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Lewis JD, Daniel SG, Li H, Hao F, Patterson AD, Hecht A, Brensinger CM, Wu GD, Bittinger K. Surgery for Crohn's Disease Is Associated with a Dysbiotic Microbiome and Metabolome: Results from Two Prospective Cohorts. Cell Mol Gastroenterol Hepatol 2024:S2352-345X(24)00111-5. [PMID: 38750900 DOI: 10.1016/j.jcmgh.2024.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 05/05/2024] [Accepted: 05/07/2024] [Indexed: 06/19/2024]
Abstract
BACKGROUND & AIMS Crohn's disease is associated with alterations in the gut microbiome and metabolome described as dysbiosis. We characterized the microbial and metabolic consequences of ileal resection, the most common Crohn's disease surgery. METHODS Patients with and without intestinal resection were identified from the Diet to Induce Remission in Crohn's Disease and Study of a Prospective Adult Research Cohort with Inflammatory Bowel Disease studies. Stool samples were analyzed with shotgun metagenomics sequencing. Fecal butyrate was measured with 1H nuclear magnetic resonance spectroscopy. Fecal bile acids and plasma 7α-hydroxy-4-cholesten-3-one (C4) was measured with mass spectrometry. RESULTS Intestinal resection was associated with reduced alpha diversity and altered beta diversity with increased Proteobacteria and reduced Bacteroidetes and Firmicutes. Surgery was associated with higher representation of genes in the KEGG pathway for ABC transporters and reduction in genes related to bacterial metabolism. Surgery was associated with reduced concentration of the But gene but this did not translate to reduced fecal butyrate concentration. Surgery was associated with decreased abundance of bai operon genes, with increased plasma C4 concentration, increased primary bile acids and reduced secondary bile acids, including isoLCA. Additionally, Egerthella lenta, Adlercreutzia equalofaciens, and Gordonibacter pamelaeae were lower in abundance among patients with prior surgery in both cohorts. CONCLUSIONS In 2 different populations, prior surgery in Crohn's disease is associated with altered fecal microbiome. Patients who had undergone ileal resection had reduction in the potentially beneficial bacteria E lenta and related actinobacteria and secondary bile acids, including isoLCA, suggesting that these could be biomarkers of patients at higher risk for disease progression.
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Affiliation(s)
- James D Lewis
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Scott G Daniel
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Hongzhe Li
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Fuhua Hao
- Center for Molecular Toxicology and Carcinogenesis, Department of Veterinary and Biomedical Sciences, Pennsylvania State University, State College, Pennsylvania
| | - Andrew D Patterson
- Center for Molecular Toxicology and Carcinogenesis, Department of Veterinary and Biomedical Sciences, Pennsylvania State University, State College, Pennsylvania
| | - Aaron Hecht
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Colleen M Brensinger
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gary D Wu
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kyle Bittinger
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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2
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Kister B, Viehof A, Rolle-Kampczyk U, Schwentker A, Treichel NS, Jennings SA, Wirtz TH, Blank LM, Hornef MW, von Bergen M, Clavel T, Kuepfer L. A physiologically based model of bile acid metabolism in mice. iScience 2023; 26:107922. [PMID: 37817939 PMCID: PMC10561051 DOI: 10.1016/j.isci.2023.107922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 07/04/2023] [Accepted: 09/12/2023] [Indexed: 10/12/2023] Open
Abstract
Bile acid (BA) metabolism is a complex system that includes a wide variety of primary and secondary, as well as conjugated and unconjugated BAs that undergo continuous enterohepatic circulation (EHC). Alterations in both composition and dynamics of BAs have been associated with various diseases. However, a mechanistic understanding of the relationship between altered BA metabolism and related diseases is lacking. Computational modeling may support functional analyses of the physiological processes involved in the EHC of BAs along the gut-liver axis. In this study, we developed a physiologically based model of murine BA metabolism describing synthesis, hepatic and microbial transformations, systemic distribution, excretion, and EHC of BAs at the whole-body level. For model development, BA metabolism of specific pathogen-free (SPF) mice was characterized in vivo by measuring BA levels and composition in various organs, expression of transporters along the gut, and cecal microbiota composition. We found significantly different BA levels between male and female mice that could only be explained by adjusted expression of the hepatic enzymes and transporters in the model. Of note, this finding was in agreement with experimental observations. The model for SPF mice could also describe equivalent experimental data in germ-free mice by specifically switching off microbial activity in the intestine. The here presented model can therefore facilitate and guide functional analyses of BA metabolism in mice, e.g., the effect of pathophysiological alterations on BA metabolism and translation of results from mouse studies to a clinically relevant context through cross-species extrapolation.
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Affiliation(s)
- Bastian Kister
- Institute for Systems Medicine with Focus on Organ Interaction, University Hospital RWTH Aachen, Aachen, Germany
- Institute of Applied Microbiology - iAMB, Aachen Biology and Biotechnology - ABBt, RWTH Aachen University, Aachen, Germany
| | - Alina Viehof
- Functional Microbiome Research Group, Institute of Medical Microbiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Ulrike Rolle-Kampczyk
- Department of Molecular Systems Biology, Helmholtz Centre for Environmental Research (UFZ), Leipzig, Germany
| | - Annika Schwentker
- Institute of Medical Microbiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Nicole Simone Treichel
- Functional Microbiome Research Group, Institute of Medical Microbiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Susan A.V. Jennings
- Functional Microbiome Research Group, Institute of Medical Microbiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Theresa H. Wirtz
- Department of Medicine III, University Hospital RWTH Aachen, Aachen, Germany
| | - Lars M. Blank
- Institute of Applied Microbiology - iAMB, Aachen Biology and Biotechnology - ABBt, RWTH Aachen University, Aachen, Germany
| | - Mathias W. Hornef
- Institute of Medical Microbiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Martin von Bergen
- Department of Molecular Systems Biology, Helmholtz Centre for Environmental Research (UFZ), Leipzig, Germany
- German Centre for Integrative Biodiversity Research (iDiv) Halle-Jena-Leipzig, Leipzig, Germany
- Faculty of Life Sciences, Institute of Biochemistry, University of Leipzig, Leipzig, Germany
| | - Thomas Clavel
- Functional Microbiome Research Group, Institute of Medical Microbiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Lars Kuepfer
- Institute for Systems Medicine with Focus on Organ Interaction, University Hospital RWTH Aachen, Aachen, Germany
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3
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Lindberg G, Mohammadian G. Loose ends in the differential diagnosis of IBS-like symptoms. Front Med (Lausanne) 2023; 10:1141035. [PMID: 37484861 PMCID: PMC10357384 DOI: 10.3389/fmed.2023.1141035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 05/30/2023] [Indexed: 07/25/2023] Open
Abstract
Two thirds of the patients we believed to have IBS in the 1970's have since been possible to diagnose with treatable conditions like bile acid diarrhea, inflammatory bowel disease, microscopic colitis, celiac disease, disaccharide malabsorption, exocrine pancreatic insufficiency, or rare genetic variants. Despite advances in diagnostic techniques a substantial proportion of patients continue suffering from IBS-like symptoms that cannot be explained by current knowledge. Although it is likely that further research will reveal small but important subgroups of patients with treatable mechanisms for IBS-like symptoms, we propose that only two large groups remain for being addressed in the clinic: those with connective tissue disorders such as Ehlers-Danlos syndrome or hypermobility spectrum disorders and those with autism spectrum disorders. Patients with connective tissue disorders exhibit identifiable disturbances of gut motor function and possibly increased gut permeability as underlying mechanisms for IBS-like symptoms. Autism spectrum disorders pose a much more difficult problem in the clinic. Disturbances of perception combined with anxiety and excessive worry about signals from the gut can lead to an endless but futile search for something being wrong. The search can involve large numbers of care givers, no one understanding the patient's suffering. Others may try to change their diet to lessen symptoms, only to find that almost all foods may cause worrying perceptions from the gut. Early recognition of autism spectrum disorders is essential for finding better ways to help patients with gastrointestinal and, as is often the case, extraintestinal symptoms.
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Affiliation(s)
- Greger Lindberg
- Department of Medicine at Huddinge, Karolinska Institutet, Stockholm, Sweden
- Neurogastroenterology Unit, Division of Gastroenterology, Department of Gastroenterology, Dermatovenereology and Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - Ghazaleh Mohammadian
- Department of Medicine at Huddinge, Karolinska Institutet, Stockholm, Sweden
- Neurogastroenterology Unit, Division of Gastroenterology, Department of Gastroenterology, Dermatovenereology and Rheumatology, Karolinska University Hospital, Stockholm, Sweden
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4
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Battat R, Sandborn WJ. Advances in the Comprehensive Management of Postoperative Crohn's Disease. Clin Gastroenterol Hepatol 2022; 20:1436-1449. [PMID: 33819666 DOI: 10.1016/j.cgh.2021.03.048] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 03/21/2021] [Accepted: 03/30/2021] [Indexed: 02/06/2023]
Abstract
Patients with postoperative Crohn's disease are difficult to manage because of their risk of experiencing a more severe course, multiple symptom confounders, and poor sensitivity of symptomatic remission to rule out intestinal inflammation. In this group, data are lacking on biologic therapeutic efficacy, and recommendations are lacking for those with multiple medication failures. Novel noninvasive testing can simultaneously exclude alternate causes of symptoms (serum C4, fecal fat, small intestinal bowel overgrowth breath testing) and assess intestinal inflammation (fecal calprotectin, endoscopic healing index). In addition, endoscopy-based disease activity assessment and management are required. Endoscopy should be performed within 6 months of surgery, and aggressive disease activity monitoring can be considered with colonoscopy every 1-2 years subsequently to ensure late recurrence is detected. Patients with multiple resections should be screened for short bowel syndrome. Predictive biomarkers are needed to guide medication selection in this high-risk population. Postoperative prophylactic biologic therapy is prudent for patients with preoperative biologic failure. However, there are no high-quality data to guide which agent should be selected. Selecting biologics with an alternative mechanism of action in those who had failed a biologic with adequate drug concentrations and selection of different agents in those with previous intolerance are reasonable. Significantly more study is required to assess the efficacy of therapies in this setting.
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Affiliation(s)
- Robert Battat
- Jill Roberts Center for IBD, Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York.
| | - William J Sandborn
- Division of Gastroenterology, University of California San Diego, La Jolla, California
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5
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Marasco G, Cremon C, Barbaro MR, Falangone F, Montanari D, Capuani F, Mastel G, Stanghellini V, Barbara G. Pathophysiology and Clinical Management of Bile Acid Diarrhea. J Clin Med 2022; 11:jcm11113102. [PMID: 35683489 PMCID: PMC9180966 DOI: 10.3390/jcm11113102] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 05/27/2022] [Accepted: 05/28/2022] [Indexed: 11/16/2022] Open
Abstract
Bile acid malabsorption (BAM) represents a common cause of chronic diarrhea whose prevalence is under-investigated. We reviewed the evidence available regarding the pathophysiology and clinical management of bile acid diarrhea (BAD). BAD results from dysregulation of the enterohepatic recirculation of bile acids. It has been estimated that 25–33% of patients with functional diarrhea and irritable bowel syndrome with diarrhea have BAM. Currently, the selenium homotaurocholic acid test is the gold standard for BAD diagnosis and severity assessment. However, it is an expensive method and not widely available. The validation of the utility in the clinical practice of several other serum markers, such as 7α-hydroxy-4-cholesten-3-one (C4) and the fibroblast growth factor 19 (FGF19) is ongoing. The first-line treatment of patients with BAD is bile acid sequestrants. Patients that are refractory to first-line therapy should undergo further diagnostics to confirm the diagnosis and to treat the underlying cause of BAD. An early and correct diagnosis of BAD would improve patient’s quality of life, avoiding additional diagnostic tests that burden health care systems. Considering the limited availability and tolerability of specific medications for BAD treatment, future research is awaited to identify other therapeutic approaches, such as gut microbiota modulating therapies.
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Affiliation(s)
- Giovanni Marasco
- Division of Internal Medicine, IRCCS Azienda Ospedaliero Universitaria di Bologna, 40138 Bologna, Italy; (G.M.); (C.C.); (M.R.B.); (D.M.); (F.C.); (G.M.); (V.S.)
- Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy
| | - Cesare Cremon
- Division of Internal Medicine, IRCCS Azienda Ospedaliero Universitaria di Bologna, 40138 Bologna, Italy; (G.M.); (C.C.); (M.R.B.); (D.M.); (F.C.); (G.M.); (V.S.)
- Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy
| | - Maria Raffaella Barbaro
- Division of Internal Medicine, IRCCS Azienda Ospedaliero Universitaria di Bologna, 40138 Bologna, Italy; (G.M.); (C.C.); (M.R.B.); (D.M.); (F.C.); (G.M.); (V.S.)
| | - Francesca Falangone
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, University Sapienza, 00185 Rome, Italy;
| | - Davide Montanari
- Division of Internal Medicine, IRCCS Azienda Ospedaliero Universitaria di Bologna, 40138 Bologna, Italy; (G.M.); (C.C.); (M.R.B.); (D.M.); (F.C.); (G.M.); (V.S.)
- Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy
| | - Federica Capuani
- Division of Internal Medicine, IRCCS Azienda Ospedaliero Universitaria di Bologna, 40138 Bologna, Italy; (G.M.); (C.C.); (M.R.B.); (D.M.); (F.C.); (G.M.); (V.S.)
- Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy
| | - Giada Mastel
- Division of Internal Medicine, IRCCS Azienda Ospedaliero Universitaria di Bologna, 40138 Bologna, Italy; (G.M.); (C.C.); (M.R.B.); (D.M.); (F.C.); (G.M.); (V.S.)
- Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy
| | - Vincenzo Stanghellini
- Division of Internal Medicine, IRCCS Azienda Ospedaliero Universitaria di Bologna, 40138 Bologna, Italy; (G.M.); (C.C.); (M.R.B.); (D.M.); (F.C.); (G.M.); (V.S.)
- Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy
| | - Giovanni Barbara
- Division of Internal Medicine, IRCCS Azienda Ospedaliero Universitaria di Bologna, 40138 Bologna, Italy; (G.M.); (C.C.); (M.R.B.); (D.M.); (F.C.); (G.M.); (V.S.)
- Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy
- Correspondence: ; Tel.: +39-0512144103
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6
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Hou JJ, Wang X, Wang YM, Wang BM. Interplay between gut microbiota and bile acids in diarrhoea-predominant irritable bowel syndrome: a review. Crit Rev Microbiol 2021; 48:696-713. [PMID: 34936854 DOI: 10.1080/1040841x.2021.2018401] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Irritable bowel syndrome (IBS) is a common functional gastrointestinal disease that disturbs the physiology and psychology of patients and increases the burden on families, the healthcare system, society, and economic development, affecting more and more people around the world. Despite the multiple factors that account for IBS remaining incompletely studied, emerging evidence demonstrated the abnormal changes in gut microbiota and bile acids (BAs) metabolism closely associated with IBS. Moreover, microbiota drives significant modifications for BAs, consisting of deconjugation, 7α-dehydroxylation, oxidation, epimerization, desulfation, esterification, and so on, while BAs, in turn, affect the microbiota directly or indirectly. In light of the complex connection among gut microbiota, BAs, and IBS, it is urgent to review the latest research progress in this field. In this review, we described the disorders of intestinal microecology and BAs profiles in IBS-D and also highlighted the cross-talk between gut microbiota and BAs in the context of IBS-D. Integrating these, we suggest that new therapeutic strategies targeting the microbiota-BAs axis for IBS-D, even for other related diseases caused by bacteria-bile acid dysbiosis should be expected.
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Affiliation(s)
- Jun-Jie Hou
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Key Laboratory of Digestive Disease, Tianjin Medical University General Hospital, Tianjin, China
| | - Xin Wang
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Key Laboratory of Digestive Disease, Tianjin Medical University General Hospital, Tianjin, China
| | - Yu-Ming Wang
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Key Laboratory of Digestive Disease, Tianjin Medical University General Hospital, Tianjin, China
| | - Bang-Mao Wang
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Key Laboratory of Digestive Disease, Tianjin Medical University General Hospital, Tianjin, China
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7
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Wei W, Wang H, Zhang Y, Zhang Y, Niu B, Chen S, Zhang W, Yao S. Faecal bile acids and colonic bile acid membrane receptor correlate with symptom severity of diarrhoea-predominant irritable bowel syndrome: A pilot study. Dig Liver Dis 2021; 53:1120-1127. [PMID: 34053874 DOI: 10.1016/j.dld.2021.04.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 04/16/2021] [Accepted: 04/19/2021] [Indexed: 02/08/2023]
Abstract
AIMS To compare both the faecal bile acids (BAs) and the levels of two bile acid receptors, Takeda G protein-coupled receptor 5 (TGR5) and vitamin D receptor (VDR), in the colonic mucosa between patients with irritable bowel syndrome with predominant diarrhea (IBS-D) and healthy controls, and explore the correlations among clinical characteristics, bile acid receptors expression, and BAs. METHODS The severity of abdominal pain and diarrhoea was assessed in IBS-D patients using validated questionnaires, faecal BAs were measured by ultraperformance liquid chromatography coupled to tandem mass spectrometry, and rectosigmoid biopsies were taken for the analyses of TGR5 and VDR expression using immunohistochemistry. RESULTS The level of TGR5 immunoreactivity in rectosigmoid mucosal biopsies was significantly higher in IBS-D patients than in controls, while the VDR immunoreactivity displayed no significant difference between patients and controls. The patients with more severe or more frequent abdominal pain had significantly higher TGR5 level. Faecal primary BAs were significantly increased in IBS-D patients and were positively correlated with the severity of diarrhoea. The level of TGR5 was positively associated with primary BAs and negatively associated with secondary BAs among all participants providing both mucosal and stool samples. CONCLUSIONS Colonic mucosal TGR5 protein expression and faecal bile acids were correlated with the symptom severity of IBS-D patients.
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Affiliation(s)
- Wei Wei
- Graduate School, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China; Department of Gastroenterology, China-Japan Friendship Hospital, Beijing, China
| | - Huifen Wang
- Department of Gastroenterology, China-Japan Friendship Hospital, Beijing, China
| | - Yanli Zhang
- Department of Gastroenterology, China-Japan Friendship Hospital, Beijing, China
| | - Yu Zhang
- Graduate School, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China; Department of Gastroenterology, China-Japan Friendship Hospital, Beijing, China
| | - Bingyu Niu
- Department of Gastroenterology, China-Japan Friendship Hospital, Beijing, China; Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Shuo Chen
- Department of Gastroenterology, China-Japan Friendship Hospital, Beijing, China
| | - Wenxue Zhang
- Graduate School, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China; Department of Gastroenterology, China-Japan Friendship Hospital, Beijing, China
| | - Shukun Yao
- Graduate School, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China; Department of Gastroenterology, China-Japan Friendship Hospital, Beijing, China.
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8
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Shiha MG, Ashgar Z, Fraser EM, Kurien M, Aziz I. High prevalence of primary bile acid diarrhoea in patients with functional diarrhoea and irritable bowel syndrome-diarrhoea, based on Rome III and Rome IV criteria. EClinicalMedicine 2020; 25:100465. [PMID: 32954237 PMCID: PMC7486326 DOI: 10.1016/j.eclinm.2020.100465] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 06/29/2020] [Accepted: 07/03/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND A high prevalence of primary bile acid diarrhoea (BAD) has been reported for Rome III defined irritable bowel syndrome (IBS)-diarrhoea and functional diarrhoea. We determined whether this still applies under the contemporaneous Rome IV criteria, given that the latter characterises IBS-diarrhoea as having more frequent abdominal pain compared with previous iterations, whilst no longer recognising abdominal discomfort. METHODS Patients referred for a 75SeHCAT test completed a baseline questionnaire comprising, i) demographic data, ii) risk factors for BAD (inflammatory bowel disease, bowel resection, cholecystectomy, microscopic colitis, celiac disease, abdominal-pelvic radiotherapy), iii) the Rome III and IV bowel disorder questionnaire, and iv) mood and somatisation scores. A diagnosis of BAD constituted a 75SeHCAT of ≤15%, with moderate to severe disease being defined as ≤10% and ≤5%, respectively. FINDINGS Of 300 patients with complete dataset, 184 had no risk factors for BAD and fulfilled criteria for either IBS-diarrhoea or functional diarrhoea. The prevalence of primary BAD was 38% (n = 70/184), with almost half having moderate (n = 16) to severe (n = 17) disease. Using the Rome III criteria, the prevalence of primary BAD was 36% in IBS-diarrhoea (n = 63/173) and 64% (n = 7/11) in functional diarrhoea; p = 0.11. Using the Rome IV criteria, the prevalence of primary BAD was 38% (n = 53/139) in IBS-diarrhoea and 38% (n = 17/45) in functional diarrhoea; p = 0.97. Patients with primary BAD experienced more frequent loose stools (p = 0.01) and had a higher body mass index (p<0.0001) compared to those without BAD, but otherwise no significant differences were seen in age, gender, mood, somatisation, or abdominal pain. The presence of primary BAD in patients classified as overweight or obese was approximately 40% and 60%, respectively. INTERPRETATION Over a third of patients with Rome IV IBS-diarrhoea or functional diarrhoea have primary BAD, similar to Rome III. We therefore recommend that, in secondary care settings, generic testing for primary BAD should be considered in patients presenting with chronic diarrhoea of presumed functional origin regardless of concomitant abdominal pain. Centres that lack tests for primary BAD, and who empirically treat instead, may consider targeting patients who are overweight or obese.
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Affiliation(s)
- Mohamed G. Shiha
- Academic Department of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, United Kingdom
| | - Zohaib Ashgar
- Academic Department of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, United Kingdom
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Ellen M. Fraser
- Academic Department of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, United Kingdom
| | - Matthew Kurien
- Academic Department of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, United Kingdom
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Imran Aziz
- Academic Department of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, United Kingdom
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
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9
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Whole-body 75SeHCAT retention is determined by entero-hepatic bile acid recycling rate. Nucl Med Commun 2020; 41:750-752. [DOI: 10.1097/mnm.0000000000001216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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10
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Labarile N, Ghosh S, Ng SC, Walters J, Iacucci M. Tests that now deserve to be more widely adopted in IBD clinical practice. Therap Adv Gastroenterol 2020; 13:1756284820944088. [PMID: 32782481 PMCID: PMC7385848 DOI: 10.1177/1756284820944088] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 06/30/2020] [Indexed: 02/04/2023] Open
Abstract
Inflammatory bowel diseases are chronic relapsing immune-mediated diseases of the intestinal tract with multifaceted manifestations and treatment related morbidity. Faecal and blood tests, radiological, endoscopic and histologic investigations are now widely used for managing both ulcerative colitis and Crohn's disease. Over the years, a number of new investigations have been proposed but not widely adopted yet. Patients with Crohn's disease may have multiple causes of diarrhoea, not always attributable to disease exacerbation, but sometimes linked to bile acid malabsorption; we have a reliable serum test, C4, that allows us to recognize and treat this cause of diarrhoea efficaciously and not empirically, but it is not available or used widely. There is genetic inter-individual variability in drug responses, in terms of both efficacy and toxicity, leading to high rates of therapeutic failure. Patients treated with thiopurine or, more rarely, 5-aminosalicylic acid may suffer from unpredictable and serious adverse events, some of these with pathogenesis related to genetic variants: myelosuppression, acute pancreatitis and nephrotoxicity. The identification of pre-treatment genetic tests can optimize therapeutic choice and avoid adverse events. With regard to biological drugs, patients can experience primary non-response or loss of response due to induction of immune responses to the drugs affecting drug efficacy and determining hypersensitivity reactions. We have specifically reviewed a number of investigations, whose use is currently limited, and highlighted four tests that deserve to be more widely incorporated in clinical practice as these could improve medical decision-making and patient outcomes.
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Affiliation(s)
| | - Subrata Ghosh
- Institute Translational of Medicine, Institute of Immunology and Immunotherapy and NIHR Birmingham Biomedical Research Centre, University Hospitals NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - Siew C Ng
- Department of Medicine and Therapeutics, Institute of Digestive Disease, State Key Laboratory of Digestive Diseases, Li Ka Shing Institute of Health Science, The Chinese University of Hong Kong, Hong Kong, China
| | - Julian Walters
- Division of Digestive Diseases, Imperial College London, Imperial College Healthcare, London, UK
| | - Marietta Iacucci
- Institute Translational of Medicine, Institute of Immunology and Immunotherapy and NIHR Birmingham Biomedical Research Centre, University Hospitals NHS Foundation Trust and University of Birmingham, Birmingham, UK
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11
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Zhao L, Yang W, Chen Y, Huang F, Lu L, Lin C, Huang T, Ning Z, Zhai L, Zhong LL, Lam W, Yang Z, Zhang X, Cheng C, Han L, Qiu Q, Shang X, Huang R, Xiao H, Ren Z, Chen D, Sun S, El-Nezami H, Cai Z, Lu A, Fang X, Jia W, Bian Z. A Clostridia-rich microbiota enhances bile acid excretion in diarrhea-predominant irritable bowel syndrome. J Clin Invest 2020; 130:438-450. [PMID: 31815740 PMCID: PMC6934182 DOI: 10.1172/jci130976] [Citation(s) in RCA: 97] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 10/18/2019] [Indexed: 12/14/2022] Open
Abstract
An excess of fecal bile acids (BAs) is thought to be one of the mechanisms for diarrhea-predominant irritable bowel syndrome (IBS-D). However, the factors causing excessive BA excretion remain incompletely studied. Given the importance of gut microbiota in BA metabolism, we hypothesized that gut dysbiosis might contribute to excessive BA excretion in IBS-D. By performing BA-related metabolic and metagenomic analyses in 290 IBS-D patients and 89 healthy volunteers, we found that 24.5% of IBS-D patients exhibited excessive excretion of total BAs and alteration of BA-transforming bacteria in feces. Notably, the increase in Clostridia bacteria (e.g., C. scindens) was positively associated with the levels of fecal BAs and serum 7α-hydroxy-4-cholesten-3-one (C4), but negatively correlated with serum fibroblast growth factor 19 (FGF19) concentration. Furthermore, colonization with Clostridia-rich IBS-D fecal microbiota or C. scindens individually enhanced serum C4 and hepatic conjugated BAs but reduced ileal FGF19 expression in mice. Inhibition of Clostridium species with vancomycin yielded opposite results. Clostridia-derived BAs suppressed the intestinal FGF19 expression in vitro and in vivo. In conclusion, this study demonstrates that the Clostridia-rich microbiota contributes to excessive BA excretion in IBS-D patients, which provides a mechanistic hypothesis with testable clinical implications.
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Affiliation(s)
- Ling Zhao
- Institute of Brain and Gut Research, School of Chinese Medicine, Hong Kong Baptist University, Hong Kong SAR, China
| | - Wei Yang
- Institute of Brain and Gut Research, School of Chinese Medicine, Hong Kong Baptist University, Hong Kong SAR, China
| | - Yang Chen
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Fengjie Huang
- Shanghai Key Laboratory of Diabetes Mellitus and Center for Translational Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Lin Lu
- Institute of Brain and Gut Research, School of Chinese Medicine, Hong Kong Baptist University, Hong Kong SAR, China
| | - Chengyuan Lin
- Institute of Brain and Gut Research, School of Chinese Medicine, Hong Kong Baptist University, Hong Kong SAR, China
| | - Tao Huang
- Institute of Brain and Gut Research, School of Chinese Medicine, Hong Kong Baptist University, Hong Kong SAR, China
| | - Ziwan Ning
- Institute of Brain and Gut Research, School of Chinese Medicine, Hong Kong Baptist University, Hong Kong SAR, China
| | - Lixiang Zhai
- Institute of Brain and Gut Research, School of Chinese Medicine, Hong Kong Baptist University, Hong Kong SAR, China
| | - Linda Ld Zhong
- Chinese Medicine Clinical Study Center, School of Chinese Medicine, Hong Kong Baptist University, Hong Kong SAR, China
| | - Waiching Lam
- Chinese Medicine Clinical Study Center, School of Chinese Medicine, Hong Kong Baptist University, Hong Kong SAR, China
| | - Zhen Yang
- Chinese Medicine Clinical Study Center, School of Chinese Medicine, Hong Kong Baptist University, Hong Kong SAR, China
| | - Xuan Zhang
- Chinese Medicine Clinical Study Center, School of Chinese Medicine, Hong Kong Baptist University, Hong Kong SAR, China
| | - Chungwah Cheng
- Chinese Medicine Clinical Study Center, School of Chinese Medicine, Hong Kong Baptist University, Hong Kong SAR, China
| | - Lijuan Han
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Qinwei Qiu
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xiaoxiao Shang
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Runyue Huang
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Haitao Xiao
- School of Pharmaceutical Sciences, Health Science Center, Shenzhen University, Shenzhen, China
| | - Zhenxing Ren
- College of Basic Medicine, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Dongfeng Chen
- College of Basic Medicine, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Silong Sun
- BGI Genomics, BGI-Shenzhen, Shenzhen, China
| | - Hani El-Nezami
- School of Biological Sciences, Faculty of Science, The University of Hong Kong, Hong Kong SAR, China
| | - Zongwei Cai
- School of Chemistry, Hong Kong Baptist University, Hong Kong SAR, China
| | - Aiping Lu
- Chinese Medicine Clinical Study Center, School of Chinese Medicine, Hong Kong Baptist University, Hong Kong SAR, China
| | - Xiaodong Fang
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China.,College of Basic Medicine, Guangzhou University of Chinese Medicine, Guangzhou, China.,BGI Genomics, BGI-Shenzhen, Shenzhen, China
| | - Wei Jia
- Shanghai Key Laboratory of Diabetes Mellitus and Center for Translational Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.,Cancer Biology Program, University of Hawaii Cancer Center, Hawaii, USA
| | - Zhaoxiang Bian
- Institute of Brain and Gut Research, School of Chinese Medicine, Hong Kong Baptist University, Hong Kong SAR, China.,Chinese Medicine Clinical Study Center, School of Chinese Medicine, Hong Kong Baptist University, Hong Kong SAR, China
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12
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Battat R, Duijvestein M, Casteele NV, Singh S, Dulai PS, Valasek MA, Mimms L, McFarland J, Hester KD, Renshaw M, Jain A, Sandborn WJ, Boland BS. Serum Concentrations of 7α-hydroxy-4-cholesten-3-one Are Associated With Bile Acid Diarrhea in Patients With Crohn's Disease. Clin Gastroenterol Hepatol 2019; 17:2722-2730.e4. [PMID: 30448597 PMCID: PMC6520204 DOI: 10.1016/j.cgh.2018.11.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 10/31/2018] [Accepted: 11/02/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with Crohn's disease (CD) often have bile acid diarrhea (BAD), due to bile acid malabsorption following ileal resection (IR). Bile acid malabsorption increases production of 7α-hydroxy-4-cholesten-3-one (C4), a bile acid precursor. We investigated relationships between serum concentrations of C4 and BAD in patients with CD. METHODS We collected demographic data, serum samples, and information on the presence of diarrhea (>3 liquid bowel movements/day), as well as clinical, endoscopic, and histologic scores from 26 patients with CD and IR, 21 patients with CD without IR, and 37 patients with ulcerative colitis (UC). We compared serum concentrations of C4 and fibroblast growth factor 19 (FGF19) between groups. We performed area under the receiver operating characteristic curve (AUROC) analysis to identify the optimal cutoff C4 concentrations for the diagnosis of diarrhea attributable to bile acid malabsorption (BAD), defined as diarrhea and a serum concentration of FGF19 <60 pg/mL. RESULTS Patients with UC had a median serum C4 concentration of 11.8 ng/mL, whereas patients with CD and IR with ileitis (documented endoscopically) had a median concentration of 100.0 ng/mL (P compared to UC < .0001) and patients with CD and IR without ileitis had a median concentration of 51.6 ng/mL (P compared to UC < .001). Patients with CD without IR did not have a significantly higher median concentration of C4 than patients with UC (P = .71), regardless of ileitis (P = .34). When endoscopic findings were confirmed histologically, similar results were found to analyses using endoscopic findings alone. A higher proportion of patients with active UC had diarrhea (72.0% vs 0 patients with inactive UC; P < .001), but their median concentrations of C4 did not differ significantly from that of patients with inactive UC (12.1 ng/mL vs 9.7 ng/mL; P = .3). A cutoff concentration of C4 of 48.3 ng/mL or greater identified patients with diarrhea attributable to bile acid malabsorption with 90.9% sensitivity, 84.4% specificity, and an AUROC 0.94. A significantly higher proportion of patients with concentrations of C4 above this cutoff had BAD (50.0%) than below this cutoff (1.8%) (P < .001). When we analyzed only patients with diarrhea, a C4 cutoff of 48.3 ng/mL identified those with low FGF19 concentrations (<60 pg/mL) with 91% sensitivity and 95.5% specificity (AUROC, 0.99). Above this cutoff, 83.3% of patients had a serum concentration of FGF19 <60 pg/mL compared to 4.5% below this threshold (P < .0001). C4 concentrations correlated with the number of daily bowel movements (r = 0.41; P = .004) and correlated inversely with FGF19 concentrations (r = -0.72; P<.0001). CONCLUSION We observed significantly increased serum concentrations of C4 in patients with CD with IR, compared to patients with UC. A cutoff concentration of C4 above 48.3 ng/mL identifies patients with diarrhea likely attributable to bile acid malabsorption (BAD) with an AUROC value of 0.94. Increased serum levels of bile acid precursors identify patients with diarrhea and a low serum concentration of FGF19, and concentrations of C4 correlate with daily liquid bowel movements and correlate inversely with FGF19 concentrations. C4 may be a biomarker to identify patients with diarrhea attributable to bile acid malabsorption.
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Affiliation(s)
- Robert Battat
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Marjolijn Duijvestein
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA.,Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, Netherlands
| | - Niels Vande Casteele
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Siddharth Singh
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Parambir S. Dulai
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Mark A. Valasek
- Department of Pathology, University of California San Diego, La Jolla, California, USA
| | - Larry Mimms
- Prometheus Laboratories Inc., San Diego, California
| | | | | | - Mark Renshaw
- Prometheus Laboratories Inc., San Diego, California
| | - Anjali Jain
- Prometheus Laboratories Inc., San Diego, California
| | - William J Sandborn
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Brigid S Boland
- Division of Gastroenterology, University of California San Diego, La Jolla, California.
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13
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Lee JM, Ong JR, Vergnes L, de Aguiar Vallim TQ, Nolan J, Cantor RM, Walters JRF, Reue K. Diet1, bile acid diarrhea, and FGF15/19: mouse model and human genetic variants. J Lipid Res 2018; 59:429-438. [PMID: 29295820 DOI: 10.1194/jlr.m078279] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 12/29/2017] [Indexed: 01/12/2023] Open
Abstract
Diet1 modulates intestinal production of the hormone, fibroblast growth factor (FGF)15, which signals in liver to regulate bile acid synthesis. C57BL/6ByJ mice with a spontaneous Diet1-null mutation are resistant to hypercholesterolemia compared with wild-type C57BL/6J mice through enhanced cholesterol conversion to bile acids. To further characterize the role of Diet1 in metabolism, we generated Diet1-/- mice on the C57BL/6J genetic background. C57BL/6J Diet1-/- mice had elevated bile acid levels, reduced Fgf15 expression, and increased gastrointestinal motility and intestinal luminal water content, which are symptoms of bile acid diarrhea (BAD) in humans. Natural genetic variation in Diet1 mRNA expression levels across 76 inbred mouse strains correlated positively with Ffg15 mRNA and negatively with serum bile acid levels. This led us to investigate the role of DIET1 genetic variation in primary BAD patients. We identified a DIET1 coding variant (rs12256835) that had skewed prevalence between BAD cases and controls. This variant causes an H1721Q amino acid substitution that increases the levels of FGF19 protein secreted from cultured cells. We propose that genetic variation in DIET1 may be a determinant of FGF19 secretion levels, and may affect bile acid metabolism in both physiological and pathological conditions.
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Affiliation(s)
- Jessica M Lee
- Department of Human Genetics, University of California, Los Angeles, Los Angeles, CA
| | - Jessica R Ong
- Department of Human Genetics, University of California, Los Angeles, Los Angeles, CA
| | - Laurent Vergnes
- Department of Human Genetics, University of California, Los Angeles, Los Angeles, CA
| | - Thomas Q de Aguiar Vallim
- Department of Biological Chemistry and Division of Cardiology, University of California, Los Angeles, Los Angeles, CA
| | - Jonathan Nolan
- Department of Medicine, Section of Hepatology and Gastroenterology, Imperial College London and Imperial College Healthcare, London, United Kingdom
| | - Rita M Cantor
- Department of Human Genetics, University of California, Los Angeles, Los Angeles, CA
| | - Julian R F Walters
- Department of Medicine, Section of Hepatology and Gastroenterology, Imperial College London and Imperial College Healthcare, London, United Kingdom
| | - Karen Reue
- Department of Human Genetics, University of California, Los Angeles, Los Angeles, CA .,David Geffen School of Medicine, and Molecular Biology Institute, University of California, Los Angeles, Los Angeles, CA
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14
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Borup C, Wildt S, Rumessen JJ, Bouchelouche PN, Graff J, Damgaard M, McQuitty C, Rainteau D, Munck LK. Chenodeoxycholic acid stimulated fibroblast growth factor 19 response - a potential biochemical test for bile acid diarrhoea. Aliment Pharmacol Ther 2017; 45:1433-1442. [PMID: 28378364 DOI: 10.1111/apt.14056] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 01/01/2017] [Accepted: 03/02/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Bile acid diarrhoea is underdiagnosed and better diagnostic tests are needed. Fasting serum fibroblast growth factor-19 (FGF19) has insufficient diagnostic value, but this may be improved by stimulation. AIM To explore if an impaired FGF19 response identifies primary bile acid diarrhoea. METHODS Eight patients with primary bile acid diarrhoea and eight healthy volunteers ingested (i) a meal plus 1250 mg chenodeoxycholic acid (CDCA), (ii) 1250 mg CDCA or (iii) the meal. Blood was sampled at fasting and repeatedly after stimulation. We analysed FGF19 by enzyme-linked immunosorbent assay and bile acids including 7α-hydroxy-4-cholesten-3-one by liquid chromatography-tandem mass spectrometry. RESULTS Stimulation with the meal plus CDCA increased median FGF19 in healthy volunteers from fasting 62 pg/mL [interquartile range (IQR): 41-138] to 99 pg/mL (IQR: 67-147; P = 0.012) after 90 min and peaked after 150 min at 313 pg/mL (IQR: 54-512). This response was impaired in primary bile acid diarrhoea patients [fasting 56 pg/mL (IQR: 42-79); 90 min: 48 pg/mL [IQR: 37-63); 150 min: 57 pg/mL (48-198)]. Receiver operating characteristics (ROCAUC ) for fasting FGF19 was 0.55 (P = 0.75) and at 90 min 0.84 (P = 0.02). The difference in FGF19 from fasting to 90 min after the meal plus CDCA separated the groups (ROCAUC 1.0; P = 0.001). 7α-hydroxy-4-cholesten-3-one was elevated in primary bile acid diarrhoea (P = 0.038) and not significantly affected by stimulation. CONCLUSIONS The FGF19 response following chenodeoxycholic acid plus meal is impaired in primary bile acid diarrhoea. This may provide a biochemical diagnostic test.
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Affiliation(s)
- C Borup
- Department of Internal Medicine, Zealand University Hospital, Køge, Denmark
| | - S Wildt
- Department of Internal Medicine, Zealand University Hospital, Køge, Denmark.,Faculty of Health and Human Sciences, University of Copenhagen, Copenhagen, Denmark
| | - J J Rumessen
- Research Unit, Herlev and Gentofte Hospital, Copenhagen, Denmark
| | - P N Bouchelouche
- Department of Clinical Biochemistry, Zealand University Hospital, Køge, Denmark
| | - J Graff
- Department of Clinical Physiology and Nuclear Medicine, Hvidovre Hospital, Hvidovre, Denmark
| | - M Damgaard
- Department of Clinical Physiology and Nuclear Medicine, Hvidovre Hospital, Hvidovre, Denmark.,Department of Clinical Physiology and Nuclear Medicine, Zealand University Hospital, Køge, Denmark
| | - C McQuitty
- Sorbonne Universités, UPMC Univ Paris 06, Paris-France INSERM-ERL 1157 CNRS UMR 7203 LBM, CHU Saint-Antoine 27, Paris, France
| | - D Rainteau
- Sorbonne Universités, UPMC Univ Paris 06, Paris-France INSERM-ERL 1157 CNRS UMR 7203 LBM, CHU Saint-Antoine 27, Paris, France
| | - L K Munck
- Department of Internal Medicine, Zealand University Hospital, Køge, Denmark.,Faculty of Health and Human Sciences, University of Copenhagen, Copenhagen, Denmark
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15
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Mottacki N, Simrén M, Bajor A. Review article: bile acid diarrhoea - pathogenesis, diagnosis and management. Aliment Pharmacol Ther 2016; 43:884-898. [PMID: 26913381 DOI: 10.1111/apt.13570] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 08/29/2015] [Accepted: 02/04/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Bile acid diarrhoea results from imbalances in the homoeostasis of bile acids in the enterohepatic circulation. It can be a consequence of ileal disease/dysfunction, associated with other GI pathology or can be idiopathic. AIMS To summarise the different types of bile acid diarrhoea and discuss the currently available diagnostic methods and treatments. RESULTS Bile acid diarrhoea is found in up to 40% of patients diagnosed as having functional diarrhoea/IBS-D, and in up to 80% of patients who have undergone ileal resection. It is likely under-diagnosed and under-treated. In idiopathic disease, errors in regulation feedback of fibroblast growth factor 19 contribute to the development of the condition. Clinical therapeutic trials for bile acid diarrhoea have been used to diagnose it, but the 75 SeHCAT test is the primary current method. It is sensitive, specific and widely available, though not in the USA. Other diagnostic methods (such as serum measurement of the bile acid intermediate 7α-hydroxy-4-cholesten-3-one, or C4) have less widespread availability and documentation, and some (such as faecal measurement of bile acids) are significantly more complex and costly. First-line treatment of bile acid diarrhoea is with the bile acid sequestrant cholestyramine, which can be difficult to administer and dose due to gastrointestinal side effects. These side effects are less prominent in newer agents such as colesevelam, which may provide higher efficacy, tolerability and compliance. CONCLUSION Bile acid diarrhoea is common, and likely under-diagnosed. Bile acid diarrhoea should be considered relatively early in the differential diagnosis of chronic diarrhoea.
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Affiliation(s)
- N Mottacki
- Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - M Simrén
- Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,University of Gothenburg Centre for Person-Centered Care (GPCC), Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - A Bajor
- Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Internal Medicine, Södra Älvsborgs Sjukhus, Borås, Sweden
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16
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Johnston IM, Nolan JD, Pattni SS, Appleby RN, Zhang JH, Kennie SL, Madhan GK, Jameie-Oskooei S, Pathmasrirengam S, Lin J, Hong A, Dixon PH, Williamson C, Walters JRF. Characterizing Factors Associated With Differences in FGF19 Blood Levels and Synthesis in Patients With Primary Bile Acid Diarrhea. Am J Gastroenterol 2016; 111:423-32. [PMID: 26856750 DOI: 10.1038/ajg.2015.424] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 12/17/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Chronic diarrhea caused by primary bile acid diarrhea (PBAD) is a common condition. We have previously shown PBAD is associated with low fasting serum levels of the ileal hormone, fibroblast growth factor 19 (FGF19). FGF19 is a negative regulator of hepatic bile acid synthesis and is stimulated by farnesoid X receptor agonists, which produce symptomatic improvement in PBAD. We aimed to assess possible causes for low serum FGF19 in patients with PBAD. METHODS Patients with PBAD, defined by reduced (75)Se-labelled homocholic acid taurine (SeHCAT) retention, and idiopathic diarrhea controls had measurements of fasting lipids and fasting/post-prandial FGF19 serum profiles. Specific functional variants in candidate genes were investigated in exploratory studies. In further groups, basal and bile acid-stimulated transcript expression was determined in ileal biopsies and explant cultures by quantitative PCR. RESULTS FGF19 profiles in PBAD patients included low fasting and meal-stimulated responses, which were both strongly correlated with SeHCAT. A subgroup of 30% of PBAD patients had fasting hypertriglyceridemia and higher FGF19. No clear significant differences were found for any genetic variant but there were borderline associations with FGFR4 and KLB. SeHCAT retention significantly correlated with the basal ileal transcript expression of FGF19 (rs=0.59, P=0.03) and apical sodium-dependent bile acid transporter (ASBT) (rs=0.49, P=0.04), and also with the degree of stimulation by chenodeoxycholic acid at 6 h for transcripts of FGF19 (median 184-fold, rs=0.50, P=0.02) and ileal bile acid binding protein (IBABP) (median 2.2-fold, rs=0.47, P=0.04). Median stimulation of FGF19 was lower in patients with SeHCAT retention <10% (P=0.01). CONCLUSIONS These studies demonstrate a complex, multifactorial etiology of PBAD, including impairments in ileal FGF19 expression and responsiveness.
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Affiliation(s)
- Ian M Johnston
- Department of Gastroenterology, Imperial College Healthcare NHS Trust, and Division of Digestive Diseases, Imperial College London, London, UK
| | - Jonathan D Nolan
- Department of Gastroenterology, Imperial College Healthcare NHS Trust, and Division of Digestive Diseases, Imperial College London, London, UK
| | - Sanjeev S Pattni
- Department of Gastroenterology, Imperial College Healthcare NHS Trust, and Division of Digestive Diseases, Imperial College London, London, UK
| | - Richard N Appleby
- Department of Gastroenterology, Imperial College Healthcare NHS Trust, and Division of Digestive Diseases, Imperial College London, London, UK
| | - Justine H Zhang
- Department of Gastroenterology, Imperial College Healthcare NHS Trust, and Division of Digestive Diseases, Imperial College London, London, UK
| | - Sarah L Kennie
- Department of Gastroenterology, Imperial College Healthcare NHS Trust, and Division of Digestive Diseases, Imperial College London, London, UK
| | - Gaganjit K Madhan
- Department of Gastroenterology, Imperial College Healthcare NHS Trust, and Division of Digestive Diseases, Imperial College London, London, UK
| | - Sina Jameie-Oskooei
- Department of Gastroenterology, Imperial College Healthcare NHS Trust, and Division of Digestive Diseases, Imperial College London, London, UK
| | - Shivani Pathmasrirengam
- Department of Gastroenterology, Imperial College Healthcare NHS Trust, and Division of Digestive Diseases, Imperial College London, London, UK
| | - Jeremy Lin
- Department of Gastroenterology, Imperial College Healthcare NHS Trust, and Division of Digestive Diseases, Imperial College London, London, UK
| | - Albert Hong
- Department of Gastroenterology, Imperial College Healthcare NHS Trust, and Division of Digestive Diseases, Imperial College London, London, UK
| | - Peter H Dixon
- Institute of Reproductive and Developmental Biology, Imperial College London, London, UK.,Division of Women's Health, King's College London, Guy's Hospital, London, UK
| | - Catherine Williamson
- Institute of Reproductive and Developmental Biology, Imperial College London, London, UK.,Division of Women's Health, King's College London, Guy's Hospital, London, UK
| | - Julian R F Walters
- Department of Gastroenterology, Imperial College Healthcare NHS Trust, and Division of Digestive Diseases, Imperial College London, London, UK
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17
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Camilleri M. Dissecting Molecular Mechanisms in Bile Acid Diarrhea. Am J Gastroenterol 2016; 111:433-5. [PMID: 27018117 DOI: 10.1038/ajg.2016.23] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 01/12/2016] [Indexed: 12/11/2022]
Abstract
It was previously demonstrated that patients with bile acid (BA) diarrhea have low fasting serum levels of the ileal hormone--fibroblast growth factor-19 (FGF-19). In this paper, the authors demonstrate a positive correlation between ileal transcripts of FGF-19 and (75)SeHCAT retention, providing further evidence of FGF-19 deficiency as an explanation for BA diarrhea. Variants in KLB and FGFR4 genes (that determine the functional re-uptake of BA in the portal circulation by hepatocytes) are also demonstrated to be associated with (75)SeHCAT retention, confirming a second potential mechanism for the development of BA diarrhea.
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Affiliation(s)
- Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Mayo Clinic, Rochester, Minnesota, USA
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18
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Abstract
Bile acid diarrhea (BAD) is usually seen in patients with ileal Crohn’s disease or ileal resection. However, 25% to 50% of patients with functional diarrhea or diarrhea-predominant irritable bowel syndrome (IBS-D) also have evidence of BAD. It is estimated that 1% of the population may have BAD. The causes of BAD include a deficiency in fibroblast growth factor 19 (FGF-19), a hormone produced in enterocytes that regulates hepatic bile acid (BA) synthesis. Other potential causes include genetic variations that affect the proteins involved in BA enterohepatic circulation and synthesis or in the TGR5 receptor that mediates the actions of BA in colonic secretion and motility. BAs enhance mucosal permeability, induce water and electrolyte secretion, and accelerate colonic transit partly by stimulating propulsive high-amplitude colonic contractions. There is an increased proportion of primary BAs in the stool of patients with IBS-D, and some changes in the fecal microbiome have been described. There are several methods of diagnosing BAD, such as 75selenium homotaurocholic acid test retention, serum C4, FGF-19, and fecal BA measurement; presently, therapeutic trials with BA sequestrants are most commonly used for diagnosis. Management involves the use of BA sequestrants including cholestyramine, colestipol, and colesevelam. FXR agonists such as obeticholic acid constitute a promising new approach to treating BAD.
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Affiliation(s)
- Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Mayo Clinic College of Medicine, Rochester, MN, USA
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19
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Aziz I, Mumtaz S, Bholah H, Chowdhury FU, Sanders DS, Ford AC. High Prevalence of Idiopathic Bile Acid Diarrhea Among Patients With Diarrhea-Predominant Irritable Bowel Syndrome Based on Rome III Criteria. Clin Gastroenterol Hepatol 2015; 13:1650-5.e2. [PMID: 25769413 DOI: 10.1016/j.cgh.2015.03.002] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Revised: 01/27/2015] [Accepted: 03/05/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Some studies have found that patients with idiopathic bile acid diarrhea (BAD) present with symptoms of diarrhea-predominant irritable bowel syndrome (D-IBS). However, these studies either were retrospective, did not define D-IBS according to current criteria, or included patients with chronic functional diarrhea. We performed a prospective study of the prevalence of idiopathic BAD in consecutive patients fulfilling the Rome III criteria for D-IBS. METHODS We analyzed data from 118 consecutive adult patients who fulfilled the Rome III criteria for D-IBS (mean age, 41.7 y; 72.9% female), seen at 2 gastroenterology clinics in the United Kingdom. We excluded patients with risk factors for BAD (previous history of cholecystectomy, terminal ileal Crohn's disease, terminal ileal resection or right hemicolectomy, pelvic or abdominal radiotherapy, celiac disease, or microscopic colitis). Participants completed questionnaires at baseline (on demographics, hospital anxiety, somatization, and depression, as well as the patient health questionnaire-12 and the Short Form-36), and then received the (75)selenium homocholic acid taurine retention test. Retention of (75)selenium homocholic acid taurine 7 days after administration was used to identify patients with idiopathic BAD (mild BAD, 10%-14.9%; moderate BAD, 5.1%-9.9%; and severe BAD, ≤5%). RESULTS Twenty-eight patients were found to have BAD (23.7% of total), with similar percentages at each study site (25.3% and 20%; P = .54). Eight patients had mild BAD (28.6%), 8 patients had moderate BAD (28.6%), and 12 patients had severe BAD (42.8%). There was no statistical difference in age, sex, depression, patient health questionnaire-12 responses, or SF-36 scores between individuals with vs without BAD. However, patients with BAD had a higher mean body mass index than patients without BAD (31.6 vs 26.4; P = .003). Physical activity (based on the Short Form-36) was significantly lower in subjects with moderate (43.8) or severe BAD (41.7), compared with patients with mild BAD (87.5) (P = .046). CONCLUSIONS Almost 25% of patients presenting with D-IBS have idiopathic BAD; most cases are moderate to severe. Guidelines should advocate testing to exclude BAD before patients are diagnosed with D-IBS.
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Affiliation(s)
- Imran Aziz
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Saqib Mumtaz
- Leeds Gastroenterology Institute, St James's University Hospital, Leeds, United Kingdom
| | - Hassan Bholah
- Leeds Gastroenterology Institute, St James's University Hospital, Leeds, United Kingdom
| | - Fahmid U Chowdhury
- Nuclear Medicine Department, St James's University Hospital, Leeds, United Kingdom
| | - David S Sanders
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Alexander C Ford
- Leeds Gastroenterology Institute, St James's University Hospital, Leeds, United Kingdom; Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, United Kingdom.
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Patel P, Bercik P, Morgan DG, Bolino C, Pintos-Sanchez MI, Moayyedi P, Ford AC. Prevalence of organic disease at colonoscopy in patients with symptoms compatible with irritable bowel syndrome: cross-sectional survey. Scand J Gastroenterol 2015; 50:816-23. [PMID: 25636675 DOI: 10.3109/00365521.2015.1007079] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Guidelines for the management of irritable bowel syndrome (IBS) encourage a positive diagnosis, but some evidence suggests organic disease may be missed unless investigations are performed. We examined yield of colonoscopy in a cohort of secondary care patients meeting criteria for IBS. MATERIALS AND METHODS Demographic data, symptoms and findings at colonoscopy were recorded prospectively in consecutive, unselected adults with gastrointestinal (GI) symptoms compatible with IBS according to the Rome III criteria. Prevalence of organic GI disease was compared between those meeting criteria for IBS, according to the presence or absence of co-existent alarm features, and by IBS subtype. RESULTS A total of 559 patients met Rome III criteria for IBS, of whom 423 reported ≥1 alarm feature and 136 none. There was a significantly higher prevalence of organic GI disease among those reporting alarm features (117 [27.7%]), compared with those without (21 [15.4%]) (p = 0.002). In the latter group of 136 patients, Crohn's disease was the commonest finding (10 [7.4%] subjects), followed by coeliac disease (4 [2.9%] subjects), and microscopic colitis (3 [2.2%] subjects). Regardless of presence or absence of alarm features, patients with constipation-predominant IBS were less likely to exhibit organic GI disease than those with diarrhea-predominant or mixed IBS (12.7% vs. 32.1% and 23.8%, p = 0.006). CONCLUSIONS One in six patients with symptoms compatible with IBS without alarm features in this selected group exhibited organic GI disease following investigation. Assessment of alarm features in a comprehensive history is vital to reduce diagnostic uncertainty that can surround IBS.
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Affiliation(s)
- Purav Patel
- Leeds Gastroenterology Institute, St. James's University Hospital , Leeds , UK
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21
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Bajor A, Törnblom H, Rudling M, Ung KA, Simrén M. Increased colonic bile acid exposure: a relevant factor for symptoms and treatment in IBS. Gut 2015; 64:84-92. [PMID: 24727487 DOI: 10.1136/gutjnl-2013-305965] [Citation(s) in RCA: 142] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Bile acids may play a role in the pathogenesis of IBS. We investigated the potential effects of bile acids entering the colon and its role in the symptom pattern in IBS. DESIGN We measured 75Se-labelled homocholic acid-taurine (75SeHCAT) retention, and serum levels of 7α-hydroxy-4-cholesten-3-one (C4) and fibroblast growth factor (FGF) 19 in patients with IBS (n=141) and control subjects (75SeHCAT n=29; C4 and FGF19 n=435). In patients with IBS stool frequency and form, as well as GI symptom severity were registered, and in a proportion of patients colonic transit time and rectal sensitivity were measured (n=66). An 8-week open-label treatment with colestipol was offered to patients with 75SeHCAT <20%, and the effect of treatment was evaluated with IBS severity scoring system and adequate relief of IBS symptoms. RESULTS Compared with controls, patients with IBS had lower 75SeHCAT values (p=0.005), higher C4c levels (C4 corrected for cholesterol) (p<0.001), but similar FGF19 levels. Abnormal 75SeHCAT retention (<10%) was seen in 18% of patients, whereas 23% had elevated C4c levels. Patients with IBS with 75SeHCAT retention <10% had more frequent stools, accelerated colonic transit time, rectal hyposensitivity, a higher body mass index, higher C4c and lower FGF19 levels. Colestipol treatment improved IBS symptoms (IBS severity scoring system 220±109 vs. 277±106; p<0.01), and 15/27 patients fulfilled criteria for treatment response (adequate relief ≥50% of weeks 5-8). CONCLUSIONS Increased colonic bile acid exposure influences bowel habit and colonic transit time in patients with IBS. A high response rate to open label treatment with colestipol supports this, but placebo-controlled studies are warranted.
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Affiliation(s)
- Antal Bajor
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Hans Törnblom
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden University of Gothenburg Centre for Person-Centred Care (GPCC), Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mats Rudling
- Department of Medicine, Metabolism Unit, Center for Endocrinology, Metabolism, and Diabetes, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden Molecular Nutrition Unit, Department of Biosciences and Nutrition, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Kjell-Arne Ung
- Department of Internal Medicine, Medicine and R&D Unit, Skaraborgs Hospital, Skövde, Sweden
| | - Magnus Simrén
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden University of Gothenburg Centre for Person-Centred Care (GPCC), Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Gothe F, Beigel F, Rust C, Hajji M, Koletzko S, Freudenberg F. Bile acid malabsorption assessed by 7 alpha-hydroxy-4-cholesten-3-one in pediatric inflammatory bowel disease: correlation to clinical and laboratory findings. J Crohns Colitis 2014; 8:1072-8. [PMID: 24666974 DOI: 10.1016/j.crohns.2014.02.027] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Revised: 02/09/2014] [Accepted: 02/10/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Measurement of 7 alpha-hydroxy-4-cholesten-3-one (C4) in serum is a semiquantitative test for bile acid malabsorption (BAM). We have previously established pediatric normal values for C4 with an upper limit of normal of 66.5 ng/mL, independent of age and sex. Here we performed the C4 test in 58 pediatric patients with Crohn's disease (CD) and ulcerative colitis (UC). METHODS C4 was measured using high performance liquid chromatography (HPLC) in fasting serum samples of 44 patients with CD (range 7-19 years) and 14 with UC (4-18 years). Disease activity was assessed by the pediatric CD and UC activity indices (PCDAI and PUCAI, respectively) plus serum (CRP, ESR) and fecal inflammatory markers (calprotectin). RESULTS C4 concentrations were increased in 10 CD (23%) (range: 70.8-269.3 ng/mL) but only one UC patient (72.9 ng/mL). CD patients with diarrhea (n=12) had higher C4-values compared to those without (76.9 vs. 30.4 ng/mL; p=0.0043). Ileal resection in CD patients (n=10) was associated with increased C4 concentrations (81.2 vs. 24.3 ng/mL, p=0.0004). No correlation was found between C4 values and inflammatory markers. Six of 7 CD patients with persistent diarrhea but quiescent disease (PCDAI ≤12.5) had C4 values indicating BAM. CONCLUSION Elevated C4 concentrations indicating BAM are common in children with CD. They are associated with ileal resection and non-bloody diarrhea in the absence of active disease or elevated inflammatory markers. The C4-test identifies a subgroup of CD patients with persistent diarrhea in spite of clinical remission which may benefit from bile acid binding therapy.
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Affiliation(s)
- F Gothe
- Dr. von Hauner Children's Hospital, Division of Gastroenterology and Hepatology, Ludwig-Maximilians-University, Munich, Germany
| | - F Beigel
- Department of Medicine II, Klinikum Großhadern, Ludwig-Maximilians-University, Munich, Germany
| | - C Rust
- Department of Medicine II, Klinikum Großhadern, Ludwig-Maximilians-University, Munich, Germany
| | - M Hajji
- Dr. von Hauner Children's Hospital, Division of Gastroenterology and Hepatology, Ludwig-Maximilians-University, Munich, Germany
| | - S Koletzko
- Dr. von Hauner Children's Hospital, Division of Gastroenterology and Hepatology, Ludwig-Maximilians-University, Munich, Germany
| | - F Freudenberg
- Dr. von Hauner Children's Hospital, Division of Gastroenterology and Hepatology, Ludwig-Maximilians-University, Munich, Germany.
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Appleby RN, Walters JRF. The role of bile acids in functional GI disorders. Neurogastroenterol Motil 2014; 26:1057-69. [PMID: 24898156 DOI: 10.1111/nmo.12370] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 04/28/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Bile acids are increasingly implicated in the pathogenesis of functional GI disorders. New mechanisms have recently been described in the irritable bowel syndrome, chronic diarrhea and chronic idiopathic constipation. Identification of bile acid signaling through farnesoid X receptor (FXR), transmembrane G-coupled receptor 5 (TGR5) and fibroblast growth factor 19 (FGF19) has led to the development of new, directly acting therapeutic agents. Despite these advances primary bile acid diarrhea remains under-recognized partly because of the lack of a widely available diagnostic test. PURPOSE In this review we will summarize the effects of bile acids on bowel function throughout the gastrointestinal tract and their roles in the pathogenesis of functional diseases. We will review established diagnostic tests and therapies for functional heartburn, dyspepsia and bile acid diarrhea. There will be a particular emphasis on recent trial data for emerging therapies such as Elobixibat and Obeticholic acid and novel diagnostic tests for bile acid diarrhea such as 7α-Hydroxy-4-cholesten-3-one (C4) and FGF19. Finally we will discuss future directions for research in this rapidly evolving field, such as bacterial bile acid modification and identification of genetic anomalies associated with functional disorders.
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Affiliation(s)
- Richard N Appleby
- Section of Hepatology and Gastroenterology, Imperial College London, Imperial College Healthcare, Hammersmith Hospital, London, UK
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24
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Abstract
Chronic diarrhoea induced by bile acids is common and the underlying mechanisms are linked to homeostatic regulation of hepatic bile acid synthesis by fibroblast growth factor 19 (FGF19). Increasing evidence, including that from several large case series using SeHCAT (selenium homocholic acid taurine) tests for diagnosis, indicates that bile acid diarrhoea (BAD) accounts for a sizeable proportion of patients who would otherwise be diagnosed with IBS. Studies of other approaches for diagnosis of BAD have shown increased bile acid synthesis, increased faecal levels of primary bile acids, dysbiosis and different urinary volatile organic compounds when compared with healthy controls or with other diseases. The role of the ileal hormone FGF19 in BAD has been strengthened: a prospective clinical study has confirmed low FGF19 levels in BAD, and so a test to measure these levels could be developed for diagnosis. In animal models, FGF19 depletion by antibodies produces severe diarrhoea. Bile acids affect colonic function through farnesoid X receptor (FXR) and TGR5 receptors. As well as these effects in the colon, FXR-dependent stimulation of ileal FGF19 production could be a logical mechanism to provide therapeutic benefit in BAD. Further studies of FGF19 in humans hold promise in providing novel treatments for this cause of chronic diarrhoea.
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Abstract
Bile acids (BA) are actively reabsorbed in the terminal ileum by the apical Na(+)-dependent bile salt transporter. This review addresses the epidemiology, pathophysiology, diagnosis and treatment of BA diarrhea (BAD). BAD is typically caused by ileal resection or disease; 25-33% of patients with chronic functional diarrhea or irritable bowel syndrome-diarrhea (IBS-D) have BAD, possibly from deficiency in the ileal hormone, FGF-19, which normally provides feedback inhibition of BA synthesis. Diagnosis of BAD is typically based on reduced BA retention of radiolabeled BA ((75)SeHCAT), increased BA synthesis (serum C4) or increased fecal BA loss. In clinical practice, diagnosis is often based on response to BA sequestrants (e.g., cholestyramine or colesevelam). Diagnostic tests for BA malabsorption (BAM) need to be used more extensively in clinical practice. In the future, farnesoid X receptor agonists that stimulate ileal production of FGF-19 may be alternative treatments of BAD.
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Affiliation(s)
- Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Mayo Clinic, 200 First St. S.W., Charlton Bldg., Rm. 8-110, Rochester, MN 55905, USA
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26
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Freudenberg F, Gothe F, Beigel F, Rust C, Koletzko S. Serum 7-alpha-hydroxy-4-cholesten-3-one as a marker for bile acid loss in children. J Pediatr 2013; 163:1367-71.e1. [PMID: 23968740 DOI: 10.1016/j.jpeds.2013.06.083] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Revised: 05/21/2013] [Accepted: 06/28/2013] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To establish age-related reference values for 7-alpha-hydroxy-4-cholesten-3-one (C4) in a pediatric population and to investigate bile acid malabsorption in children with short bowel syndrome (SBS). STUDY DESIGN Serum was obtained between 8:00 a.m. and 11:00 a.m. from 100 healthy children (52% males, 9 months to 18 years of age) after 10 hours of fasting. Pediatric patients with SBS served as disease controls (n = 12). Following solid-phase extraction and purification, C4 was determined by high-performance liquid chromatography using a ultraviolet detector at a wavelength of 241 nm. The upper limit of normal for C4 concentrations was defined as the mean plus 2 SD of the log-normal distribution. RESULTS The mean concentration and SD of C4 in healthy children was 22.8 ± 15.8 ng/mL with no relation to age or sex and an upper limit of normal of 66.5 ng/mL. Normal C4 values were found in 97 of 100 healthy children, and all 12 patients with SBS had C4 concentrations above 100 ng/mL (mean 299.6 ± 167.8 ng/mL; range 105.7-562.1 ng/mL, P < .0001 compared with controls). CONCLUSIONS The determined upper limit of normal for C4 concentration in healthy children corresponds to previously published levels in healthy adults and is independent of age and sex. The consistently elevated C4 concentrations in our patients with SBS confirm the reliability of this noninvasive, nonisotopic method to assess bile acid malabsorption in children.
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Affiliation(s)
- Folke Freudenberg
- Department of Pediatric Gastroenterology and Hepatology, Dr von Hauner Children's Hospital, Ludwig-Maximilians University, Munich, Germany.
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Pattni SS, Brydon WG, Dew T, Johnston IM, Nolan JD, Srinivas M, Basumani P, Bardhan KD, Walters JRF. Fibroblast growth factor 19 in patients with bile acid diarrhoea: a prospective comparison of FGF19 serum assay and SeHCAT retention. Aliment Pharmacol Ther 2013; 38:967-76. [PMID: 23981126 DOI: 10.1111/apt.12466] [Citation(s) in RCA: 93] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Revised: 12/12/2012] [Accepted: 08/06/2013] [Indexed: 12/14/2022]
Abstract
BACKGROUND Bile acid diarrhoea is a common, under-diagnosed cause of chronic watery diarrhoea, responding to specific treatment with bile acid sequestrants. We previously showed patients with bile acid diarrhoea have lower median levels compared with healthy controls, of the ileal hormone fibroblast growth factor 19 (FGF19), which regulates bile acid synthesis. AIM To measure serum FGF19 and SeHCAT retention prospectively in patients with chronic diarrhoea. METHODS One hundred and fifty-two consecutive patients were grouped according to (75) Se-homocholic acid taurine (SeHCAT) 7-day retention: normal (>15%) in 72 (47%) diarrhoea controls; ≤15% in 54 (36%) with primary bile acid diarrhoea, and in 26 (17%) with secondary bile acid diarrhoea. Fasting blood was assayed for FGF19, 7α-hydroxy-4-cholesten-3-one (C4) and total bile acids. RESULTS FGF19 was significantly lower in the primary bile acid diarrhoea group compared with the diarrhoea control group (median 147 vs. 225 pg/mL, P < 0.001), and also in the secondary group (P < 0.006). FGF19 and SeHCAT values were positively correlated (rs = 0.44, P < 0.001); both were inversely related to C4. Other significant relationships included SeHCAT and body mass index (BMI)(P = 0.02), and FGF19 with age (P < 0.01). The negative and positive predictive values of FGF19 ≤ 145 pg/mL for a SeHCAT <10% were 82% and 61%, respectively, and were generally improved in an index including BMI, age and C4. In a subset of 28 primary patients, limited data suggested that FGF19 could predict response to sequestrant therapy. CONCLUSIONS Reduced fibroblast growth factor 19 is a feature of bile acid diarrhoea. Further studies will fully define its role in predicting the response of these patients to therapy.
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Affiliation(s)
- S S Pattni
- Department of Medicine, Section of Hepatology & Gastroenterology, Imperial College London & Imperial College Healthcare, London, UK
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Recycling rate of bile acids in the enterohepatic recirculation as a major determinant of whole body 75SeHCAT retention. Eur J Nucl Med Mol Imaging 2013; 40:1618-21. [PMID: 23740376 DOI: 10.1007/s00259-013-2466-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2013] [Accepted: 05/14/2013] [Indexed: 12/12/2022]
Abstract
Measurement of the whole body retention of orally administered (75)SeHCAT is used to investigate patients with unexplained diarrhoea. Retention values of <15 % at 7 days post-administration are taken to indicate bile acid malabsorption (BAM). Whilst idiopathic BAM is frequently diagnosed with (75)SeHCAT, functional and morphological studies of the terminal ileum rarely show any abnormality, so the disorder may be more appropriately termed bile acid diarrhoea (BAD). In addition to malabsorption, excess bile acid may reach the colon, where the events leading to diarrhoea take place, as a result firstly of increased bile acid synthesis and secondly of an increased recycling rate of bile acids. Increased recycling has been largely ignored as a cause of BAD, but, as shown in this study, can readily result in excess bile acids reaching the colon even when ileal absorption efficiency is normal (i.e. 95-97 %). There needs to be a re-evaluation of the causes of BAD in patients without a history of previous intestinal resection or evidence of ileal pathology, such as Crohn's disease.
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Stotzer PO, Abrahamsson H, Bajor A, Sadik R. Effect of Cholestyramine on Gastrointestinal Transit in Patients with Idiopathic Bile Acid Diarrhea: A Prospective, Open-Label Study. ACTA ACUST UNITED AC 2013. [DOI: 10.4303/ne/235657] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Gracie DJ, Kane JS, Mumtaz S, Scarsbrook AF, Chowdhury FU, Ford AC. Prevalence of, and predictors of, bile acid malabsorption in outpatients with chronic diarrhea. Neurogastroenterol Motil 2012; 24:983-e538. [PMID: 22765392 DOI: 10.1111/j.1365-2982.2012.01953.x] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Many physicians do not consider the diagnosis of bile acid malabsorption in patients with chronic diarrhea, or do not have access to testing. We examined yield of 23-seleno-25-homo-tauro-cholic acid (SeHCAT) scanning in chronic diarrhea patients, and attempted to identify predictors of a positive test. METHODS Consecutive patients with chronic diarrhea undergoing SeHCAT scan over a 7-year period were identified retrospectively. Bile acid malabsorption was defined as present at a retention of <15%. Medical records were reviewed to obtain information regarding proposed risk factors. Gastrointestinal symptoms were recorded, and patients were classified as having diarrhea-predominant irritable bowel syndrome (IBS-D) if they reported abdominal pain or discomfort. Independent risk factors were assessed using multivariate logistic regression, and odds ratios (ORs) with 99% confidence intervals (CIs) were calculated. KEY RESULTS Of 373 patients, 190 (50.9%) had bile acid malabsorption. Previous cholecystectomy (OR 2.51; 99% CI 1.10-5.77), terminal ileal resection or right hemicolectomy for Crohn's disease (OR 12.4; 99% CI 2.42-63.8), and terminal ileal resection or right hemicolectomy for other reasons (OR 7.94; 99% CI 1.02-61.6) were associated with its presence. Seventy-seven patients had IBS-D, and 21 (27.3%) tested positive. There were 168 patients with no risk factors for a positive SeHCAT scan, other than chronic diarrhea, and 63 (37.5%) had bile acid malabsorption. CONCLUSIONS & INFERENCES Bile acid malabsorption was present in 50% of patients undergoing SeHCAT scanning. Almost 40% of those without risk factors had evidence of bile acid malabsorption, and in those meeting criteria for IBS-D prevalence was almost 30%.
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Affiliation(s)
- D J Gracie
- Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, UK
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31
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Abstract
Bile acid malabsorption occurs when there is impaired absorption of bile acids in the terminal ileum, so interrupting the normal enterohepatic circulation. The excess bile acids in the colon cause diarrhea, and treatment with bile acid sequestrants is beneficial. The condition can be diagnosed with difficulty by measuring fecal bile acids, or more easily by retention of selenohomocholyltaurine (SeHCAT), where this is available. Chronic diarrhea caused by primary bile acid diarrhea appears to be common, but is under-recognized where SeHCAT testing is not performed. Measuring excessive bile acid synthesis with 7α-hydroxy-4-cholesten-3-one may be an alternative means of diagnosis. It appears that there is no absorption defect in primary bile acid diarrhea but, instead, an overproduction of bile acids. Fibroblast growth factor 19 (FGF19) inhibits hepatic bile acid synthesis. Defective production of FGF19 from the ileum may be the cause of primary bile acid diarrhea.
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Bjørnbak C, Engel PJH, Nielsen PL, Munck LK. Microscopic colitis: clinical findings, topography and persistence of histopathological subgroups. Aliment Pharmacol Ther 2011; 34:1225-34. [PMID: 21967618 DOI: 10.1111/j.1365-2036.2011.04865.x] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Uncertainty remains on topography and persistence of histological subgroups of microscopic colitis (MC). AIM To assess longitudinal clinical, endoscopic, histological, and therapeutic description of MC subgroups including patients with incomplete findings of MC (MCi). METHODS Retrospective review of a consecutive cohort with MC and histological reassessment of MCi. RESULTS Clinical characteristics of 168 patients with lymphocytic colitis (LC), 270 with collagenous colitis (CC) and 101 with MCi were similar. At colonoscopy 95% (95% CI: 91-98%) of CC and 98% (93-100%) of LC cases had diagnostic histopathology of MC in both left and right colon. Eight and three patients had characteristics of MC only in the left and right colon, respectively. Histology findings resembling coexistence of the other MC subtype was present in 48% (40-55%) with CC and 24% (18-31%) with LC. A first diagnosis of MC was made in 49 (30%) of 164 patients only at repeat endoscopy. Another 34 of 115 (30%) with MC in the first endoscopy did not fulfil the MC criteria at repeat endoscopy. Only seven cases had a primary endoscopy without histopathological abnormalities. Fifteen percentage of MCi were reclassified as MC. Ileal inflammation was present in 33 of 81 patients. Budesonide was efficacious in all MC subgroups irrespective of bile acid malabsorption. CONCLUSIONS Clinical characteristics of microscopic colitis subgroups are indistinguishable. Biopsies from the left colon suffice to exclude microscopic colitis, and the histological diagnosis of microscopic colitis is inconsistent over time. Ileal inflammation is common. The term microscopic colitis should perhaps be considered one clinical entity and include lymphocytic colitis, collagenous colitis, and incomplete findings of microscopic colitis.
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Affiliation(s)
- C Bjørnbak
- Section of Gastroenterology, Department of Medicine, Køge Hospital, Køge, Denmark
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An evaluation of the use of serum 7-alpha-hydroxycholestenone as a diagnostic test of bile acid malabsorption causing watery diarrhea. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2011; 25:319-23. [PMID: 21766092 DOI: 10.1155/2011/701287] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Bile acid malabsorption (BAM) is a recognized cause of watery diarrhea, often diagnosed empirically based on clinical response to cholestyramine. The radionuclide selenium-labelled homocholic acid-taurine whole body retention test is expensive, labour intensive and of limited availability. OBJECTIVE To report on the clinical performance of serum 7-alphahydroxy-4-cholesten-3-one (7HCO) as a test of BAM in adult patients with unexplained diarrhea. METHODS Patients with unexplained diarrhea were investigated over a three-year period. Final diagnosis was determined based on medical history and investigations, serum levels of 7HCO and response to cholestyramine. ROC analysis was used to determine the ideal upper reference range cut-off value to optimize sensitivity/specificity for BAM. Time of blood specimen collection was recorded to investigate possible variation in results throughout the working day. RESULTS ROC analysis yielded a sensitivity/specificity of 90%/77% for type 1 BAM (ileal disease/resection) and 97%/74% for type 2 BAM (idiopathic) using 30 ng/mL as the upper limit of normal for serum 7HCO when compared with all other patients. Of 813 patients, 196 tested positive. Serum 7HCO levels were significantly higher in blood specimens that were collected between 12:00 and 13:00 (median 24 ng/mL) than in specimens collected between 09:00 and 10:00 (median 17 ng/mL) (P<0.05). CONCLUSION Serum 7HCO testing is a simple, sensitive, noninvasive, inexpensive alternative to other more commonly used tests for BAM. Time of specimen collection, however, resulted in small but significant result variations and, although unlikely to have much impact on test value, it should ideally be standardized.
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Lenicek M, Duricova D, Komarek V, Gabrysova B, Lukas M, Smerhovsky Z, Vitek L. Bile acid malabsorption in inflammatory bowel disease: assessment by serum markers. Inflamm Bowel Dis 2011; 17:1322-7. [PMID: 21058331 DOI: 10.1002/ibd.21502] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2010] [Accepted: 08/23/2010] [Indexed: 12/31/2022]
Abstract
BACKGROUND Bile acid malabsorption (BAM) is a common feature of Crohn's disease (CD). We aimed to determine whether BAM develops only in patients with a resected distal ileum or if it also occurs in patients who have not undergone surgery for CD. METHODS The study included 347 patients with CD or ulcerative colitis (UC) and 119 healthy subjects (controls). BAM was assessed by measurement of serum levels of 7α-hydroxycholest-4-en-3-one (C4) and fibroblast growth factor 19 (FGF19). We surveyed members of the European Crohn's and Colitis Organization and International Organization for the Study of Inflammatory Bowel Disease to collect current information about BAM diagnosis. RESULTS The severity of BAM was associated with resection of the distal ileum. Compared with controls, patients who received moderate or extensive ileal resection had significantly increased levels of serum C4 (12 versus 62 versus 243 μg/L, respectively; P < 0.001). However, BAM was also present in a substantial number of the patients with CD who were not treated by surgery who had ileitis or colitis (14% and 11%, respectively). There was an indirect, proportional relationship between levels of C4 and FGF19 (P < 0.001). CONCLUSIONS The most severe BAM occurs in CD patients after resection of the distal ileum, but BAM can occur in surgically untreated CD patients, regardless of disease localization. Laboratory tests for BAM should become a part of the algorithm for diagnosis of CD to identify patients who might respond to therapies such as bile acid sequestrants. FGF19 appears to be a reliable marker of BAM.
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Affiliation(s)
- Martin Lenicek
- Department of Clinical Biochemistry and Laboratory Diagnostics, 1st Faculty of Medicine, Charles University in Prague, Czech Republic
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Abstract
Bowel symptoms including diarrhoea can be produced when excess bile acids (BA) are present in the colon. This condition, known as bile acid or bile salt malabsorption, has been under recognized, as the best diagnostic method, the (75)Se-homocholic acid taurine (SeHCAT) test, is not available in many countries and is not fully utilized in others. Reduced SeHCAT retention establishes that this is a complication of many other gastrointestinal diseases. Repeated studies show SeHCAT tests are abnormal in about 30% of patients otherwise diagnosed as diarrhoea-predominant irritable bowel syndrome or functional diarrhoea, with an estimated population prevalence of around 1%. Recent work suggests that the condition previously called idiopathic bile acid malabsorption (BAM) is not in fact due to a defect in absorption, but results from an overproduction of BA because of defective feedback inhibition of hepatic bile acid synthesis, a function of the ileal hormone fibroblast growth factor 19 (FGF19). The approach to treatment currently depends on binding excess BA, to reduce their secretory actions, using colestyramine, colestipol and, most recently, colesevelam. Colesevelam has a number of potential advantages that merit further investigation in trials directed at patients with bile acid diarrhoea.
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Affiliation(s)
- Julian R. F. Walters
- Section of Hepatology and Gastroenterology, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
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Walters JRF. Defining primary bile acid diarrhea: making the diagnosis and recognizing the disorder. Expert Rev Gastroenterol Hepatol 2010; 4:561-7. [PMID: 20932141 DOI: 10.1586/egh.10.54] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Chronic diarrhea due to bile acid malabsorption may be considered as contributing to the diagnosis when it results from secondary causes, such as ileal resection affecting the enterohepatic circulation. However, the primary form (also known as idiopathic bile acid malabsorption) is not well recognized as a common condition and patients are left undiagnosed. Primary bile acid diarrhea can be diagnosed by the nuclear medicine 75Se-homocholyltaurine (SeHCAT) test, although this is unavailable or underutilized in many settings. A systematic review suggests that approximately 30% of patients who would otherwise be diagnosed with diarrhea-predominant irritable bowel syndrome or functional diarrhea have abnormal SeHCAT retention. Serum 7α-hydroxy-4-cholesten-3-one can also be measured to show increased bile acid synthesis. The reasons for the lack of recognition of primary bile acid diarrhea are discussed, and these are compared with the other common cause of malabsorption, celiac disease. The lack of a clear pathophysiological mechanism has been a problem, but recent evidence suggests that impaired feedback control of hepatic bile acid synthesis by the ileal hormone FGF19 results in overproduction of bile acids. The identification of FGF19 as the central mechanism opens up new areas for development in the diagnosis and treatment of primary bile acid diarrhea.
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Affiliation(s)
- Julian R F Walters
- Section of Hepatology & Gastroenterology, Department of Medicine, Imperial College London and, Imperial College Healthcare, London, UK.
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Abstract
Bile acids have secretory, motility and antimicrobial effects in the intestine. In patients with bile acid malabsorption the amount of primary bile acids in the colon is increased compared to healthy controls. Deoxycholic acid is affecting the intestinal smooth muscle activity. Chenodeoxycholic acid has the highest potency to affect intestinal secretion. Litocholic acid has little effect in the lumen of intestine compared to both deoxycholic acid and chenodeoxycholic acid. There is no firm evidence that clinically relevant concentrations of bile acids induce colon cancer. Alterations in bile acid metabolism may be involved in the pathophysiology of constipation.
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Affiliation(s)
- Antal Bajor
- Department of Internal Medicine, Sahlgrenska University Hospital, Göteborg, Sweden
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Hofmann AF, Mangelsdorf DJ, Kliewer SA. Chronic diarrhea due to excessive bile acid synthesis and not defective ileal transport: a new syndrome of defective fibroblast growth factor 19 release. Clin Gastroenterol Hepatol 2009; 7:1151-4. [PMID: 19665580 PMCID: PMC2850200 DOI: 10.1016/j.cgh.2009.07.026] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2009] [Revised: 07/16/2009] [Accepted: 07/27/2009] [Indexed: 02/07/2023]
Affiliation(s)
- Alan F. Hofmann
- Department of Medicine, University of California, San Diego 92093-063
| | - David J. Mangelsdorf
- Department of Pharmacology, University of Texas, Southwestern Medical Center, Dallas,Department of Howard Hughes Medical Institute, University of Texas, Southwestern Medical Center, Dallas
| | - Steven A. Kliewer
- Department of Pharmacology, University of Texas, Southwestern Medical Center, Dallas,Department of Molecular Biology, University of Texas, Southwestern Medical Center, Dallas
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Walters JRF, Tasleem AM, Omer OS, Brydon WG, Dew T, le Roux CW. A new mechanism for bile acid diarrhea: defective feedback inhibition of bile acid biosynthesis. Clin Gastroenterol Hepatol 2009; 7:1189-94. [PMID: 19426836 DOI: 10.1016/j.cgh.2009.04.024] [Citation(s) in RCA: 241] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2008] [Revised: 04/14/2009] [Accepted: 04/20/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Primary (idiopathic) bile acid malabsorption (BAM) is a common, yet underrecognized, chronic diarrheal syndrome. Diagnosis is difficult without selenium homocholic acid taurine (SeHCAT) testing. The diarrhea results from excess colonic bile acids, but the pathogenesis is unclear. Fibroblast growth factor 19 (FGF19), produced in the ileum in response to bile acid absorption, regulates hepatic bile acid synthesis. We proposed that FGF19 is involved in bile acid diarrhea and measured its levels in patients with BAM. METHODS Blood was collected from fasting patients with chronic diarrhea; BAM was diagnosed by SeHCAT. Serum FGF19 was measured by enzyme-linked immunosorbent assay. Serum 7alpha-hydroxy-4-cholesten-3-one (C4) was determined using high-performance liquid chromatography, to quantify bile acid synthesis. Data were compared between patients and subjects without diarrhea (controls). Samples were taken repeatedly after meals from several subjects. RESULTS The median C4 level was significantly higher in patients with primary BAM than in controls (51 vs 18 ng/mL; P < .0001). The median FGF19 level was significantly lower in patients with BAM (120 vs 231 pg/mL; P < .0005). There was a significant inverse relationship between FGF19 and C4 levels (P < .0004). Low levels of FGF19 were also found in patients with postcholecystectomy and secondary bile acid diarrhea. Abnormal patterns of FGF19 levels were observed throughout the day in some patients with primary BAM. CONCLUSIONS Patients with BAM have reduced serum FGF19 which may be useful in diagnosis. We propose a mechanism whereby impaired FGF19 feedback inhibition causes excessive bile acid synthesis that exceeds the normal capacity for ileal reabsorption, producing bile acid diarrhea.
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Affiliation(s)
- Julian R F Walters
- Department of Gastroenterology, Imperial College, London, United Kingdom.
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Bajor A, Ung KA, Ohman L, Simren M, Thomas EA, Bornstein JC, Sjövall H. Indirect evidence for increased mechanosensitivity of jejunal secretomotor neurones in patients with idiopathic bile acid malabsorption. Acta Physiol (Oxf) 2009; 197:129-37. [PMID: 19432585 DOI: 10.1111/j.1748-1716.2009.01993.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM The interdigestive motor rhythm, the migrating motor complex (MMC), is accompanied by active secretion of chloride during periods of distally propagating maximal motor activity (MMC phase III). We studied the behaviour of this system in bile acid malabsorption (BAM), a relative common cause of chronic diarrhoea. We measured motor activity and transmucosal potential difference (PD, reflecting active chloride secretion), in the proximal jejunum in healthy controls (n = 18) and in a group of patients with BAM (n = 11). The phase III-generated voltage was related to the degree of BAM quantified by the (75)SeHCAT test. METHODS We used a multi-channel intestinal infusion system to simultaneously measure jejunal pressure and PD. Saline passing calomel half-cells was infused into the jejunum and subcutaneously. Pressure and PD were recorded in the fasting state and after a test meal. RESULTS In the absence of motor activity, jejunal PD was not significantly different from zero in either group. During MMC phase III, PD reached significantly higher mean and peak levels in BAM patients. The product of MMC phase III length multiplied by voltage, over 3 h, was also significantly higher in BAM patients (controls: median 307 mV x cm, range 70-398; BAM: median 511, range 274-2271, P < 0.01). This value was also significantly correlated with the degree of BAM as reflected by the (75)SeHCAT test (P < 0.05). CONCLUSION Phase III induced jejunal secretion may be upregulated in BAM patients, resulting in overload of colonic reabsorption capacity.
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Affiliation(s)
- A Bajor
- Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Hofmann AF. Chronic diarrhea caused by idiopathic bile acid malabsorption: an explanation at last. Expert Rev Gastroenterol Hepatol 2009; 3:461-4. [PMID: 19817666 DOI: 10.1586/egh.09.49] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
INTRODUCTION Bile acid malabsorption (BAM) is a syndrome of chronic watery diarrhoea with excess faecal bile acids. Disruption of the enterohepatic circulation of bile acids following surgical resection is a common cause of BAM. The condition is easily diagnosed by the selenium homocholic acid taurine (SeHCAT) test and responds to bile acid sequestrants. Idiopathic BAM (IBAM, primary bile acid diarrhoea) is the condition where no definitive cause for low SeHCAT retention can be identified. SOURCES OF DATA Review of PubMed and major journals. AREAS OF AGREEMENT Evidence is accumulating that BAM is more prevalent than first thought. Management of chronic diarrhoea involves excluding secondary causes. Treatment of the condition is with bile acid binders. AREAS OF CONTROVERSY SeHCAT testing is not widely performed, limiting awareness of how common this condition can be. The underlying mechanism for IBAM has been unclear. GROWING POINTS Increasing awareness of the condition is important. Alternative mechanisms of IBAM have been suggested which involve an increased bile acid pool size and reduced negative feedback regulation of bile acid synthesis by FGF19. New sequestrants are available. AREAS TIMELY FOR DEVELOPING RESEARCH Further research into the precise mechanism of IBAM is needed. Improvements in the recognition of the condition and optimization of treatment are required.
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Affiliation(s)
- Sanjeev Pattni
- Department of Gastroenterology, Hammersmith Hospital, Imperial Healthcare NHS Trust, London W12 0HS, UK
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Bajor A, Kilander A, Sjövall H, Rudling M, Ung KA. The bile acid turnover rate assessed with the (75)SeHCAT test is stable in chronic diarrhoea but slightly decreased in healthy subjects after a long period of time. Dig Dis Sci 2008; 53:2935-40. [PMID: 18437571 DOI: 10.1007/s10620-008-0256-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2008] [Accepted: 03/26/2008] [Indexed: 12/09/2022]
Abstract
The stability of bile acid turnover rate was evaluated retrospectively using repeat SeHCAT tests in patients with chronic diarrhoea and prospectively for 16 years in healthy subjects. The SeHCAT values were stable in 39 patients with chronic diarrhoea, as shown by a comparison of the test results [data presented as median and (25th-75th percentile)]: 18% (8-23) in the first test versus 14% (9-21) in the second test [n = 39, P = 0.37, time interval 44 months (16-68), repeatability index >95%]. In contrast, they were reduced after 16 years in healthy subjects: 38% (30-49.5) in the first test versus 31% (21-49.5) in the second test (P < 0.03). In healthy subjects, the body mass index increased by 13% from 23.2 kg/m(2) (21-24.6) to 26.2 kg/m(2) (22.5-27.8) (P < 0.01) during the 16 years. There was a negative correlation between hepatic bile acid synthesis and the SeHCAT values (r = -0.615, P = 0.02, n = 14). In conclusion, the turnover rate of bile acids is stable over a long period of time in patients with chronic diarrhoea irrespective of bile acid malabsorption, suggesting that a repeat SeHCAT test is dispensable. There is a significant negative correlation between bile acid synthesis and SeHCAT test results in healthy subjects. The SeHCAT test values are slightly reduced in healthy subjects after 16 years.
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Affiliation(s)
- Antal Bajor
- Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, 41345, Gothenburg, Sweden.
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Exploring possible mechanisms for primary bile acid malabsorption: evidence for different regulation of ileal bile acid transporter transcripts in chronic diarrhoea. Eur J Gastroenterol Hepatol 2008; 20:413-22. [PMID: 18403943 DOI: 10.1097/meg.0b013e3282f41b82] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Chronic diarrhoea resulting from primary idiopathic bile acid malabsorption (IBAM) is common, but its aetiology is largely unknown. We investigated possible mechanisms, first looking for common sequence variations in the cytoplasmic ileal bile acid-binding protein (IBABP, gene symbol FABP6), and secondly, determining the expression of ileal mucosal transcripts for the apical sodium-linked bile acid transporter (ASBT), IBABP, the putative basolateral transporters, OSTalpha and OSTbeta, and regulatory factors. METHODS Genomic DNA was prepared from two cohorts of patients and two control groups; the promoter and exonic regions of FABP6 were sequenced. In intestinal biopsies, transcript expression was measured by quantitative real time-PCR, using ileum from 17 patients and 21 controls. RESULTS Sequence variations were identified in FABP6, but overall frequencies were similar in patients and controls. Transcripts of ASBT and IBABP, but not OSTalpha and OSTbeta, were expressed at higher levels in ileum than duodenum. The transcription factors farnesoid-X-receptor (FXR) and liver-receptor-homologue (LRH-1) were also more abundant in ileum, as was fibroblast growth factor 19 (FGF19), unlike short heterodimer partner (SHP), c-Fos, or CDX2. No significant differences in mean or median values were found between the groups for any of these transcripts. However, findings on regression analysis suggested that these transporters differ in their regulation, particularly in the relationships of CDX2, LRH-1 and FXR with OSTalpha. CONCLUSION Most cases of IBAM are unlikely to be caused by genetic variation in FABP6 or by major differences in transporter transcript expression. Our evidence indicates that other factors, such as regulation of expression of the basolateral bile acid transporter, should be considered as possible causes.
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Montagnani M, Abrahamsson A, Gälman C, Eggertsen G, Marschall HU, Ravaioli E, Einarsson C, Dawson PA. Analysis of ileal sodium/bile acid cotransporter and related nuclear receptor genes in a family with multiple cases of idiopathic bile acid malabsorption. World J Gastroenterol 2006; 12:7710-4. [PMID: 17171805 PMCID: PMC4088058 DOI: 10.3748/wjg.v12.i47.7710] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The etiology of most cases of idiopathic bile acid malabsorption (IBAM) is unknown. In this study, a Swedish family with bile acid malabsorption in three consecutive generations was screened for mutations in the ileal apical sodium-bile acid cotransporter gene (ASBT; gene symbol, SLC10A2) and in the genes for several of the nuclear receptors known to be important for ASBT expression: the farnesoid X receptor (FXR) and peroxisome proliferator activated receptor alpha (PPARα). The patients presented with a clinical history of idiopathic chronic watery diarrhea, which was responsive to cholestyramine treatment and consistent with IBAM. Bile acid absorption was determined using 75Se-homocholic acid taurine (SeHCAT); bile acid synthesis was estimated by measuring the plasma levels of 7α-hydroxy-4-cholesten-3-one (C4). The ASBT, FXR, and PPARα genes in the affected and unaffected family members were analyzed using single stranded conformation polymorphism (SSCP), denaturing HPLC, and direct sequencing. No ASBT mutations were identified and the ASBT gene did not segregate with the bile acid malabsorption phenotype. Similarly, no mutations or polymorphisms were identified in the FXR or PPARα genes associated with the bile acid malabsorption phenotype. These studies indicate that the intestinal bile acid malabsorption in these patients cannot be attributed to defects in ASBT. In the absence of apparent ileal disease, alternative explanations such as accelerated transit through the small intestine may be responsible for the IBAM.
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Affiliation(s)
- Marco Montagnani
- Dipartimento di Medicina Interna e Gastroenterologia, Università di Bologna, Bologna, Italy
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Bajor A, Kilander A, Gälman C, Rudling M, Ung KA. Budesonide treatment is associated with increased bile acid absorption in collagenous colitis. Aliment Pharmacol Ther 2006; 24:1643-9. [PMID: 17094773 DOI: 10.1111/j.1365-2036.2006.03168.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Bile acid malabsorption is frequent in collagenous colitis and harmful bile acids may play a pathophysiological role. Glucocorticoids increase ileal bile acid transport. Budesonide have its main effect in the terminal ileum. AIMS To evaluate whether the symptomatic effect of budesonide is linked to increased uptake of bile acids. METHODS Patients with collagenous colitis were treated with budesonide 9 mg daily for 12 weeks. Prior to and after 8 weeks of treatment, the (75)SeHCAT test, an indirect test for the active uptake of bile acid-s, measurements of serum 7alpha-hydroxy-4-cholesten-3-one, an indicator of hepatic bile acid synthesis, and registration of symptoms were performed. RESULTS The median (75)SeHCAT retention increased from 18% to 35% (P < 0.001, n = 25) approaching the values of healthy controls (38%). The 7alpha-hydroxy-4-cholesten-3-one values decreased significantly among those with initially high synthesis (from 36 to 23 ng/mL, P = 0.04, n = 9); however, for the whole group the values were not altered (19 ng/mL vs. 13 ng/mL, P = 0.23, N.S., n = 19). CONCLUSION The normalization of the (75)SeHCAT test and the reduction of bile acid synthesis in patients with initially high synthetic rate, suggests that the effect of budesonide in collagenous colitis may be in part due to decreased bile acid load on the colon.
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Affiliation(s)
- A Bajor
- Department of Internal Medicine, Sahlgrenska University Hospital, Göteborg, Sweden.
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