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Kim HJ, Kim HJ. [Bile Acid Diarrhea]. THE KOREAN JOURNAL OF GASTROENTEROLOGY = TAEHAN SOHWAGI HAKHOE CHI 2024; 83:133-142. [PMID: 38659249 DOI: 10.4166/kjg.2023.119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 12/17/2023] [Accepted: 12/18/2023] [Indexed: 04/26/2024]
Abstract
Diarrhea is a very common gastrointestinal symptom, and the presence of higher concentrations of bile acid in the colon leads to bile acid diarrhea (BAD). In BAD patients, a portion of bile from the small intestine that is normally controlled by enterohepatic circulation is present at a high concentration in the lumen of the large intestine, resulting in increased motility and secretion of the large intestine. The prevalence of BAD is estimated to be 1-2% of the general population, and it comprises one-third of the instances of diarrhea-predominant irritable bowel syndrome. The clinical symptoms of BAD include chronic diarrhea, increased frequency of defecation, urgency to defecate, fecal incontinence, and cramping abdominal pain. The pathophysiology of BAD has not yet been fully elucidated. However, recent studies have reported increased intestinal permeability, shortened intestinal transit time, and changes in the intestinal microbial community to be the possible causes of BAD. Although fecal and serum bile acid tests are widely used for diagnosis, new test methods that are non-invasive, inexpensive, and have high sensitivity and specificity are needed at various institutions to facilitate the diagnosis. The selenium homo-tauro-cholic acid (SeHCAT) test is the gold standard for BAD diagnosis and severity assessment. The validation of several other serum markers, such as 7-hydroxy-4-cholesten-3-one (serum 7αC4) and the fibroblast growth factor 19 (FGF19) for use in clinical practice is ongoing. Although bile acid sequestrants are the mainstay of treatment, the development of drugs that are more effective and have better compliance is required. Farnesoid X receptor (FXR) agonists are showing promising results.
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Affiliation(s)
- Hee Jin Kim
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Gyeongsang National University College of Medicine, Changwon, Korea
| | - Hyun Jin Kim
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Gyeongsang National University College of Medicine, Changwon, Korea
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Borup C, Vinter-Jensen L, Jørgensen SPG, Wildt S, Graff J, Gregersen T, Zaremba A, Andersen TB, Nøjgaard C, Timm HB, Lamazière A, Rainteau D, Hansen SH, Rumessen JJ, Munck LK. Prospective comparison of diagnostic tests for bile acid diarrhoea. Aliment Pharmacol Ther 2024; 59:39-50. [PMID: 37794830 DOI: 10.1111/apt.17739] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 05/23/2023] [Accepted: 09/21/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND Bile acid diarrhoea is often missed because gold standard nuclear medicine tauroselcholic [75-Se] acid (SeHCAT) testing has limited availability. Empirical treatment effect has unknown diagnostic performance, whereas plasma 7α-hydroxy-4-cholesten-3-one (C4) is inexpensive but lacks sensitivity. AIMS To determine diagnostic characteristics of empirical treatment and explore improvements in diagnostics with potential better availability than SeHCAT. METHODS This diagnostic accuracy study was part of a randomised, placebo-controlled trial of colesevelam. Consecutive patients with chronic diarrhoea attending SeHCAT had blood and stool sampled. Key thresholds were C4 > 46 ng/mL and SeHCAT retention ≤10%. A questionnaire recorded patient-reported empirical treatment effect. We analysed receiver operating characteristics and explored machine learning applied logistic regression and decision tree modelling with internal validation. RESULTS Ninety-six (38%) of 251 patients had SeHCAT retention ≤10%. The effect of empirical treatment assessed with test results for bile acid studies blinded had 63% (95% confidence interval 44%-79%) sensitivity and 65% (47%-80%) specificity; C4 > 46 ng/mL had 47% (37%-57%) and 92% (87%-96%), respectively. A decision tree combining C4 ≥ 31 ng/mL with ≥1.1 daily watery stools (Bristol type 6 and 7) had 70% (51%-85%) sensitivity and 95% (83%-99%) specificity. The logistic regression model, including C4, the sum of measured stool bile acids and daily watery stools, had 77% (58%-90%) sensitivity and 93% (80%-98%) specificity. CONCLUSIONS Diagnosis of bile acid diarrhoea using empirical treatment was inadequate. Exploration suggested considerable improvements in the sensitivity of C4-based testing, offering potential widely available diagnostics. Further validation is warranted. CLINICALTRIALS gov: NCT03876717.
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Affiliation(s)
- Christian Borup
- Department of Internal Medicine, Zealand University Hospital, Køge, Køge, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Lars Vinter-Jensen
- Department of Medical Gastroenterology, Aalborg University Hospital, Aalborg, Denmark
| | | | - Signe Wildt
- Unit of Medical and Surgical Gastroenterology, Hvidovre University Hospital, Hvidovre, Denmark
| | - Jesper Graff
- Department of Clinical Physiology and Nuclear Medicine, Hvidovre University Hospital, Hvidovre, Denmark
| | - Tine Gregersen
- Department of Nuclear Medicine and PET, Aarhus University Hospital, Aarhus, Denmark
| | - Anna Zaremba
- Department of Medical Gastroenterology, Aalborg University Hospital, Aalborg, Denmark
| | | | - Camilla Nøjgaard
- Unit of Medical and Surgical Gastroenterology, Hvidovre University Hospital, Hvidovre, Denmark
| | - Hans Bording Timm
- Unit of Medical and Surgical Gastroenterology, Hvidovre University Hospital, Hvidovre, Denmark
| | - Antonin Lamazière
- Département de Métabolomique Clinique METOMICS, Hôpital Saint Antoine, Sorbonne University, Paris, France
| | - Dominique Rainteau
- Département de Métabolomique Clinique METOMICS, Hôpital Saint Antoine, Sorbonne University, Paris, France
| | - Svend Høime Hansen
- Department of Clinical Biochemistry, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | - Lars Kristian Munck
- Department of Internal Medicine, Zealand University Hospital, Køge, Køge, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Lupianez-Merly C, Dilmaghani S, Camilleri M. Recent developments in diagnosing bile acid diarrhea. Expert Rev Gastroenterol Hepatol 2023; 17:1185-1195. [PMID: 38086533 DOI: 10.1080/17474124.2023.2293814] [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: 09/21/2023] [Accepted: 12/08/2023] [Indexed: 01/19/2024]
Abstract
INTRODUCTION Bile acid diarrhea (BAD) commonly causes chronic diarrhea. Symptoms may be mistaken for disorders of gut brain interaction. Due to the lack of widely available diagnostic tests and poor recognition of BAD, there is a delay in diagnosis leading to increased healthcare system burden and decreased patient quality of life. AREAS COVERED A thorough review of the literature was conducted using PubMed for articles on the biological functions of bile acids, pathophysiology and management of BAD, but focusing on diagnostic testing including 75SeHCAT retention, 7αC4, FGF-19, fecal bile acids, and single stool tests. This narrative review discusses available modalities focusing on noninvasive stool and serum testing that are more widely available and show good sensitivity and specificity for diagnosis of BAD. 75SeHCAT retention is not available in many countries. Alternative diagnostic tests include total and primary fecal bile acid (BA) excretion in 48-hour collection or a single stool sample, serum7αC4 >46 or 52.5 ng/mL, and combination of single stool and serum 7αC4 ±watery stools (Bristol Stool Form Scale 6-7). EXPERT OPINION Given the ease of serum and single stool sample acquisition and diagnostic advances, clinical practice should embrace positive diagnosis, rather than BAS therapeutic trial. BAD needs to be considered in diverse gastrointestinal diseases.
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Affiliation(s)
- Camille Lupianez-Merly
- Division of Gastroenterology and Hepatology, Mayo Clinic, Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Rochester, MN, USA
| | - Saam Dilmaghani
- Division of Gastroenterology and Hepatology, Mayo Clinic, Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Rochester, MN, USA
| | - Michael Camilleri
- Division of Gastroenterology and Hepatology, Mayo Clinic, Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Rochester, MN, USA
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Ismail FQ, Öberg S, Wozniak AB, Oggesen BT, Rosenberg J. Variation in the length of terminal ileum specimen in right hemicolectomy: a descriptive study. ANZ J Surg 2022; 93:951-955. [PMID: 36368701 DOI: 10.1111/ans.18153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 10/22/2022] [Accepted: 10/28/2022] [Indexed: 11/13/2022]
Abstract
AIM The aim of this study was to clarify the length of the bowel specimen and to assess if the length was affected by certain characteristics. METHODS Eligible patients were adults who had undergone right hemicolectomy for cancer in caecum, appendix, ascending colon or transverse colon from September 2019 to September 2020 at Herlev Hospital, Denmark. Data were collected from medical records. The primary outcome was the length of the resected terminal ileum. Secondary outcomes were to assess if body mass index (BMI), surgical approach, and neoadjuvant chemotherapy affected the length of the terminal ileum specimen, and to report the length of the colon specimen subdivided on the cancer locations. RESULTS In total, 50 patients were included. The median age was 74 years (range 36-91), 30 patients (60%) were females, and BMI was median 26 (range 17-45). The variation in the length of terminal ileum specimen was median 5 cm (range 1-17). The explorative analyses showed significant positive correlation between the length of terminal ileum specimen and BMI (P = 0.050) but not surgical approach (P = 0.23) nor neoadjuvant chemotherapy (P = 0.51). The length of the colon specimen naturally differed according to the cancer location with a median length of 26 cm (range 14-90). CONCLUSION We found a variation in the length of the terminal ileum specimen without an apparent explanation for this variation. The colon specimen also varied naturally according to cancer location.
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Affiliation(s)
- Fatima Qays Ismail
- Center for Perioperative Optimization, Department of Surgery, Herlev and Gentofte Hospital University of Copenhagen Herlev Denmark
- The Late‐complication Clinic, Capital Region of Denmark, Department of Surgery, Herlev and Gentofte Hospital University of Copenhagen Herlev Denmark
| | - Stina Öberg
- Center for Perioperative Optimization, Department of Surgery, Herlev and Gentofte Hospital University of Copenhagen Herlev Denmark
| | - Anita Bilde Wozniak
- The Late‐complication Clinic, Capital Region of Denmark, Department of Surgery, Herlev and Gentofte Hospital University of Copenhagen Herlev Denmark
| | - Birthe Thing Oggesen
- Center for Perioperative Optimization, Department of Surgery, Herlev and Gentofte Hospital University of Copenhagen Herlev Denmark
- The Late‐complication Clinic, Capital Region of Denmark, Department of Surgery, Herlev and Gentofte Hospital University of Copenhagen Herlev Denmark
| | - Jacob Rosenberg
- Center for Perioperative Optimization, Department of Surgery, Herlev and Gentofte Hospital University of Copenhagen Herlev Denmark
- The Late‐complication Clinic, Capital Region of Denmark, Department of Surgery, Herlev and Gentofte Hospital University of Copenhagen Herlev Denmark
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Islam MS, Sharif A, Kwan N, Tam KC. Bile Acid Sequestrants for Hypercholesterolemia Treatment Using Sustainable Biopolymers: Recent Advances and Future Perspectives. Mol Pharm 2022; 19:1248-1272. [PMID: 35333534 DOI: 10.1021/acs.molpharmaceut.2c00007] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Bile acids, the endogenous steroid nucleus containing signaling molecules, are responsible for the regulation of multiple metabolic processes, including lipoprotein and glucose metabolism to maintain homeostasis. Within our body, they are directly produced from their immediate precursors, cholesterol C (low-density lipoprotein C, LDL-C), through the enzymatic catabolic process mediated by 7-α-hydroxylase (CYP7A1). Bile acid sequestrants (BASs) or amphiphilic resins that are nonabsorbable to the human body (being complex high molecular weight polymers/electrolytes) are one of the classes of drugs used to treat hypercholesterolemia (a high plasma cholesterol level) or dyslipidemia (lipid abnormalities in the body); thus, they have been used clinically for more than 50 years with strong safety profiles as demonstrated by the Lipid Research Council-Cardiovascular Primary Prevention Trial (LRC-CPPT). They reduce plasma LDL-C and can slightly increase high-density lipoprotein C (HDL-C) levels, whereas many of the recent clinical studies have demonstrated that they can reduce glucose levels in patients with type 2 diabetes mellitus (T2DM). However, due to higher daily dosage requirements, lower efficacy in LDL-C reduction, and concomitant drug malabsorption, research to develop an "ideal" BAS from sustainable or natural sources with better LDL-C lowering efficacy and glucose regulations and lower side effects is being pursued. This Review discusses some recent developments and their corresponding efficacies as bile removal or LDL-C reduction of natural biopolymer (polysaccharide)-based compounds.
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Affiliation(s)
- Muhammad Shahidul Islam
- Department of Chemical Engineering, Waterloo Institute for Nanotechnology, University of Waterloo, 200 University Avenue West, Waterloo, Ontario N2L 3G1, Canada
| | - Anjiya Sharif
- Department of Chemical Engineering, Waterloo Institute for Nanotechnology, University of Waterloo, 200 University Avenue West, Waterloo, Ontario N2L 3G1, Canada
| | - Nathania Kwan
- Department of Chemical Engineering, Waterloo Institute for Nanotechnology, University of Waterloo, 200 University Avenue West, Waterloo, Ontario N2L 3G1, Canada
| | - Kam C Tam
- Department of Chemical Engineering, Waterloo Institute for Nanotechnology, University of Waterloo, 200 University Avenue West, Waterloo, Ontario N2L 3G1, Canada
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Berti G, Rettura F, Lambiase C, Bellini M. Empirical trial or diagnostic tests for bile acid diarrhea? That is the question! J Dig Dis 2021; 22:557-558. [PMID: 34415680 DOI: 10.1111/1751-2980.13044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 08/16/2021] [Indexed: 12/11/2022]
Affiliation(s)
- Ginevra Berti
- Department of New Technologies and Translational Research in Medicine and Surgery, Gastroenterology Unit, University of Pisa, Pisa, Italy
| | - Francesco Rettura
- Department of New Technologies and Translational Research in Medicine and Surgery, Gastroenterology Unit, University of Pisa, Pisa, Italy
| | - Christian Lambiase
- Department of New Technologies and Translational Research in Medicine and Surgery, Gastroenterology Unit, University of Pisa, Pisa, Italy
| | - Massimo Bellini
- Department of New Technologies and Translational Research in Medicine and Surgery, Gastroenterology Unit, University of Pisa, Pisa, Italy
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