down fats before crystallization. According to research published in the World Journal of Gastroenterology, ursodeoxycholic acid, a naturally occurring bile acid, can be used as an anti-inflammatory agent that works as an alternative therapeutic approach in high surgical risk patients with symptomatic gallstones. (6)

5. Allow for the Digestion and Absorption of Fats and Nutrients

One of the main functions of bile salts is to solubilize ingested fat and fat-soluble vitamins, which allow for their digestion and absorption. This happens when bile salts cause fat globules to break down into very small, microscopic droplets. This process is called emulsification, and it’s important for the digestion of fats because it increases the surface area of the fat so it can be digested by lipases, the main enzymes that break down dietary fats. (7)

Why is this so important? Because these healthy fats and fat-soluble nutrients (like vitamins A, E, D, K, magnesium, iron and calcium) are crucial to our health, so we need bile salts to make it easier for our bodies to absorb and digest them. If we don’t have enough bile salts in the body, we can develop nutrient deficiencies because they aren’t being properly absorbed.

6. Affect Bacteria in the Gut

Bile salts have antimicrobial activity and can protect us against gram-positive bacteria that grow in the gut, and they actually play a role in intestinal homeostasis by controlling the size and composition of the gut.

Bile salts are antibacterial compounds that disrupt bacterial membranes, and a decrease in them may be correlated with an alteration of the gut microbiome and an overgrowth of potential pathogens. Bile salts also work as environmental signals for intestinal bacteria and species that are adapted to the gut and able to endure the antibacterial activities of the salts. This is an intricate relationship that helps regulate the bacteria present in the microbiota. (8)

7. Help Control Blood Sugar Levels

Bile acids act as metabolic regulators and play a role in glucose, lipid and energy expenditure. Research out of the Medica Sur Clinic & Foundation’s Department of Internal Medicine, Department of Endocrinology and Department of Gastroenterology in Mexico City shows that enhancing bile acid signaling in the intestine can contribute to glucose homeostasis, making bile acids useful as potential therapeutic targets for diabetes. (9)

According to research published in the Journal of Clinical Investigation, bile acids activate receptors to overcome the loss of insulin sensitivity and inhibit inflammation. Scientists are now looking for molecules that can mimic the effect of bile acids and help patients with type 2 diabetes. (10)

8. Trigger the Release of Glutathione

Studies indicate that when bile salts allow for the increase of bile flow, the amount of biliary glutathione increases as well. What’s so special about glutathione? Well, it’s considered the “mother of all antioxidants” because it plays a role in several vital bodily processes. It helps the liver detoxify fat before bile is emitted — taking stress off of the gallbladder — protects the liver against oxidative injury, helps detoxify certain toxins, and conjugates with drugs so they are more digestible and effective.

Various forms of liver disease show reduced cellular glutathione and increased oxidative stress levels. Bile acids play an important physiological role in regulating glutathione metabolism. (11)

9. Eliminate Bilirubin

Bile salts work to eliminate bilirubin from the body, which is important because the accumulation of this waste product can have harmful effects on your health. (12) In fact, according to research published in the Journal of Lipid Research conducted at Northwestern University’s Department of Surgery, too much bilirubin in the skin and mucous membranes can lead to jaundice, a condition in which the skin and whites of your eyes become yellow, your urine darkens, and the color of your stool becomes lighter.

How Bile Salts Work

To understand how bile salts work, it’s helpful to become familiar with the role of bile in our bodies. Bile helps enzymes in the body break down fats into fatty acids, which are needed for many body functions. Bile is made in the liver, then travels to the gallbladder through a channel that’s called the cystic duct. It is then stored in the gallbladder between meals, and when we eat, it’s squeezed through the bile duct to break down the food before it moves to the intestines.

Bile salts are components of bile that allow it to mix fats with the water, electrolytes and other organic molecules that are found in bile. Bile needs bile salts to break down fats and prevent them from crystallizing. These salts are made naturally by our bodies, but some people choose to use bile salts supplements to improve specific health conditions. (13)

What’s the difference between bile salts and bile acid? Most of the time, these terms are used interchangeably, but technically they are different because of their structure and biological characteristics. Bile salts make up the collective term that’s used for bile acids and bile alcohol sulfates, another major component of bile. When bile acid is combined with amino acids glycine or taurine, this forms bile salts. So bile acid actually turns into bile salts when conjugated with these amino acids. That being said, you may notice that bile salts are sometimes called bile acid.

How to Increase Bile Salts

If you have a bile salt deficiency, you may benefit from bile salt supplements that are available online and at your local health or vitamin stores. Bile salts supplements work to restore cholesterol-lowing effects by emulsifying lipids. When you have a bile salt deficiency, there aren’t enough functioning bile salts to absorb and initiate the breakdown of fats, so they can accumulate in the intestines and cause a list of symptoms.

Bile salts supplements are usually taken with a meal so they can aid in the absorption and digestion of fats and fat-soluble vitamins. When shopping for bile salts supplements, start with lower doses and monitor how you feel after meals. Look for a supplement that contains more cholic acid, which is a more water-soluble bile acid. You’ll also find that most supplements are made with chenodeoxycholic acid. Bile salt supplements are usually made from sterilized ox or bovine bile. It’s recommended to take bile salts supplements along with taurine, which can help restore healthy bile formation.

Bile Salts Deficiency

What are the symptoms of a bile salt deficiency?

A deficiency in bile or bile salts may lead to the following symptoms or conditions:

  • Vitamin deficiencies: If you have a bile salts deficiency, you may also develop a fat-soluble vitamin deficiency, specifically vitamins D, A, E and K.
  • Heartburn: If bile salts are not able to neutralize the acidic foods that you’ve eaten, this may lead to heartburn symptoms.
  • Bloating and abdominal tightness: Without enough bile or bile salts present in your digestive tract, you will have difficulty digesting fats, which can lead to bloating and tightness in the abdomen.
  • Digestive issues: When fats pass through your colon without being broken down by bile salts, they can cause digestive issues like diarrhea, gas and stomach cramps.
  • Gallstones: Without bile salts to dissolve gallstones, which are made up of cholesterol, calcium deposits and other minerals, you may experience gallbladder symptoms like pain in the abdomen, tension around the stomach and nausea.
  • Jaundice: If bile salts aren’t present to eliminate bilirubin from the body, this can cause jaundice.
  • Hormone imbalance: When fats aren’t digested and utilized properly, this can lead to hormone imbalance.
  • Low cholesterol levels: Cholesterol levels lower than 170 may indicate a bile acid deficiency.
  • Liver damage: When bile salts aren’t created and released, this can lead to the formation of harmful chemical byproducts that may damage the liver.

What conditions are associated with a bile salt deficiency?

Bile acid synthesis disorders are rare metabolic disorders that involve defects in the creation of bile acids. When the body fails to produce functional bile acids, it results in the accumulation of substances that would normally be broken down within the body, which can be damaging to certain organs. Bile acid synthesis disorders are caused by mutations in specific genes, and they can lead to serious health issues like cirrhosis and liver failure. These disorders can usually be treated with bile acid replacement therapy. (14)

Cholestasis is a condition that involves the reduction of bile flow, which can be caused by disorders of the liver, bile duct and pancreas. Cholestasis can be problematic because when bile flow is impaired, substances that are normally excreted into bile are retained. (15)

What causes bile salt deficiency?

Abnormal bile salts or bile acids formation is the result of improper bile flow, which is usually caused by a gene mutation. The improper synthesis of bile acids occurs when bile acids aren’t properly synthesized by the liver, which normally occurs through a series of complex chemical reactions that involve at least 17 enzymatic steps. When a gene that’s in charge of encoding a bile acid enzyme is mutated, this will lead to low bile acid functioning and can cause a deficiency. If bile acids can’t be made in the liver, then they aren’t available to conjugate with taurine or glycine, which forms bile salts.

A bile salts abnormality may also be caused by pancreatic insufficiency or having the gallbladder removed.

What are the best remedies for conditions affecting bile and bile salts?

  • Betaine: Betaine is an amino acid that’s created by choline in combination with the amino acid glycine. It benefits liver health by assisting with the process of digesting fats. By promoting liver detoxification, betaine helps break down and remove fats, toxins and chemicals so they don’t accumulate and cause damage to the liver. (16)
  • Pectin: Pectin is a carbohydrate that acts as a gelling, thickening and stabilizing agent. It can help relieve diarrhea, a common side effect of bile salts supplements and among people who have had their gallbladders removed. Pectin also helps lower cholesterol by binding to the lipids in the gut so they can be excreted. (17)
  • Choline: Choline plays a role in transporting fat from the liver to the cells throughout the body. It helps keep the liver clear from fat buildup that can accumulate, especially when you have a bile salts deficiency. (18)
  • Stay hydrated: To improve bile function, it’s important to stay well-hydrated, as 85 percent of bile is made up of water.

Bile Salts Supplements Side Effects

Taking bile salts supplements may cause diarrhea for some people because when they are unabsorbed, they move directly to the colon and have laxative effects. If you are experiencing diarrhea from bile salts supplements, it may be helpful to lower your dose.

Other digestive problems that may be caused by bile salts supplements include constipation, vomiting and stomach pain. Taking too much bile salt supplements can also lead to inflammation of the colon and skin, and it may even cause conditions like pruritus and erythema.

Talk to your doctor or health care provider before taking bile salts supplements. Start with low doses, and monitor how your body, specifically your digestive system, reacts to the supplements.

Final Thoughts

  • Bile is a digestive liquid that’s produced in the liver and contains bile salts and other substances that help to break down fats from our diet.
  • Bile salts are important for our health because they allow the body to excrete cholesterol and potentially toxic compounds, like bilirubin and drug metabolites. Other bile salts benefits include its ability to promote gallbladder and liver function, help dissolve gallstones, affect bacteria in the gut, control blood sugar levels, and release glutathione.
  • If you have a bile salts deficiency, you may benefit from bile salts supplements, which are available online and in vitamin stores. Bile salts supplements work to restore cholesterol-lowing effects by emulsifying lipids.
  • How do you know if you need bile salts supplements? You may be experiencing bile salts deficiency symptoms, such as heartburn, bloating and abdominal tightness, digestive issues, gallstones, vitamin deficiencies, liver damage, jaundice, and low cholesterol.

Read Next: Pancreatic Enzymes Benefits for Gut & Immune Health

Bile is a vital fluid the body makes to digest fats and absorb fat-soluble vitamins. Bile supplements can eliminate gallstones, help the body detox, and improve liver and gut diseases. They come in a variety of forms, of which ox bile is the most common. Continue reading to learn about the function of bile and the health effects of bile supplements.

What is Bile?

Digests Fats

Bile is a complex, vital, and unique fluid produced by the liver to aid in the digestion of fats in the small intestine. The components of bile are actually quite eclectic. It’s yellow-green in color and composed of 95% water in which the following compounds are dissolved, such as :

  • Bile acids and salts
  • Phospholipids, cholesterol, and steroid hormones
  • Pigments and amino acids
  • Electrolytes and vitamins
  • Antioxidants like melatonin and glutathione
  • Antibodies like IgA
  • Heavy metals, drugs, and environmental toxins

The liver secretes about 600 ml of bile every day, which amounts to almost 3 cups .

Removes Toxins

Bile is the body’s main way of eliminating harmful fat-soluble substances like toxins, drugs, and heavy metals. It’s also the main pathway for eliminating excessive cholesterol from the body .

Helps You Absorb Nutrients

Bile dissolves dietary fats so that they can be more easily broken down by lipases. Bile acids enable the digestion and absorption of fats and fat-soluble vitamins like A, D, E, and K in the gut. Bile also protects the gut from infection by stimulating the gut immune system .

Bile Production

Signals from the Gallbladder

The liver constantly makes bile that’s transported to the gallbladder via bile ducts. The gallbladder, a small sac-like organ located below the liver, stores and concentrates bile. After food intake, the gallbladder delivers bile into the small intestine where it aids in the digestion of fats .

The main signal in the body for the gallbladder to contract and release bile is cholecystokinin. Others include secretin, gastrin, and somatostatin and the vagus nerve .

Bile salts are resistant to strong digestive enzymes in the gut are mostly reabsorbed after they achieve their effects. This way, the body recycles bile salts, which can be stored and used again .

Bile Acids & Bile Salts

Bile acids are made in the liver from cholesterol .

The 2 main bile acids made in the liver are cholic acid and chenodeoxycholic acid. Gut bacteria can modify these into 2 slightly different bile acids (into deoxycholic acid and lithocholic acid), but the liver still makes most bile acids overall .

Transforming cholesterol into bile acids is a multistep process that involves many different liver enzymes. Many of these enzymes are part of cytochrome P450, the body’s key detox pathway .

These are the most important cytochrome P450 enzymes for bile production :

  • CYP7A1
  • CYP8B1
  • CYP27A1

Bile acids can affect their own production in the body. If they increase too much, they stop their own production. If they’re not produced enough, low levels activate receptors that tell the body to make more bile. The most important one is called the bile acid receptor (FXR) .

The activity of these enzymes is also strictly controlled by hormone and drug levels in the body. Hormones, toxins, and drugs can activate certain receptors (so-called nuclear receptors, which include VDR) that affect gene expression. By turning on key genes, they help lower blood lipids, cholesterol, and detox drugs and toxins .

When bile acids are taken back to the liver and bound to the amino acids glycine or taurine when they become bile salts. An enzyme called n-acetyltransferase is crucial for this step known as conjugation .

If this enzyme is not working properly, free bile acids are released instead of bile salts. Bile acids are incapable of digesting fats. Only bile salts act as natural gut detergents – they have the power to emulsify, dissolve and digest fats in the gut .


1) Bile Salts Remove Excess Cholesterol

Bile salts are crucial for maintaining balanced cholesterol levels in the body .

Producing bile acids from cholesterol is the key pathway for removing cholesterol from the body. About half of the total cholesterol produced in the body is used to make bile acids .

2) Bile Eliminates Bilirubin From the Body

Bile salts play a key role in the removal of bilirubin from the body .

Bilirubin is the main pigment in bile. It’s a waste product of hemoglobin breakdown and has harmful effects in the body if accumulated. Bilirubin buildup in the body causes jaundice .

The liver takes bilirubin bound to proteins from the bloodstream and then modifies it to make it into a yellow water-soluble form. It then secretes this bilirubin into bile with bile salts. The gut microbiome then breaks down it down into its basic form (free bilirubin) that is darker in color and can finally be eliminated in the stool .

3) Bile Salts Digest Proteins and Starches

Bile salts are essential for digesting proteins and starches. They help break down dietary proteins by enhancing the digestive activity of protease enzymes in the pancreas .

4) Bile Salts Help Remove Toxins

Bile salts help the bile remove toxic substances from the body .

This includes drugs, environmental pollutants, and heavy metals such as mercury, lead, silver, and cadmium .

Scientists are still debating exactly how bile salts are able to do this. Toxins can activate genes that help make bile and phase II detox enzymes. Once the bile is produced, toxins are modified and added to bile along with bile salts. They travel along the gut and can be eliminated through the stool .

5) Bile Salts Help Absorb Fat-Soluble Vitamins

Without bile salts, fat-soluble vitamins (Vitamin A, D, E, and K) cannot be absorbed. Bile salts break down fats and the vitamins dissolved in it into small particles called “micelles”. This allows cells in the gut lining to transport them into the body .

And it’s not just that bile salts affect vitamin absorption. Some fat-soluble vitamins themselves can have an effect on the amount of bile the body makes. This way, vitamins regulate their own levels .

When the dietary intake of fat-soluble vitamins is high, Vitamin A and vitamin D can deactivate genes that make bile to reduce their own absorption and vice versa. Vitamin A and vitamin D have a strong effect on the receptors that affect bile gene expression (via RAR, RXR, and VDR). This prevents a buildup or deficiency of vitamins A, D, E, and K under normal conditions .

In fact, vitamin A may have specific therapeutic potential. It can help the bile re-establish its own feedback loops if it was interrupted for any reason. For example, vitamin A may help in cases when the body stops re-absorbing bile salts from the gut, which is needed to recycle bile salts that are re-used .

6) Bile Protects the Gut from Infections

Bile protects the organism from gut infections by :

  • Making immunoglobulin A (IgA), the first line of defense against harmful microbes
  • Stimulating the gut immune system

On the other hand, chronic inflammation reduces bile production in the body. Increased inflammatory substances ( IL-1 beta, IL-6, TNF-alpha, and nitric oxide) all reduce bile secretion, this way making the gut vulnerable to infections .

When Bile Flow Becomes Dysfunctional

Dysfunctional bile flow reduces the digestion of fats, absorption of vitamins, and toxins detox in the small intestine .

This leads to a condition known as cholestasis, which means “blocked bile flow”. Dysfunctional bile flow causes :

  • Fats to build up in the gut instead of being broken down, which causes indigestion, stomach pain, loss of appetite, and greasy or gray-colored stools
  • Vitamin A, D, E, and K deficiencies
  • A buildup of toxic substances such as bilirubin. Increased bilirubin causes jaundice – itchy yellow-colored skin and eyes. Bilirubin has to be eliminated via urine, coloring it light-brown.
  • Bile acid buildup increases oxidative stress, which can damage the liver and may even increase the risk of cancer
  • Bile cholesterol buildup that forms gallstones in the gallbladder
  • Gallstones cause inflammation not only of the gallbladder but also of the liver and pancreas. In such cases, the surgical removal of the gallbladder is recommended .
  • Increased susceptibility to gut infections

Bile production and flow can become dysfunctional due to various causes. Some conditions that worsen the flow of bile salts include chronic inflammation, liver diseases such as hepatitis or cirrhosis, cystic fibrosis, and diabetes .

Bile Supplements: What Are the Options?

How They Work

Under normal conditions, the gallbladder releases the stored bile into the small intestine in response to food. Bile, containing bile salts, initiates the breakdown and absorption of fats .

But under abnormal conditions caused by diseases of the pancreas, liver, or hormones, bile salts are not properly absorbed, leading to the increased accumulation of fats in the gut .

Bile supplements (like ox bile, other animal biles, UDCA, TUDCA, or other bile acids) act to counter bile salts deficiency in the gut and may :

  • Break down and eliminate cholesterol gallstones .
  • Protect the gut from damage and infections .
  • Protect the liver and restore natural bile acid production and bile flow .
  • Help absorb fats and fat-soluble vitamins, reducing symptoms of indigestion and greasy stools .
  • Restore the cholesterol-lowering effect of bile salts. Once supplemented bile is mixed up with gut contents, it’s removed with the stool. This loss of bile acids forces the liver to release more bile acids to compensate, transforming more cholesterol to bile acids.
  • Reduce cholesterol production in the liver mediating the cholesterol-lowering effects .
  • Reduce anxiety and promote sleep, due to their melatonin content .

Types of Supplements

Various types of bile supplements are available, including all of the following:

  • Ox bile
  • Ox bile combined with various digestive enzymes (such as Pancrelipase, Pancreatic Protease, Pancreatic Amylase, Pancreatic Lipase, Papain, Bromelain) and/or Betaine HCl
  • Ox bile combined with herbs such as dandelion root or artichoke
  • Ox bile in combination with probiotics
  • Ox bile combined with Taurine
  • Purified bile salts such as TUDCA, ursodeoxycholic acid (Ursodiol or UDCA), cholic acid
  • TCM bile supplements (see below)

In most supplements, the dosage of ox bile varies between 100 – 500 mg.

The content of pure bile acids in ox bile is about 40%. Some supplements may be purified to contain higher amounts .

In Traditional Chinese Medicine

Ox bile and other animal bile supplements were an important part of Traditional Chinese Medicine (TCM) since ancient times. There was a wide assortment of animal biles for medicinal use, the total number adding up to 44, of which ox bile was perhaps the most important one .

The first mention of bile in TCM dates back to scriptures from 500 BC that mention the use of ox and dog bile for therapeutic purposes. Biles mentioned in other TCM books are from: the common carp fish, goat, sheep, mouse, shark, wild boar, elephant, tiger, and even bile from pythons and venomous vipers !

Interestingly, python bile was traditionally used to eliminate parasites and reduce gum inflammation and tooth cavities.

Ox bile was used in combination with gentian root, other herbs, and honey to combat jaundice or used on the skin for hemorrhoids.

A recent analysis showed that different animal biles have different components. Accordingly, specific animal bile supplements are used for a variety of acute and chronic diseases in TCM .

Only pig, ox and bear biles are extensively used in China today.

Health Benefits of Ox Bile Supplements

1) Eliminate Gallstones

Bile supplements may reduce cholesterol gallstones in the gallbladder (cholelithiasis), potentially reducing the need for surgical removal of the gallbladder.

In one clinical trial of 24 people, bile acids (UDCA up to 1,000 mg/day) reduced cholesterol in gallstones after one month .

Bile acids (UDCA) reduced gallstones in 6 people with hepatitis B after 3 – 20 months (daily dose of 8 – 11 mg/kg). It completely dissolved the stones in 5 people and reduced liver enzymes. They remained gallstone free for at least 2 years .

The primary bile acid chenodeoxycholic acid (0.75 – 4.5 g/day) eliminated gallstones in a trial of 7 women with 6 – 22 months. It also restored bile acid production in the liver .

2) Help Remove Toxic Substances From the Body

Bile supplements assist in the removal of toxic substances from the body .

Toxins that enter the body via pollution, food, or medications, as well as those that build up in the body, are usually broken down by the liver. They are then combined with bile salts, secreted into the gut as bile, and removed through the stool. However, they lack bile salt production results in the accumulation of these toxins in the liver, which can trigger many chronic diseases .

Bile acids and toxins activate the same receptors in the body, which increase liver detox pathways. In a way, the body views all fat-soluble pollutants (and the majority of environmental pollutants and drugs are fat-soluble) as “toxic bile acids”, which triggers the detox process .

Aside from bile supplements themselves, herbal supplements that activate this pathway (PXR activators) may also be useful for people with bile issues .

3) May Help Clear Gut Infections and SIBO

Impaired bile salts production creates favorable conditions for intestinal bacterial overgrowth. Bacterial toxins, known as endotoxins, can damage the gut. If the gut damage is severe enough and gut immunity low, the result is a leaky gut barrier that can cause bacteria to enter the bloodstream and cause a systemic infection. On the other hand, lack of bile salts can also cause small intestinal overgrowth (SIBO) .

Bile salts have antimicrobial activity and protect the body against harmful bacteria .

Bile salt supplements may be especially useful for people with liver cirrhosis who are very susceptible to SIBO and bacterial infections .

In several studies of rats with liver damage, bile acids supplements reduced bacterial overgrowth and prevented the bacteria and their toxins from entering the blood .

In mice, bile salt supplements could turn on genes that activate the defense system against harmful bacteria .

4) May Help with Psoriasis

Bacterial endotoxins might play a role in developing psoriasis. People with psoriasis have detectable levels of endotoxins in the blood, which can cause or worsen inflammation. Bile deficiency may be the underlying cause, as it allows endotoxin to enter the blood and reach the skin. People with psoriasis also often complain of gut and gallbladder problems .

The buildup of toxins and inflammatory substances in the skin can cause red, itchy, and scaly skin patches in psoriasis. Bile acids can balance the gut microbiome, protect from bacterial gut endotoxins, and reduce inflammation .

In a large clinical trial of 800 patients with psoriasis, oral bile acid supplementation (dehydrocholic acid) resolved psoriasis symptoms in 79% of all cases after 1 – 8 weeks. It had even better results in people with acute psoriasis, clearing symptoms in 95% of the cases. Two years later, 58% of chronic psoriasis patients were also symptom-free, compared to only 6% of those on conventional treatment .

In bile-deficient rats, bile acid supplements caused helped blocked gut toxins from entering the blood and helped detox them from the body. Enhancing detox with bile salts may also be useful for viral infections, herpes, and clogged arteries in heart disease – all conditions in which bacterial toxins build up in the body .

5) May Improve Liver Disease

Bile supplements are used for a number of diseases including cystic fibrosis (a genetic disease) and chronic liver diseases such as primary biliary cirrhosis and non-alcoholic fatty liver disease.

Cystic fibrosis is a genetic disease that affects many organs of the body including the liver. It leads to an abnormal structure and function of the liver .

In one clinical study, the bile acid UDCA improved liver function, reduced liver enzymes, and reversed damage in people with cystic fibrosis. All participants were also supplementing with pancreatic enzymes and taurine .

Primary biliary cirrhosis is a chronic liver disease in which the bile ducts become dysfunctional.

Immune system dysfunction has been linked to its development. Bile supplements may help reduce and reverse the symptoms and bile duct damage .

In one clinical trial, the bile acid UDCA (13 – 16 mg/kg/day) prevented the worsening, improved symptoms, and prolonged survival in people with primary biliary cirrhosis .

In one study, UDCA had even more striking benefits when combined with s-adenosylmethionine (SAM-e) in 19 people with this disease. The combination of prolonged remission, reduced elevated liver enzymes, bilirubin, and cholesterol .

Non-alcoholic fatty liver disease happens when the liver can’t break down fats, so fat builds up in the liver. It’s not caused by alcohol use and is most common in obese people. People with this disease don’t have functional bile salts, which worsens inflammation and damage. Bile supplements may help, but more research is needed .

6) Help with Diarrhea and Fatty Stool

Disrupted bile flow leads to fat buildup in the gut and stool, which causes diarrhea and stomach pain. This condition is known as steatorrhea.

Several diseases are linked to it: gut diseases like Celiac and Crohn’s, cystic fibrosis, kidney, pancreas, and liver diseases. A diet high in hard-to-digest fats, fibers, grains, and excessive drinking can also trigger it.

Bile supplements can help make up for the lack of bile salts and reduce steatorrhea.

A synthetic bile salt cholylsarcosine (2 g/meal) greatly improved fat absorption in the gut and reduced steatorrhea and diarrhea in a clinical trial of 4 people who had part of their bowel surgically removed (short bowel syndrome). In comparison, natural bile salts improved steatorrhea but worsened diarrhea .

Taurine, an amino acid that conjugates with bile acids in the bile, can also help the body make more bile salts. It’s needed to conjugate bile acids into bile salts, which is key for their digestive action .

In one clinical trial, taurine (30 mg/kg/day) increased fat digestion and absorption in 22 children with cystic fibrosis over six months .

Taurine supplementation enhanced the activity of the key enzyme needed to convert cholesterol into bile acids (called 7α-hydroxylase) in animals. That’s why it’s also used for people with heart disease and high cholesterol levels .

7) Help People without a Gallbladder

People who have had their gallbladder removed suffer from a deficiency of bile acids.

Without the gallbladder, they are unable to control bile secretion to the intestines. This causes many digestive problems such as constipation, bloating, and diarrhea .

The use of bile supplements can make up for the lack of bile, helps in the digestion of fats and absorption of fat-soluble vitamins.

The bile acid TUDCA reduced indigestion and improved symptoms in one trial of 203 people without a gallbladder .

8) May Improve Eye Health

The bile acid TUDCA improved eye health in mice and reduced the buildup of harmful free radicals. It may help prevent eye damage .

9) May Enhance Weight Loss

Bile acids may help prevent or reverse obesity by enhancing fat-burning. In animal studies, they helped with weight loss, improved insulin sensitivity and protected the heart.

In fat cells, the bile acid chenodeoxycholic acid increased fat breakdown and energy use. This bile acid also reversed obesity in mice fed a high-fat diet by reducing food intake .

In obese mice fed a high-fat diet, bile acids increased energy use, fat-burning, lowered glucose and improved the gut microbiome. They improved the overall metabolic profile .

Another bile acid – deoxycholic acid – helps break down fat cells when injected directly under the skin into the fat tissue. Solutions of this bile acid are used in the USA and EU to improve the appearance of neck and chin fat. Several clinical trials proved its effectiveness in improving the appearance of neck and chin fullness. It seems to be a well-tolerated and safe option in plastic surgery .

10) Help Heal Skin Burns and Infections

In Traditional Chinese Medicine (TCM), animal bile is used to form an “artificial skin” to dress and cover burns and wounds. Bile fats are isolated from bile have unique properties, which enables them to form a protective layer on the damaged skin. They also act as an antioxidant and anti-inflammatory due to the fat-soluble vitamins content while bile acids can kill bacteria .

As appealing or repelling as it may sound, bile has some great potential for repairing damaged skin. These studies are still limited to TCM, though, and more research is needed.

Limitations and Caveats

Although the knowledge about the function of bile and various bile salts is growing, the information about bile supplements themselves is limited. The additional difficulty is that there are big differences between various bile acids as well as between different types of animal bile supplements.

Some studies are limited to specific bile salts or TCM observations. Proper, larger, clinical trials are needed, especially with popular ox bile supplements.

Side Effects of Bile Supplements


It’s important to note these side effects really depend on the exact composition of bile salts and other ingredients in the supplement. Taking purified bile salts is not the same as taking mixed salts or various animal bile supplements.

The side effects also depend on your health condition. The side effects in people with a surgically removed gallbladder or bowel part will not necessarily be the same as in someone with mild indigestion.

Digestive Problems

Bile supplements can cause digestive problems such as diarrhea, constipation, stomach pain, and vomiting. Although recommended for diarrhea, some natural bile salts may worsen diarrhea, as was the case with ox bile in people with a short bowel .

Chenodeoxycholic acid, present in some bile supplements, can too much water to be secreted into the gut, worsening diarrhea. It may even impair the gut barrier .

Gut Inflammation

Some components in bile supplements may cause gut inflammation.

Deoxycholic acid is a bile acid produced by gut bacteria and an ingredient in some supplements. In IBS, this acid is probably elevated, which worsens inflammation. In mice, deoxycholate supplementation triggered IBS and DNA/RNA damage .

Skin Inflammation (Rare)

In one clinical trial of 24 people, direct exposure to bile salts caused skin itching and blisters .

Oral bile supplements probably can’t cause skin inflammation, but skin application of the purified salts or their waste products found in the stool can. Purified digestive enzymes from the stool caused redness and irritation in a skin study. However, the mixture used also contained protein-degrading (proteolytic) and fat-degrading (lipolytic) enzymes that are not found in pure bile .

Also, this would be relevant perhaps only if applying bile supplements to the skin, which is not typical. Bile supplements that are applied to the skin are only occasionally used in China and specially modified and prepared.

Possible Cancer Risk

In a mice study, excessive and long-term exposure to bile salts caused colon cancer .

Some bile acids have been linked to a number of different cancers in animal studies, such as intestinal, stomach, pancreas, breast, and esophageal cancer .

It was first reported that bile acids may be carcinogenic in the 1930s .

Recent reports point to the cancer-promoting activity of bile acids .

Evidence suggests that high amounts of bile acids in the gastrointestinal tract might increase oxidative stress and DNA damage. High exposure to bile acids also happens in people with high dietary fat intake. However, the exact mechanism of how bile salts may promote cancer upon chronic exposure remains unknown .

A clear link between supplementing with bile salts and cancer is missing, though. A lot of the studies looked at high bile acid production caused by a high-fat diet in people, not at the use of bile supplements .

Bile acids can cause damage if they accumulate in the gut or liver. But a lot of the seen cancer-promoting effects could be a result of factors that cause increased bile acid production in the first place – such as a high-fat, unhealthy diet, or obesity – and not directly from bile salts themselves. More research is needed to shed light on this

Genetic Factors

1% – 2% of bile duct disorders in children are caused by defects in bile acid production .

Some other genetic mutations in enzymes that make bile acids or aid in their activity can cause liver disease or fat-soluble vitamin deficiencies. Some examples include defects in the following genes :

  • CYP7A1
  • CYP7B1
  • VDR
  • RAR and RXR
  • FXR

These variations may also affect the efficacy and side effects of bile supplements.



Bile, an aqueous solution produced and secreted by the liver, consists mainly of bile salts, phospholipids, cholesterol, conjugated bilirubin, electrolytes, and water. Bile travels through the liver in a series of ducts, eventually exiting through the common hepatic duct. Bile flows through this duct into the gallbladder where it is concentrated and stored. When stimulated by the hormone cholecystokinin (CCK), the gallbladder contracts, pushing bile through the cystic duct and into the common bile duct. Simultaneously, the sphincter of Oddi relaxes, permitting bile to enter the duodenal lumen. The hormone secretin also plays an important role in the flow of bile into the small intestine. By stimulating biliary and pancreatic ductular cells to secrete bicarbonate and water in response to the presence of acid in the duodenum, secretin effectively expands the volume of bile entering the duodenum. In the small intestine, bile acids facilitate lipid digestion and absorption. Only approximately 5% of these bile acids are eventually excreted. The majority of bile acids are efficiently reabsorbed from the ileum, secreted into the portal venous system, and returned to the liver in a process known as enterohepatic recirculation.



Bile is produced by hepatocytes, which is then modified by the cholangiocytes lining the bile ducts. The production and secretion of bile require active transport systems within hepatocytes and cholangiocytes in addition to a structurally and functionally intact biliary tree. Initially, hepatocytes produce bile by secreting conjugated bilirubin, bile salts, cholesterol, phospholipids, proteins, ions, and water into their canaliculi (thin tubules between adjacent hepatocytes that eventually join to form bile ducts). The canalicular membrane of the hepatocyte is the main bile secretory apparatus which contains the intracellular organelles, the cytoskeleton of the hepatocyte and carrier proteins. The carrier proteins in the canalicular membrane transport bile acid and ions. Transporter proteins found within the canalicular membrane use energy to secrete molecules into bile against concentration gradients. Through this active transport, osmotic and electrochemical gradients are formed. When conjugated bile salts enter the canaliculus, water follows by osmosis. The electrochemical gradient allows for the passive diffusion of inorganic ions such as sodium. The most significant promoter of bile formation is the passage of conjugated bile salts into the biliary canaliculus. The total bile flow in a day is approximately 600 ml, of which 75% is derived from the hepatocyte, and 25% is from the cholangiocytes. Approximately half of the hepatocyte component of bile flow (about 225 ml per day) is bile salt-dependent and the remaining half bile salt independent. Osmotically active solutes such as glutathione and bicarbonate promote bile salt independent bile flow.

Canaliculi empty bile into ductules or cholangioles or canals of Hering. The ductules connect with interlobular bile ducts, which are accompanied by branches of the portal vein and hepatic artery forming portal triads. Bile is subsequently modified by ductular epithelial cells as it passes through the biliary tree. These cells, known as cholangiocytes, dilute and alkalinize the bile through hormone-regulated absorptive and secretory processes. The cholangiocytes have receptors which modulate the bicarbonate-rich ductular bile flow, which is regulated by hormones. These receptors include receptors for secretin, somatostatin, cystic fibrosis transmembrane conductance Regulator (CFTR) and chloride-bicarbonate exchanger. For example, when secretin stimulates receptors in the cholangiocyte, a cascade is initiated which activates the CFTR chloride channel and allows the exchange of bicarbonate for chloride. In contrast, somatostatin inhibits the cAMP synthesis within the cholangiocytes causing the opposite effect. While bombesin, vasoactive intestinal polypeptide, acetylcholine, and secretin enhances bile flow, somatostatin, gastrin, insulin, and endothelin inhibit the flow.

Bile Acids

Cholesterol catabolism by hepatocytes results in the synthesis of the 2 major primary bile acids, cholic acid, and chenodeoxycholic acid. This process involves multiple steps, with cholesterol 7alpha-hydroxylase acting as the rate-limiting enzyme. Primary bile acids undergo dehydroxylation by bacteria in the small intestine, forming the secondary bile acids deoxycholic acid and lithocholic acid, respectively. Both primary and secondary bile acids are conjugated by the liver with an amino acid, either glycine or taurine. Conjugated bile acids are known as bile salts. Bile salts inhibit cholesterol 7alpha-hydroxylase, decreasing the synthesis of bile acids. Despite the increased water solubility of bile salts, they are amphipathic molecules overall. This critical property allows them to effectively emulsify lipids and form micelles with the products of lipid digestion. The bile acid pool is maintained via mainly the enterohepatic circulation and to a small extent (about 5%) by hepatic synthesis of bile acids, as long as the daily fecal loss of bile acids do not exceed 20% of the pool.

Low Bile Acid – Ask a Naturopath

February 4, 2018

My son just recently had a stool test done and it came back with low bile acid. I was wondering if I could give him bile salts?

Low bile salts is generally indicative also of low bile acid and therefore reduced digestive capability. Bile acids are the detergent produced by the liver from cholesterol to help break down fats and oils in the diet so that the body can absorb them, including the fat soluble vitamins A, D, E and K.

Common symptoms of low bile acid/ impaired bile flow

  • Jaundice
  • Poor growth
  • Liver or spleen enlargemen
  • Bleeding
  • Rickets (Vitamin D deficiency)
  • Liver disease

Causes of low bile acid

  • Poor gut bacteria
  • Recent anti-biotic therapy
  • Low digestive pH levels
  • Side effect of pharmaceutical medications
  • Decreased liver and gall bladder function

Functions of bile acids

  • Eliminating cholesterol from the body
  • Driving the flow of bile to eliminate catabolites from the liver
  • Emulsifying lipids and fat-soluble vitamins in the intestine to form micelles that can be transported via the lacteal system
  • Aiding in the reduction of the bacteria flora found in the small intestine and biliary tract

Diet tips for low bile acid

  • Begin each day with a glass of warm water with ½ lemon squeezed in it. Lemon juice stimulates digestive and liver function, including the gall bladder
  • Consume good raw oils in your diet. Foods which contain good oils are raw olive oil, fish oil capsules, flaxseed oil capsules, fish, nuts and seeds and avocados
  • Reduce saturated fats (animal fats and dairy foods), transfatty acids, processed foods and simple sugars. Saturated fats and transfatty acids are commonly found in foods such as cakes, cookies, biscuits, bakery foods, margarine, donuts, processed and deep fried foods
  • Eat more bitter foods to stimulate liver and gall bladder function such as rocket, endive, raddichio and kale. Also eating foods high in sulphur such as garlic, brussels sprouts, cabbage, onions, broccoli, cauliflower and radish
  • Introduce herbal teas such as Dandelion, Burdock, Peppermint, Green Tea, lemon and ginger to support liver detoxification, digestion and the production of bile
  • Increase omega 3 essential fatty acids in the form of deep sea oily fish (Salmon, Snapper, Mackeral, Anchovies, Cod, Sardines, Halibut)
  • Lecithin sprinkled on your food, cereal or in a smoothie helps to emulsify fats, lipids and oils and the break down of cholesterol and bile in the digestion due to the phosphotidylcholine

Natural remedies for low bile acid

  • Probiotics increase beneficial bacteria, as an imbalance of good vs bad bacteria in the bowels is a contributing factor to poor gall bladder function and limited synthesis of bile acids
  • Vitamin C and bioflavinoid help to stimulate bile movement
  • Liver herbs may help to encourage liver and gall bladder herbs due to their cholagogue (bile stimulant) effects such as Globe Artichoke, Dandelion, St Marys Thistle, Bupleurum, Citrus Peel, Greater Celandine, Agrimony, Golden Seal, Barberry, Yellow Dock, Chamomile, Ginger and Turmeric
  • The amino acids Taurine, Choline (lecithin) and Methionine are beneficial for encouraging bile acid. They contain sulphur components which help to increase liver detoxification processes and stimulate the synthesis of bile and gall bladder function

Lifestyle factors for low bile acid

  • Healthy bacteria in the digestive tract coverts bile from the gall bladder into bile acids, low gut bacteria may therefore be a contributing factor. You may consider introducing more probiotics into the diet, especially if he has had courses of anti-biotics in the past
  • Low digestive pH levels
  • Address poor gut bacteria
  • Address any side effects of pharmaceutical medications
  • Address sluggish bowel function
  • It is also recommended to take a blood test to determine the functioning of the liver, as liver complications may be a related cause. Elevated serum ALT (liver enzymes) and AST should be tested as well as bilirubin, alkaline phosphate and AST/ ALT levels
  • Check gall bladder and liver function as a decline in the function of these can dramatically affect the storage of bile in the bile duct and the production of bile in the liver. Bile produced in the gall bladder ensures adequate break down of foods and also helps to lubricate the bowel

Bile Duct Leaks

A small hole anywhere along the bile ducts can cause bile to leak into the abdominal cavity. A bile duct leak can arise either as a complication of a surgery, such as gallbladder removal or liver transplant, or from trauma to the biliary system. At the Bile Duct and Pancreatic Diseases Program, part of the University of Michigan’s Division of Gastroenterology, our multidisciplinary team provides the newest minimally invasive treatments for bile duct leaks. These treatments are not widely available, and are performed by experienced gastroenterologists with high volumes in these procedures.

Bile is a digestive fluid produced by the liver and stored in the gallbladder, and is used by the body to break down fats so they can be absorbed. The biliary system—which includes the gallbladder and bile ducts—produces and transports bile into the duodenum (the first part of the small intestine) to aid in digestion. A bile duct leak can cause pain, inflammation and infection in the abdominal cavity where the bile has leaked.

Bile Duct Leak Symptoms

  • Severe abdominal pain
  • Nausea
  • Vomiting
  • Fever
  • Jaundice

Diagnosing a Bile Duct Leak

To diagnose a bile duct leak, we begin with a comprehensive exam and collecting a thorough history. Blood work is typically ordered to look at issues including elevated liver enzymes.

A biliary study called a hepatobiliary (HIDA) scan may be ordered. A HIDA scan shows the flow of bile from the liver to the small intestine. To perform this test, a radioactive tracer is injected into a vein in the arm and then a special camera takes pictures of the tracer as it moves through the bile ducts.

A leak can also be diagnosed by using a needle to remove a small amount of abdominal fluid. If the fluid contains bile, then a bile duct leak is confirmed.

Treating Leaks in the Biliary System

Our standard treatment for a bile duct leak is an endoscopic retrograde cholangiopancreatography (ERCP) with placement of a temporary bile duct stent (which looks like a plastic straw).

An endoscopic retrograde cholangiopancreatography is a minimally invasive procedure that combines x-ray and upper endoscopy—an exam of the upper gastrointestinal tract, consisting of the esophagus, stomach, and duodenum (the first part of the small intestine)—using an endoscope, which is a lighted, flexible tube, about the thickness of a finger. The doctor passes the tube through the mouth and into the stomach, then injects a contrast dye into the ducts to view the bile ducts, which can be seen on x-ray. Special tools can be guided through the endoscope to insert a stent to stop the leak.

Patients can typically go home same day, once their sedation wears off.

Other Information About Digestive and Liver Health

To see related medical services we offer, visit our Digestive and Liver Health overview page.

Make an Appointment

To schedule an appointment to discuss your need for bile duct stone treatment, call us at 888-229-7408.

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