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Calzadilla N, Comiskey SM, Dudeja PK, Saksena S, Gill RK, Alrefai WA. Bile acids as inflammatory mediators and modulators of intestinal permeability. Front Immunol 2022; 13:1021924. [PMID: 36569849 PMCID: PMC9768584 DOI: 10.3389/fimmu.2022.1021924] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 10/26/2022] [Indexed: 12/12/2022] Open
Abstract
Bile acids are critical for the digestion and absorption of lipids and fat-soluble vitamins; however, evidence continues to emerge supporting additional roles for bile acids as signaling molecules. After they are synthesized from cholesterol in the liver, primary bile acids are modified into secondary bile acids by gut flora contributing to a diverse pool and making the composition of bile acids highly sensitive to alterations in gut microbiota. Disturbances in bile acid homeostasis have been observed in patients with Inflammatory Bowel Diseases (IBD). In fact, a decrease in secondary bile acids was shown to occur because of IBD-associated dysbiosis. Further, the increase in luminal bile acids due to malabsorption in Crohn's ileitis and ileal resection has been implicated in the induction of diarrhea and the exacerbation of inflammation. A causal link between bile acid signaling and intestinal inflammation has been recently suggested. With respect to potential mechanisms related to bile acids and IBD, several studies have provided strong evidence for direct effects of bile acids on intestinal permeability in porcine and rodent models as well as in humans. Interestingly, different bile acids were shown to exert distinct effects on the inflammatory response and intestinal permeability that require careful consideration. Such findings revealed a potential effect for changes in the relative abundance of different bile acids on the induction of inflammation by bile acids and the development of IBD. This review summarizes current knowledge about the roles for bile acids as inflammatory mediators and modulators of intestinal permeability mainly in the context of inflammatory bowel diseases.
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Affiliation(s)
- Nathan Calzadilla
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Illinois, Chicago, IL, United States
- Department of Bioengineering, University of Illinois, Chicago, IL, United States
| | - Shane M. Comiskey
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Illinois, Chicago, IL, United States
| | - Pradeep K. Dudeja
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Illinois, Chicago, IL, United States
- Research and Development, Jesse Brown VA Medical Center, Chicago, IL, United States
| | - Seema Saksena
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Illinois, Chicago, IL, United States
- Research and Development, Jesse Brown VA Medical Center, Chicago, IL, United States
| | - Ravinder K. Gill
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Illinois, Chicago, IL, United States
| | - Waddah A. Alrefai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Illinois, Chicago, IL, United States
- Research and Development, Jesse Brown VA Medical Center, Chicago, IL, United States
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2
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McKenzie YA, Sremanakova J, Todd C, Burden S. Effectiveness of diet, psychological, and exercise therapies for the management of bile acid diarrhoea in adults: A systematic review. J Hum Nutr Diet 2022; 35:1087-1104. [PMID: 35274385 PMCID: PMC9790321 DOI: 10.1111/jhn.13005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 02/23/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Bile acid diarrhoea (BAD) causes chronic diarrhoea and is primarily treated pharmacologically. This systematic review aimed to evaluate the effectiveness of non-pharmacological therapies for evidence-based management of BAD in adults. METHODS A systematic review of the medical literature was performed from 1975 to 13 July 2021 to identify studies on diet, psychological, and exercise therapies that met diagnostic criteria for BAD in adults with diarrhoea. Effectiveness was judged by responder or improvement in diarrhoea at study endpoint according to each study's definition of diarrhoea. Therapeutic effect on abdominal pain and flatulence was also measured. Risk of bias was assessed using the Risk Of Bias In Non-Randomised Studies of Interventions tool. A narrative review was conducted using 'Synthesis Without Meta-analysis' guidance. Certainty of the evidence was assessed using Grading of Recommendations Assessment, Development, and Evaluation. RESULTS Eight prospective cohort studies were identified on diet therapies from 2 weeks to over 2 years involving 192 patients. No psychological or exercise therapies were found. Carbohydrate modification (one study, n = 2) in primary BAD, and dietary fat intake reductions (five studies, n = 181) and an exclusive elemental diet therapy (two studies, n = 9) in secondary BAD, showed beneficial directions of effect on diarrhoea, abdominal pain, and flatulence. Risks of bias for each study and across studies for each therapy type were serious. Certainty of the evidence was very low for all outcomes. CONCLUSIONS No conclusions could be drawn on the effectiveness of diet, psychological, or exercise therapies on diarrhoea, abdominal pain, and flatulence for the management of BAD in adults. High-quality randomised controlled trials are needed.
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Affiliation(s)
- Yvonne A. McKenzie
- School of Health Sciences, Faculty of Biology, Medicine and HealthUniversity of ManchesterUK
| | - Jana Sremanakova
- School of Health Sciences, Faculty of Biology, Medicine and HealthUniversity of ManchesterUK
| | - Chris Todd
- School of Health Sciences, Faculty of Biology, Medicine and HealthUniversity of ManchesterUK
- Manchester University NHS Foundation TrustManchesterUK
| | - Sorrel Burden
- School of Health Sciences, Faculty of Biology, Medicine and HealthUniversity of ManchesterUK
- Salford Royal NHS Foundation TrustSalfordUK
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3
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Li N, Zhan S, Tian Z, Liu C, Xie Z, Zhang S, Chen M, Zeng Z, Zhuang X. Alterations in Bile Acid Metabolism Associated With Inflammatory Bowel Disease. Inflamm Bowel Dis 2021; 27:1525-1540. [PMID: 33399195 DOI: 10.1093/ibd/izaa342] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Indexed: 12/12/2022]
Abstract
Inflammatory bowel disease (IBD) is a chronic relapsing inflammatory disorder closely related to gut dysbiosis, which is associated with alterations in an important bacterial metabolite, bile acids (BAs). Although certain findings pertinent to BA changes in IBD vary among studies owing to the differences in sample type, quantitated BA species, study methodology, and patient characteristics, a specific trend concerning variations of BAs in IBD has been identified. In elaborating on this observation, it was noted that primary BAs and conjugated BAs are augmented in fecal samples but there is a reduction in secondary BAs in fecal samples. It is not entirely clear why patients with IBD manifest these changes and what role these changes play in the onset and development of IBD. Previous studies have shown that IBD-associated BA changes may be caused by alterations in BA absorption, synthesis, and bacterial modification. The complex relationship between bacteria and BAs may provide additional and deeper insight into host-gut microbiota interactions in the pathogenesis of IBD. The characteristic BA changes may generate profound effects in patients with IBD by shaping the gut microbiota community, affecting inflammatory processes, causing BA malabsorption associated with diarrhea, and even leading to intestinal dysplasia and cancer. Thus, therapeutic strategies correcting the alterations in the composition of BAs, including the elimination of excess BAs and the supplementation of deficient BAs, may prove promising in IBD.
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Affiliation(s)
- Na Li
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Shukai Zhan
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Zhenyi Tian
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Caiguang Liu
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Zonglin Xie
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Shenghong Zhang
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Minhu Chen
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Zhirong Zeng
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Xiaojun Zhuang
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
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Jackson A, Lalji A, Kabir M, Muls A, Gee C, Vyoral S, Shaw C, Andreyev HJN. The efficacy of a low-fat diet to manage the symptoms of bile acid malabsorption - outcomes in patients previously treated for cancer. Clin Med (Lond) 2017; 17:412-418. [PMID: 28974589 PMCID: PMC6301937 DOI: 10.7861/clinmedicine.17-5-412] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Dietary fat ingestion triggers bile secretion into the gastrointestinal tract. Bile acid malabsorption affects >1% of the population, causing loose stool and other gastrointestinal symptoms. The diagnosis is frequently missed. Treatments are often considered ineffective. We evaluated low-fat diets for managing gastrointestinal symptoms in these patients. All patients reporting type 6 or 7 stool were offered a selenium-75 homocholic acid taurine (SeHCAT) scan. Prospective data in patients with 7-day scan retention <20% were analysed. -Patients requiring a bile acid sequestrant were given this before receiving dietary advice. Patients completed a 7-day food diary before dietetic consultations. Personalised dietary interventions, providing 20% of daily energy from fat, were prescribed. Symptoms were assessed using a modified gastrointestinal symptom rating scale questionnaire before and 4-12 weeks after dietary intervention. A total of 114 patients (49 male, median age 64 years, median body mass index 27 kg/m2) were evaluated. 44% of these patients were taking colesevelam. After dietary intervention, there was statistically significant improvement in abdominal pain and nocturnal defecation (0.2% alpha, p=0.001). Improvement in bowel frequency, urgency, flatulence, belching, borborygmi and stool consistency were seen, but did not reach statistical significance (p≤0.004-0.031). Dietary intervention is an effective treatment option for patients with symptomatic bile acid malabsorption and should be routinely considered.
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Affiliation(s)
- Amy Jackson
- GI unit, Royal Marsden NHS Foundation Trust, London and Sutton, UK
| | - Amyn Lalji
- GI unit, Royal Marsden NHS Foundation Trust, London and Sutton, UK
| | - Mohammed Kabir
- Department of Research and Development, Royal Marsden NHS Foundation Trust, London and Sutton, UK
| | - Ann Muls
- GI unit, Royal Marsden NHS Foundation Trust, London and Sutton, UK
| | - Caroline Gee
- GI unit, Royal Marsden NHS Foundation Trust, London and Sutton, UK
| | - Susan Vyoral
- Royal Marsden NHS Foundation Trust, London and Sutton, UK
| | - Clare Shaw
- Royal Marsden NHS Foundation Trust, London and Sutton, UK
| | - H Jervoise N Andreyev
- GI unit, United Licolnshire Hospitals NHS Trust, Lincoln County Hospital, Lincoln, UK
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Kent ACC, Cross G, Taylor DR, Sherwood RA, Watson PJ. Measurement of serum 7α-hydroxy-4-cholesten-3-one as a marker of bile acid malabsorption in dogs with chronic diarrhoea: a pilot study. Vet Rec Open 2016; 3:e000163. [PMID: 27110372 PMCID: PMC4838766 DOI: 10.1136/vetreco-2015-000163] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 01/04/2016] [Accepted: 01/07/2016] [Indexed: 01/29/2023] Open
Abstract
Bile acid malabsorption is a common cause of chronic diarrhoea in people, however it has never previously been investigated in dogs, despite clinical suspicion of its existence. The goal of this study was to assess the feasibility of measuring serum 7α-hydroxy-4-cholesten-3-one (C4) in dogs, as a potential marker of bile acid malabsorption, and to see whether this is related to clinical disease severity or the presence of hypocobalaminaemia. Serum C4 concentration was measured in 20 clinically healthy control dogs and 17 dogs with chronic diarrhoea. Three of the 17 affected dogs (17.6 per cent) had a C4 concentration significantly above the range of clinically healthy dogs; these dogs were all poorly responsive to conventional therapy. These results suggest that bile acid malabsorption may be a clinically relevant disorder in dogs with chronic diarrhoea and serum C4 may be a useful tool to investigate this further.
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Affiliation(s)
- A C C Kent
- Department of Veterinary Medicine, University of Cambridge, Cambridge, UK; Willows Referral Service, Highlands Road, Shirley, Solihull, UK
| | - G Cross
- Clinical Biochemistry Department , King's College Hospital , London , UK
| | - D R Taylor
- Clinical Biochemistry Department , King's College Hospital , London , UK
| | - R A Sherwood
- Clinical Biochemistry Department , King's College Hospital , London , UK
| | - P J Watson
- Department of Veterinary Medicine , University of Cambridge , Cambridge , UK
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Outcomes from treating bile acid malabsorption using a multidisciplinary approach. Support Care Cancer 2015; 23:2881-90. [DOI: 10.1007/s00520-015-2653-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 02/08/2015] [Indexed: 12/22/2022]
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Wilcox C, Turner J, Green J. Systematic review: the management of chronic diarrhoea due to bile acid malabsorption. Aliment Pharmacol Ther 2014; 39:923-39. [PMID: 24602022 DOI: 10.1111/apt.12684] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 12/01/2013] [Accepted: 02/12/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND Bile acid malabsorption (BAM) is a common, yet under-recognised, cause of chronic diarrhoea, with limited guidance available on the appropriate management of patients with BAM. AIM To summarise the evidence supporting different treatments available for patients with bile acid malabsorption, noting their impact on clinical outcomes, tolerability and associated side effects. METHODS A literature search was conducted through PubMed, the Cochrane Database of Systematic Reviews and Scopus. Relevant articles studied patients who had been diagnosed with BAM and were clinically assessed before and after therapy. RESULTS A total of 30 relevant publications (1241 adult patients) were identified, which investigated the clinical response to drugs, including colestyramine, colestipol, colesevelam, aluminium hydroxide and obeticholic acid. The most commonly used diagnostic test of bile acid malabsorption was the SeHCAT test (24 studies). Colestyramine treatment was by far the most studied of these agents, and was successful in 70% of 801 patients (range: 63-100%). CONCLUSIONS Colestyramine and colestipol are generally effective treatments of gastrointestinal symptoms from BAM, but may be poorly tolerated and reduce the bioavailability of co-administered agents. Alternative therapies (including colesevelam and aluminium hydroxide) as well as dietary intervention may also have a role, and the promising results of the first proof-of-concept study of obeticholic acid suggest that its novel approach may have an exciting future in the treatment of this condition. Future trials should employ accurate diagnostic testing and be conducted over longer periods so that the long-term benefits and tolerability of these different approaches can be evaluated.
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Affiliation(s)
- C Wilcox
- Cochrane Medical Education Centre, Cardiff University School of Medicine, Cardiff, UK
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Nagel E, Canzler H, Pichlmayr R. [What is the role of nutrition in Crohn disease? A contribution to the importance of dietary therapy in regional enteritis]. LANGENBECKS ARCHIV FUR CHIRURGIE 1991; 376:238-46. [PMID: 1943412 DOI: 10.1007/bf00186819] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The clinical appearance of Crohn's disease (CD) is especially marked by nutritional deficits and insufficiencies. For a long time the goal of nutritional care was reduced to the readjustment of the nutritional status. The development and clinical use of controlled parenteral nutrition (TPN) and enteral nutritive solutions (EN) did not only emphasize this therapeutical issue, but furthermore showed positive effects on the conservative as well as on the surgical treatment concepts. Therefore today artificial nutritional support is a firm part of therapy in acute, active phases or in the contact of surgical management of CD. This is especially valid in children, where complications in general and growth failure in particular can be reduced. EN is the preferred feeding method in most of the cases, due to a lower complication rate and reduced cost when compared to TPN. The question regarding the importance of nutritional support as primary therapy has also been investigated. The results differ extensively, but point towards the conclusion that patients with solitary small bowel disease do profit from this therapeutical concept. Nevertheless it is unclear, how TPN or EN interfere in the pathophysiology or -biochemistry in this process. A question about reduction e.g. of allergic components of daily diet did stimulate new theories regarding the hypothesis of a possible causal relationship between diet and the pathogenesis of CD. Investigations on dietary habits and daily dietary therapy did not reveal an overall accepted dietary guideline. Nevertheless it seems obvious that dietary counselling has a positive effect on the disease process. It does appear, that today in the acute, active phase as well as in the long term management of Crohn's disease nutritional-care is an important therapeutical method.
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Affiliation(s)
- E Nagel
- Klinik für Abdominal- und Transplantationschirurgie, Medizinische Hochschule, Hannover, BRD
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Regöly-Mérei A, Ferencz A, Frenkl R, Gergely A, Zajkás G, Antal M. Effect of fat and retinol loading on serum triglyceride and retinol levels in patients with ulcerative colitis. DIE NAHRUNG 1991; 35:21-6. [PMID: 1865886 DOI: 10.1002/food.19910350106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Serum copper, zinc, selenium, magnesium, calcium, cholesterol, triglyceride and retinol contents were determined in 11 patients with ulcerative colitis and in 20 healthy volunteers. Lipid and retinol loadings were performed as well. No differences were found in serum copper, zinc, calcium and selenium levels between the groups. Serum magnesium levels were somewhat lower in the patients than in the volunteers. During the period of loading, cholesterol levels did not differ between the two groups at any time. Triglyceride levels except for two persons, were higher in patients. Triglyceride curves showed pathological courses in each case. Retinol concentrations in patients remained below the values observed in volunteers. Data suggest a disturbed utilization of fat and retinol in patients with ulcerative colitis.
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Affiliation(s)
- A Regöly-Mérei
- National Institute of Food Hygiene and Nutrition, Budapest, Hungary
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Schiller LR, Bilhartz LE, Santa Ana CA, Fordtran JS. Comparison of endogenous and radiolabeled bile acid excretion in patients with idiopathic chronic diarrhea. Gastroenterology 1990; 98:1036-43. [PMID: 2311860 DOI: 10.1016/0016-5085(90)90031-u] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Fecal recovery of radioactivity after ingestion of a bolus of radiolabeled bile acid is abnormally high in most patients with idiopathic chronic diarrhea. To evaluate the significance of this malabsorption, concurrent fecal excretion of both exogenous radiolabeled bile acid and endogenous (unlabeled) bile acid were measured in patients with idiopathic chronic diarrhea. Subjects received a 2.5-microCi oral dose of taurocholic acid labeled with 14C in the 24th position of the steroid moiety. Endogenous bile acid excretion was measured by a hydroxysteroid dehydrogenase assay on a concurrent 72-h stool collection. Both radiolabeled and endogenous bile acid excretion were abnormally high in most patients with chronic diarrhea compared with normal subjects, even when equivoluminous diarrhea was induced in normal subjects by ingestion of osmotically active solutions. The correlation between radiolabeled and endogenous bile acid excretion was good. However, neither radiolabeled nor endogenous bile acid excretion was as abnormal as is typically seen in patients with ileal resection, and none of these diarrhea patients responded to treatment with cholestyramine with stool weights less than 200 g. These results suggest (a) that this radiolabeled bile acid excretion test accurately reflects excess endogenous bile acid excretion; (b) that excess endogenous bile acid excretion is not caused by diarrhea per se; (c) that spontaneously occurring idiopathic chronic diarrhea is often associated with increased endogenous bile acid excretion; and (d) that bile acid malabsorption is not likely to be the primary cause of diarrhea in most of these patients.
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Affiliation(s)
- L R Schiller
- Department of Internal Medicine, Baylor University Medical Center, Dallas, Texas
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Bosaeus I, Carlsson NG, Andersson H. Low-fat versus medium-fat enteral diets. Effects on bile salt excretion in jejunostomy patients. Scand J Gastroenterol 1986; 21:891-6. [PMID: 3095912 DOI: 10.3109/00365528609011135] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Nine jejunostomy patients were given three low-residue enteral diets in random order through a nasogastric tube. Total bile salt excretion in the jejunostomy contents was 13-17% lower (p less than 0.05) on low-fat diets than on a medium-fat diet. Cholate excretion was 14-20% lower, but chenodeoxycholate excretion showed no difference on the low-fat diets. The study supports the idea of a lower excretion of bile salts to the colon as an explanation of reduced diarrhoea when a low-fat diet is prescribed to patients after ileal resection.
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