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Di Ciaula A, Khalil M, Baffy G, Portincasa P. Advances in the pathophysiology, diagnosis and management of chronic diarrhoea from bile acid malabsorption: a systematic review. Eur J Intern Med 2024:S0953-6205(24)00291-7. [PMID: 39069430 DOI: 10.1016/j.ejim.2024.07.008] [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: 04/25/2024] [Revised: 07/04/2024] [Accepted: 07/05/2024] [Indexed: 07/30/2024]
Abstract
Bile acid malabsorption (BAM) is an important disorder of digestive pathophysiology as it generates chronic diarrhoea. This condition originates from intricate pathways involving bile acid synthesis and metabolism in the liver and gut, the composition of gut microbiota, enterohepatic circulation and key receptors as farnesoid X receptor (FXR), fibroblast growth factor receptor 4 (FGFR4), and the G-protein bile acid receptor-1 (GPBAR-1). Although symptoms can resemble those related to disorders of gut brain interaction, accurate diagnosis of BAM may greatly benefit the patient. The empiric diagnosis of BAM is primarily based on the clinical response to bile acid sequestrants. Specific tests including the 48-hour fecal bile acid test, serum levels of 7α-hydroxy-4-cholesten-3-one (C4) and fibroblast growth factor 19 (FGF19), and the 75Selenium HomotauroCholic Acid Test (SeHCAT) are not widely available. Nevertheless, lack of diagnostic standardization of BAM may account for poor recognition and delayed management. Beyond bile acid sequestrants, therapeutic approaches include the use of FXR agonists, FGF19 analogues, glucagon-like peptide-1 (GLP-1) receptor agonists, and microbiota modulation. These novel agents can best make their foray into the therapeutic armamentarium if BAM does not remain a diagnosis of exclusion. Ignoring BAM as a specific condition may continue to contribute to increased healthcare costs and reduced quality of life. Here, we aim to provide a comprehensive review of the pathophysiology, diagnosis, and management of BAM.
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Affiliation(s)
- Agostino Di Ciaula
- Clinica Medica "A. Murri", Department of Precision and Regenerative Medicine and Ionian Area (DiMePre-J), University of Bari "Aldo Moro", Medical School, Bari, Italy.
| | - Mohamad Khalil
- Clinica Medica "A. Murri", Department of Precision and Regenerative Medicine and Ionian Area (DiMePre-J), University of Bari "Aldo Moro", Medical School, Bari, Italy.
| | - Gyorgy Baffy
- Division of Gastroenterology, Hepatology and Endoscopy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Section of Gastroenterology, Department of Medicine, VA Boston Healthcare System, Boston, MA, USA.
| | - Piero Portincasa
- Clinica Medica "A. Murri", Department of Precision and Regenerative Medicine and Ionian Area (DiMePre-J), University of Bari "Aldo Moro", Medical School, Bari, Italy.
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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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3
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McKenzie YA, French C, Todd C, Burden S. Food intolerance related to gastrointestinal symptoms amongst adults living with bile acid diarrhoea: A cross-sectional study. J Hum Nutr Diet 2024; 37:79-93. [PMID: 37735850 DOI: 10.1111/jhn.13232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 08/16/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND The role of food in managing bile acid diarrhoea (BAD) is poorly understood. The present study explored the prevalence of food intolerance amongst adults with BAD. METHODS The study comprised a cross-sectional survey of adults with BAD determined by the 75 selenium homotaurocholic acid test (SeHCAT) living in the UK. Participants anonymously completed an online questionnaire on 39 food items. Frequency of food in general affecting BAD symptoms, as well as frequencies of diarrhoea, abdominal pain, bloating, flatulence and consequential food avoidance after food item ingestion, were assessed. Food group avoidance was also assessed. RESULTS There were 434 participants who completed the questionnaire between April and May 2021 of whom 80% reported moderate to severe chronic diarrhoea. Food intolerances were reported by 88.0% (95% confidence interval [CI] = 84.6-90.9) of participants. Diarrhoea was reported most frequently after take-away food, fish and chips, creamy sauces, cream and large quantities of fruit (range 41.0%-33.6%). Lowest frequencies were for potato, avocado, mango, watermelon and pear (range 3.7%-7.4%) for the foods listed in the questionnaire. Similar trends were found for abdominal pain, bloating, flatulence and consequential food avoidance. Symptom-triggering within 30 min of ingestion was more prevalence than after 30 min for almost all foods. Food group avoidance was highest for fatty foods (81.2%; 95% CI = 77.8-85.3) followed by dairy (53.9%; 95% CI = 49.1-58.7). CONCLUSIONS Perceived food intolerance amongst adults with BAD and persisting diarrhoeal symptoms is high. Important triggers were meals with a higher fat content and higher-fat dairy products. Diets amongst those with persisting diarrhoeal symptoms may be overly restrictive.
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Affiliation(s)
- Yvonne A McKenzie
- School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Chloe French
- School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Chris Todd
- School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Sorrel Burden
- School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Salford Royal Hospital, Northern Care Alliance Foundation Trust, Scott Lane, Salford, UK
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McKenzie YA, Sremanakova J, Todd C, Burden S. Effectiveness of diet, psychological, and exercise therapies for the management of bile acid diarrhoea in adults: A systematic review. J Hum Nutr Diet 2022; 35:1087-1104. [PMID: 35274385 PMCID: PMC9790321 DOI: 10.1111/jhn.13005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 02/23/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Bile acid diarrhoea (BAD) causes chronic diarrhoea and is primarily treated pharmacologically. This systematic review aimed to evaluate the effectiveness of non-pharmacological therapies for evidence-based management of BAD in adults. METHODS A systematic review of the medical literature was performed from 1975 to 13 July 2021 to identify studies on diet, psychological, and exercise therapies that met diagnostic criteria for BAD in adults with diarrhoea. Effectiveness was judged by responder or improvement in diarrhoea at study endpoint according to each study's definition of diarrhoea. Therapeutic effect on abdominal pain and flatulence was also measured. Risk of bias was assessed using the Risk Of Bias In Non-Randomised Studies of Interventions tool. A narrative review was conducted using 'Synthesis Without Meta-analysis' guidance. Certainty of the evidence was assessed using Grading of Recommendations Assessment, Development, and Evaluation. RESULTS Eight prospective cohort studies were identified on diet therapies from 2 weeks to over 2 years involving 192 patients. No psychological or exercise therapies were found. Carbohydrate modification (one study, n = 2) in primary BAD, and dietary fat intake reductions (five studies, n = 181) and an exclusive elemental diet therapy (two studies, n = 9) in secondary BAD, showed beneficial directions of effect on diarrhoea, abdominal pain, and flatulence. Risks of bias for each study and across studies for each therapy type were serious. Certainty of the evidence was very low for all outcomes. CONCLUSIONS No conclusions could be drawn on the effectiveness of diet, psychological, or exercise therapies on diarrhoea, abdominal pain, and flatulence for the management of BAD in adults. High-quality randomised controlled trials are needed.
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Affiliation(s)
- Yvonne A. McKenzie
- School of Health Sciences, Faculty of Biology, Medicine and HealthUniversity of ManchesterUK
| | - Jana Sremanakova
- School of Health Sciences, Faculty of Biology, Medicine and HealthUniversity of ManchesterUK
| | - Chris Todd
- School of Health Sciences, Faculty of Biology, Medicine and HealthUniversity of ManchesterUK
- Manchester University NHS Foundation TrustManchesterUK
| | - Sorrel Burden
- School of Health Sciences, Faculty of Biology, Medicine and HealthUniversity of ManchesterUK
- Salford Royal NHS Foundation TrustSalfordUK
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5
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Fitzpatrick JA, Melton SL, Yao CK, Gibson PR, Halmos EP. Dietary management of adults with IBD - the emerging role of dietary therapy. Nat Rev Gastroenterol Hepatol 2022; 19:652-669. [PMID: 35577903 DOI: 10.1038/s41575-022-00619-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/12/2022] [Indexed: 02/08/2023]
Abstract
Historically, dietitians played a minor part in the management of inflammatory bowel disease (IBD), including Crohn's disease and ulcerative colitis. Patients were commonly referred for consequences of uncontrolled disease, such as malnutrition and bowel obstruction risk. Today, dietitians are fundamental members of the multidisciplinary IBD team, from educating on the role of diet at diagnosis and throughout the lifespan of a patient with IBD to guiding primary induction therapy. This aspect is reflected in published guidelines for IBD management, which previously placed diet as only a minor factor, but now have diet-specific publications. This Review describes a four-step approach in a dietitian's assessment and management of diet in patients with IBD: (1) identifying and correcting nutritional gaps and dietary imbalances; (2) considering diet to treat active disease with the use of exclusive enteral nutrition (EEN) or emerging diets that could replace EEN; (3) using therapeutic diets to control existing complications of IBD, such as reduced fibre to prevent bowel obstruction in stricturing disease or a fermentable oligosaccharides, disaccharides, monosaccharides and polyols diet to manage co-existing functional gut symptoms; and (4) considering the role of diet in preventing IBD development in high-risk populations.
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Affiliation(s)
- Jessica A Fitzpatrick
- Department of Gastroenterology, The Alfred Hospital and Monash University, Melbourne, Victoria, Australia
| | - Sarah L Melton
- Department of Gastroenterology, The Alfred Hospital and Monash University, Melbourne, Victoria, Australia
| | - Chu Kion Yao
- Department of Gastroenterology, The Alfred Hospital and Monash University, Melbourne, Victoria, Australia
| | - Peter R Gibson
- Department of Gastroenterology, The Alfred Hospital and Monash University, Melbourne, Victoria, Australia
| | - Emma P Halmos
- Department of Gastroenterology, The Alfred Hospital and Monash University, Melbourne, Victoria, Australia.
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Borre M, Fassov J, Juul T, Laurberg S, Christensen P, Bräuner AB, Thorlacius Ussing O, Lauritzen MB, Drewes AM, Faaborg PM, Krogh K. Diet and bowel symptoms among colon cancer survivors. Acta Oncol 2022; 61:1192-1199. [DOI: 10.1080/0284186x.2022.2101901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Mette Borre
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
- Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects after Cancer in the Pelvic Organs, Aarhus University Hospital, Aarhus, Denmark
| | - Janne Fassov
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
- Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects after Cancer in the Pelvic Organs, Aarhus University Hospital, Aarhus, Denmark
| | - Therese Juul
- Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects after Cancer in the Pelvic Organs, Aarhus University Hospital, Aarhus, Denmark
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Søren Laurberg
- Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects after Cancer in the Pelvic Organs, Aarhus University Hospital, Aarhus, Denmark
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Peter Christensen
- Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects after Cancer in the Pelvic Organs, Aarhus University Hospital, Aarhus, Denmark
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Annette Boesen Bräuner
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Surgery, Regional Hospital Viborg, Viborg, Denmark
| | - Ole Thorlacius Ussing
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Department of Gastrointestinal Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Michael Bødker Lauritzen
- Department of Gastrointestinal Surgery, Aalborg University Hospital, Aalborg, Denmark
- Department of Surgery, North Denmark Regional Hospital, Hjoerring, Denmark
| | - Asbjørn Mohr Drewes
- Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects after Cancer in the Pelvic Organs, Aarhus University Hospital, Aarhus, Denmark
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Pia Møller Faaborg
- Department of Surgery, Danish Colorectal Cancer Center South, Vejle, Denmark
| | - Klaus Krogh
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
- Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects after Cancer in the Pelvic Organs, Aarhus University Hospital, Aarhus, Denmark
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7
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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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8
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Gu Y, Li L, Yang M, Liu T, Song X, Qin X, Xu X, Liu J, Wang B, Cao H. Bile acid-gut microbiota crosstalk in irritable bowel syndrome. Crit Rev Microbiol 2022; 49:350-369. [PMID: 35389754 DOI: 10.1080/1040841x.2022.2058353] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Irritable bowel syndrome (IBS) is a common disorder of gut-brain interaction with an increasing prevalence, and its precise aetiology remains unclear. Gut microbiota dysbiosis has been found to be associated with IBS pathogenesis. In addition, a high incidence of bile acid diarrhoea and disturbed bile acid metabolism has been observed in IBS patients. The abundant microorganisms inhabited in human gut have essential functions in bile acid biotransformation, and can immensely affect the size and constitution of bile acid pool. Meanwhile, the alterations of bile acid profile can inversely interfere with the gut microbiota. This review discussed the role of intricate correlations between bile acids and gut microbiota in IBS pathogenesis and delineated the possible molecular mechanisms, mainly the signalling induced by farnesoid X receptor and transmembrane G protein-coupled receptor 5. Besides, some biomarkers for identifying bile acid diarrhoea in IBS population were listed, assisting the diagnosis and classification of IBS. Moreover, it also assessed some therapeutic strategies for IBS that regulate the bile acid-gut microbiota axis, such as dietary modulation, probiotics/prebiotics, faecal microbiota transplantation, and antibiotics. Collectively, this article illustrated the relationship between bile acids and gut microbiota in IBS pathophysiology and might offer some novel therapeutic options for IBS.
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Affiliation(s)
- Yu Gu
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
| | - Lingfeng Li
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
| | - Min Yang
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
| | - Tianyu Liu
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
| | - Xueli Song
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
| | - Xiali Qin
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
| | - Xin Xu
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
| | - Jinghua Liu
- Department of Gastroenterology, Tianjin TEDA hospital, Tianjin, China
| | - Bangmao Wang
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
| | - Hailong Cao
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
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Sarchet D, Bold J. An opportunity for integrative approaches: bile acid diarrhoea and bile acid malabsorption. ADVANCES IN INTEGRATIVE MEDICINE 2022. [DOI: 10.1016/j.aimed.2022.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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10
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Gee C, Fleuret C, Wilson A, Levine D, Elhusseiny R, Muls A, Cunningham D, Kohoutova D. Bile Acid Malabsorption as a Consequence of Cancer Treatment: Prevalence and Management in the National Leading Centre. Cancers (Basel) 2021; 13:6213. [PMID: 34944833 PMCID: PMC8699462 DOI: 10.3390/cancers13246213] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 12/08/2021] [Indexed: 01/14/2023] Open
Abstract
The aim was to establish prevalence of bile acid malabsorption (BAM) and management in patients who underwent treatment for malignancy. Retrospective evaluation of data in patients seen within six months (August 2019-January 2020) was carried out. Demographic, nuclear medicine (Selenium Homocholic Acid Taurine (SeHCAT) scan result), clinical (previous malignancy, type of intervention (medication, diet), response to intervention) and laboratory (vitamin D, vitamin B12 serum levels) data were searched. In total, 265 consecutive patients were reviewed. Out of those, 87/265 (33%) patients (57 females, 66%) were diagnosed with BAM. Mean age was 59 +/- 12 years. The largest group were females with gynaecological cancer (35), followed by haematology group (15), colorectal/anal (13), prostate (9), upper gastrointestinal cancer (6), another previous malignancy (9). Severe BAM was most common in haematology (10/15; 67%) and gynaecological group (21/35; 60%). Medication and low-fat diet were commenced in 65/87 (75%), medication in 10/87 (11%), diet in 6/87 (7%). Colesevelam was used in 71/75 (95%). Symptoms improved in 74/87 (85%) patients. Vitamin D insufficiency/deficiency was diagnosed in 62/87 (71%), vitamin B12 deficiency in 39/87 (45%). BAM is a common condition in this cohort however treatments are highly effective.
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Affiliation(s)
- Caroline Gee
- The Royal Marsden Hospital NHS Foundation Trust, Fulham Road, Chelsea, London SW3 6JJ, UK; (C.G.); (C.F.); (A.W.); (D.L.); (R.E.); (A.M.); (D.C.)
| | - Catherine Fleuret
- The Royal Marsden Hospital NHS Foundation Trust, Fulham Road, Chelsea, London SW3 6JJ, UK; (C.G.); (C.F.); (A.W.); (D.L.); (R.E.); (A.M.); (D.C.)
| | - Ana Wilson
- The Royal Marsden Hospital NHS Foundation Trust, Fulham Road, Chelsea, London SW3 6JJ, UK; (C.G.); (C.F.); (A.W.); (D.L.); (R.E.); (A.M.); (D.C.)
- St Marks Hospital, Watford Road, Harrow, Middlesex, London HA1 3UJ, UK
| | - Daniel Levine
- The Royal Marsden Hospital NHS Foundation Trust, Fulham Road, Chelsea, London SW3 6JJ, UK; (C.G.); (C.F.); (A.W.); (D.L.); (R.E.); (A.M.); (D.C.)
| | - Ramy Elhusseiny
- The Royal Marsden Hospital NHS Foundation Trust, Fulham Road, Chelsea, London SW3 6JJ, UK; (C.G.); (C.F.); (A.W.); (D.L.); (R.E.); (A.M.); (D.C.)
| | - Ann Muls
- The Royal Marsden Hospital NHS Foundation Trust, Fulham Road, Chelsea, London SW3 6JJ, UK; (C.G.); (C.F.); (A.W.); (D.L.); (R.E.); (A.M.); (D.C.)
| | - David Cunningham
- The Royal Marsden Hospital NHS Foundation Trust, Fulham Road, Chelsea, London SW3 6JJ, UK; (C.G.); (C.F.); (A.W.); (D.L.); (R.E.); (A.M.); (D.C.)
| | - Darina Kohoutova
- The Royal Marsden Hospital NHS Foundation Trust, Fulham Road, Chelsea, London SW3 6JJ, UK; (C.G.); (C.F.); (A.W.); (D.L.); (R.E.); (A.M.); (D.C.)
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What Are the Pearls and Pitfalls of the Dietary Management for Chronic Diarrhoea? Nutrients 2021; 13:nu13051393. [PMID: 33919083 PMCID: PMC8143080 DOI: 10.3390/nu13051393] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 04/14/2021] [Accepted: 04/15/2021] [Indexed: 11/16/2022] Open
Abstract
Chronic diarrhoea affects up to 14% of adults, it impacts on quality of life and its cause can be variable. Patients with chronic diarrhoea are presented with a plethora of dietary recommendations, often sought from the internet or provided by those who are untrained or inexperienced. In this review, we summarise the possible causes of chronic diarrhoea that can be managed by diet, the symptom improvement and quality of life benefits but also the potential risks of such dietary treatments. Clinicians need to consider both the benefits and risks of dietary treatments before making dietary recommendations to manage chronic diarrhoea. The pivotal role that dietitians have in ensuring optimal symptom improvement without jeopardising nutritional and overall health is discussed.
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12
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Flores V, Martínez-Lozano H, Bighelli F, Orcajo J, García-Lledó J, Alonso-Farto JC, Menchén L. Prevalence of biliary acid malabsorption in patients with chronic diarrhoea of functional characteristics: a prospective study. BMC Gastroenterol 2021; 21:56. [PMID: 33563227 PMCID: PMC7871394 DOI: 10.1186/s12876-021-01637-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 02/02/2021] [Indexed: 12/22/2022] Open
Abstract
Background Bile acid malabsorption occurs in up to one third of patients with chronic diarrhoea of functional characteristics. The gold standard test for its diagnosis is the 75Selenium homocholic acid taurine (75SeHCAT) test. The aim of this work is to confirm previous data suggesting that bile acid malabsorption, diagnosed by 75Se-HCAT test, is the underlying cause of diarrhoea in a significant proportion of patients previously diagnosed with a functional disorder. In addition, we have analysed the clinical response of bile acid sequestrants in those patients with a bile acid diarrhoea diagnosis. Methods This is a prospective, single-centre study including consecutive adult patients diagnosed with chronic diarrhoea of unknown origin and with functional characteristics; systematic rule out of common causes of chronic diarrhoea was performed before bile acid malabsorption evaluation by 75SeHCAT scanning. A retention percentage less than 10% was considered positive. Clinical response to cholestyramine was further evaluated in those patients with a positive diagnosis of bile acid diarrhoea Results 38 patients (20 male, mean age 37.5 years) were finally included. Twenty (52.6%) patients included had a positive 75SeHCAT test. Median body mass index was significantly higher in those patients. We did not find significant differences in other clinical or biochemical variables 75SeHCAT-positive and 75SeHCAT-negative groups. Only 6 of 17 (35.3%) patients responded to cholestyramine treatment; 10 patients did not have response or withdraw the drug due to adverse events. Logistic regression analysis showed that none of the included variables was a predictor of clinical response to cholestyramine. Conclusions Bile acid malabsorption occurs in a high proportion of patients suffering from chronic diarrhoea with functional characteristics. Systematic investigation of bile acid malabsorption should be included in the diagnostic algorithms of patients with chronic watery diarrhoea in the routine clinical practice. Absence of response to cholestyramine does not rule out bile acid diarrhoea.
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Affiliation(s)
- Virginia Flores
- Servicio de Aparato Digestivo, Hospital General Universitario Gregorio Marañón - Instituto de Investigación Sanitaria Gregorio Marañón, C/ Dr. Esquerdo 46, 28007, Madrid, Spain
| | - Helena Martínez-Lozano
- Servicio de Aparato Digestivo, Hospital General Universitario Gregorio Marañón - Instituto de Investigación Sanitaria Gregorio Marañón, C/ Dr. Esquerdo 46, 28007, Madrid, Spain
| | - Federico Bighelli
- Servicio de Aparato Digestivo, Hospital General Universitario Gregorio Marañón - Instituto de Investigación Sanitaria Gregorio Marañón, C/ Dr. Esquerdo 46, 28007, Madrid, Spain
| | - Javier Orcajo
- Servicio de Medicina Nuclear, Hospital General Universitario Gregorio Marañón - Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Javier García-Lledó
- Servicio de Aparato Digestivo, Hospital General Universitario Gregorio Marañón - Instituto de Investigación Sanitaria Gregorio Marañón, C/ Dr. Esquerdo 46, 28007, Madrid, Spain
| | - Juan Carlos Alonso-Farto
- Servicio de Medicina Nuclear, Hospital General Universitario Gregorio Marañón - Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Luis Menchén
- Servicio de Aparato Digestivo, Hospital General Universitario Gregorio Marañón - Instituto de Investigación Sanitaria Gregorio Marañón, C/ Dr. Esquerdo 46, 28007, Madrid, Spain. .,Departamento de Medicina, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas Y Digestivas (CIBEREHD), Universidad Complutense de Madrid, Madrid, Spain. .,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas Y Digestivas (CIBEREHD), Madrid, Spain.
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13
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Larsen HM, Mekhael M, Juul T, Borre M, Christensen P, Mohr Drewes A, Thorlacius-Ussing O, Laurberg S, Krogh K, Ladefoged Fassov J. Long-term gastrointestinal sequelae in colon cancer survivors: prospective pilot study on identification, the need for clinical evaluation and effects of treatment. Colorectal Dis 2021; 23:356-366. [PMID: 33511684 DOI: 10.1111/codi.15544] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 01/14/2021] [Accepted: 01/17/2021] [Indexed: 12/11/2022]
Abstract
AIM The aim of the present pilot study was to describe the type and frequency of long-term gastrointestinal symptoms within a well-defined cohort of colon cancer survivors, their wish for clinical evaluation and treatment outcomes. METHOD A screening survey was sent to colon cancer survivors 12, 24 and 36 months after surgery. Based on their main symptoms, patients who wished to have a consultation were referred to the gastroenterological or surgical unit of our late cancer sequelae clinic. Treatment effect was monitored by questionnaires on bowel symptoms and the EuroQol five-dimensional (EQ-5D) quality-of-life score. RESULTS Overall, 953 patients who had survived colon cancer received the screening survey and 767 replied (response rate 80.5%). Of these, 76 (9.9%; 95% CI 7.9%-12.2%) were referred for algorithm-based clinical evaluation and treatment of bowel dysfunction. The majority were women (69.7%) who had undergone a right-sided colonic resection (65.8%). Patients reported various symptoms, mainly including urgency, fragmented defaecation, loose stools and incontinence for liquid stools. Patients with emptying difficulties and low anterior resection syndrome-like symptoms were referred to the surgical unit and patients with diarrhoea were referred to the gastroenterological unit for clinical work-up. Our main endpoint, mean EQ-5D index after treatment, was improved compared with baseline (baseline 0.809, after treatment 0.846; p = 0.049). After treatment, self-rated bowel function and several bowel symptoms were improved as well. CONCLUSION This study highlights the importance of identifying colon cancer survivors in need of treatment of late gastrointestinal sequelae and clinical management in a multidisciplinary team setting.
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Affiliation(s)
- Helene M Larsen
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark.,Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects after Cancer in the Pelvic Organs, Aarhus/Aalborg, Denmark
| | - Mira Mekhael
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark.,Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects after Cancer in the Pelvic Organs, Aarhus/Aalborg, Denmark
| | - Therese Juul
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark.,Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects after Cancer in the Pelvic Organs, Aarhus/Aalborg, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Mette Borre
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark.,Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects after Cancer in the Pelvic Organs, Aarhus/Aalborg, Denmark
| | - Peter Christensen
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark.,Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects after Cancer in the Pelvic Organs, Aarhus/Aalborg, Denmark
| | - Asbjørn Mohr Drewes
- Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects after Cancer in the Pelvic Organs, Aarhus/Aalborg, Denmark.,Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Ole Thorlacius-Ussing
- Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects after Cancer in the Pelvic Organs, Aarhus/Aalborg, Denmark.,Department of Gastrointestinal Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Søren Laurberg
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark.,Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects after Cancer in the Pelvic Organs, Aarhus/Aalborg, Denmark
| | - Klaus Krogh
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark.,Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects after Cancer in the Pelvic Organs, Aarhus/Aalborg, Denmark
| | - Janne Ladefoged Fassov
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark.,Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects after Cancer in the Pelvic Organs, Aarhus/Aalborg, Denmark
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14
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Habib SM, Zwicker BL, Wykes L, Agellon LB. Sexually dimorphic response of mice to the Western-style diet caused by deficiency of fatty acid binding protein 6 (Fabp6). Physiol Rep 2021; 9:e14733. [PMID: 33527741 PMCID: PMC7851434 DOI: 10.14814/phy2.14733] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 12/30/2020] [Accepted: 01/04/2021] [Indexed: 11/24/2022] Open
Abstract
Bile acids are natural detergents that aid in the absorption of dietary lipids. Fatty acid binding protein 6 (Fabp6) is a component of the bile acid recovery system that operates in the small intestine. The aim of this study was to determine if Fabp6 deficiency causes dietary fat malabsorption. Wild-type and Fabp6-deficient mice were fed a Western-style diet (WSD) or a reference low-fat diet (LFD) for 10 weeks. The body weight gain, bile acid excretion, fat excretion, energy metabolism, and major gut microbial phyla of the mice were assessed at the end of the controlled diet period. Fabp6-/- mice exhibited enhanced excretion of both bile acids and fat on the WSD but not on the LFD diet. Paradoxically, male Fabp6-/- mice, but not female Fabp6-/- mice, had greater adiposity despite increased fat excretion. Analysis of energy intake and of expenditure by indirect calorimetry revealed sex differences in physical activity level and respiratory quotient, but these did not account for the enhanced adiposity displayed by male Fabp6-/- mice. Analysis of stool DNA showed sex-specific changes in the abundance of major phyla of bacteria in response to Fabp6 deficiency and WSD feeding. The results obtained indicate that the malabsorption of bile acids that occurs in Fabp6-/- mice is associated with dietary fat malabsorption on the high-fat diet but not on the low-fat diet. The WSD induced a sexually dimorphic increase in adiposity displayed by Fabp6-/- mice and sexually distinct pattern of change in gut microbiota composition.
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Affiliation(s)
- Salam M. Habib
- School of Human NutritionMcGill UniversityMontrealQCCanada
| | - Brittnee L. Zwicker
- School of Human NutritionMcGill UniversityMontrealQCCanada
- Present address:
McGill University Health CentreMontrealQCH4A 3J1Canada
| | - Linda Wykes
- School of Human NutritionMcGill UniversityMontrealQCCanada
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15
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Hughes LE, Ford C, Brookes MJ, Gama R. Bile acid diarrhoea: Current and potential methods of diagnosis. Ann Clin Biochem 2020; 58:22-28. [PMID: 32998535 DOI: 10.1177/0004563220966139] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Chronic diarrhoea is common and mostly due to diarrhoea predominant irritable bowel syndrome. Diarrhoea predominant irritable bowel syndrome affects about 11% of the population; however, up to a third of these patients actually have bile acid diarrhoea. There are, therefore, more than one million sufferers of bile acid diarrhoea in the UK. Bile acid diarrhoea is caused by small bowel malabsorption of bile acids and the increased bile acids in the large intestine cause diarrhoea. Once diagnosed, the treatment of bile acid diarrhoea is simple and effective. Bile acid diarrhoea , however, is often not diagnosed because of a lack of easily available and reliable diagnostic methods. In the United Kingdom, the radiolabelled 23-seleno-25-homotaurocholic acid test is the gold-standard method of diagnosis. 23-seleno-25-homotaurocholic acid test, however, is expensive, inconvenient to the patient, involves radiation exposure and has limited availability. As such, a laboratory biomarker is desirable. This review briefly discusses the pathophysiology and management of bile acid diarrhoea and critically evaluates methods for its diagnosis, including serum 7α-hydroxy-4-cholesten-3-one, faecal bile acid measurement, serum fibroblast growth factor 19, urine-2-propanol, and the 14C-glycocholate breath and stool test.
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Affiliation(s)
- Lauren E Hughes
- Clinical Chemistry, Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Clare Ford
- Clinical Chemistry, Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Matthew J Brookes
- Department of Gastroenterology, Royal Wolverhampton NHS Trust, Wolverhampton, UK.,Faculty of Education, Health and Wellbeing, University of Wolverhampton, Wolverhampton, UK
| | - Rousseau Gama
- Clinical Chemistry, Royal Wolverhampton NHS Trust, Wolverhampton, UK.,School of Medicine and Clinical Practice, Wolverhampton University, Wolverhampton, UK
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16
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Farrugia A, Arasaradnam R. Bile acid diarrhoea: pathophysiology, diagnosis and management. Frontline Gastroenterol 2020; 12:500-507. [PMID: 34712468 PMCID: PMC8515273 DOI: 10.1136/flgastro-2020-101436] [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: 02/18/2020] [Revised: 05/14/2020] [Accepted: 05/27/2020] [Indexed: 02/04/2023] Open
Abstract
The actual incidence of bile acid diarrhoea (BAD) is unknown, however, there is increasing evidence that it is misdiagnosed in up to 30% with diarrhoea-predominant patients with irritable bowel syndrome. Besides this, it may also occur following cholecystectomy, infectious diarrhoea and pelvic chemoradiotherapy. BAD may result from either hepatic overproduction of bile acids or their malabsorption in the terminal ileum. It can result in symptoms such as bowel frequency, urgency, nocturnal defecation, excessive flatulence, abdominal pain and incontinence of stool. Bile acid synthesis is regulated by negative feedback loops related to the enterohepatic circulation, which are dependent on the farnesoid X receptor and fibroblast growth factor 19. Interruption of these feedback loops is thought to cause bile acid overproduction leading to BAD. This process may occur idiopathically or following a specific trigger such as cholecystectomy. There may also be an interplay with the gut microbiota, which has been reported to be significantly different in patients with severe BAD. Patients with suspected BAD are investigated in various ways including radionucleotide imaging such as SeHCAT scans (though this is not available worldwide) and blood tests. However, other methods such as bile acid measurement in stool (either spot test or 48 hours samples) and urine tests have been explored. Importantly, delay in diagnosis and treatment of BAD greatly affects patient's quality of life and may double the overall cost of diagnosis.
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Affiliation(s)
- Alexia Farrugia
- Surgery, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK,Divison of Biomedical Sciences, University of Warwick, Warwick Medical School, Coventry, Coventry, UK
| | - Ramesh Arasaradnam
- Divison of Biomedical Sciences, University of Warwick, Warwick Medical School, Coventry, Coventry, UK,Gastroenterology, University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK
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17
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Nakano K, Takahashi T, Tsunoda A, Shimizu Y. Effects of Dietary Guidance without Dietary Fiber Supplements on the Symptoms, Quality of Life, and Dietary Intake in Patients with Fecal Incontinence. JOURNAL OF THE ANUS RECTUM AND COLON 2020; 4:128-136. [PMID: 32743115 PMCID: PMC7390611 DOI: 10.23922/jarc.2020-008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 05/20/2020] [Indexed: 12/12/2022]
Abstract
Objectives Dietary fiber (DF) supplements improve fecal incontinence (FI). Here, we investigated the effects of dietary guidance without DF supplements in patients with FI. Methods This was an interventional study on the nutritional guidance alone by a dietitian where outcomes were compared before and one month after the guidance. In this study, participants attended a one 20-min dietary guidance session and received individual guidance on dietary management according to the 2017 Japanese FI guidelines, between January 2016 and March 2019. The main assessment items used were as follows: (i) the Fecal Incontinence Severity Index (FISI) to assess symptoms, (ii) the Fecal Incontinence Quality of Life Scale (FIQL) to assess the quality of life, and (iii) the dietary intake per day. Results Out of 61 patients who participated in this study, 50 (82%) completed the entire study and 29 (48%) continued a self-controlled diet therapy without drug treatment. Of the 50 patients, the FISI and FIQL scores were significantly improved after the guidance (FISI: 19 before vs. 10.5 after, P < 0.001; FIQL: 2.9 before vs. 3.2 after, P < 0.001). There was no statistically significant difference in the overall DF intake before and after the dietary guidance. However, foods containing DF changed significantly after the guidance. The intake of rice was significantly increased, whilst that of fruits, dairy products, and confectioneries was significantly reduced after the guidance. Conclusions Individual dietary guidance without DF supplements was effective. These results suggested that increasing rice consumption and restricting some foods had positive effects on improving FI.
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Affiliation(s)
| | - Tomoko Takahashi
- Department of Gastroenterological Surgery, Kameda Medical Center, Chiba, Japan
| | - Akira Tsunoda
- Department of Gastroenterological Surgery, Kameda Medical Center, Chiba, Japan
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18
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Jeffery IB, Das A, O'Herlihy E, Coughlan S, Cisek K, Moore M, Bradley F, Carty T, Pradhan M, Dwibedi C, Shanahan F, O'Toole PW. Differences in Fecal Microbiomes and Metabolomes of People With vs Without Irritable Bowel Syndrome and Bile Acid Malabsorption. Gastroenterology 2020; 158:1016-1028.e8. [PMID: 31843589 DOI: 10.1053/j.gastro.2019.11.301] [Citation(s) in RCA: 110] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 11/16/2019] [Accepted: 11/01/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Irritable bowel syndrome (IBS) is a heterogeneous disorder, but diagnoses and determination of subtypes are made based on symptoms. We profiled the fecal microbiomes of patients with and without IBS to identify biomarkers of this disorder. METHODS We collected fecal and urine samples from 80 patients with IBS (Rome IV criteria; 16-70 years old) and 65 matched individuals without IBS (control individuals), along with anthropometric, medical, and dietary information. Shotgun and 16S ribosomal RNA amplicon sequencing were performed on feces, whereas urine and fecal metabolites were analyzed by gas chromatography and liquid chromatography-mass spectrometry. Co-occurrence networks were generated based on significant Spearman correlations between data. Bile acid malabsorption (BAM) was identified in patients with diarrhea by retention of radiolabeled selenium-75 homocholic acid taurine. RESULTS Patients with IBS had significant differences in network connections between diet and fecal microbiomes compared with control individuals; these were accompanied by differences in fecal metabolomes. We did not find significant differences in fecal microbiota composition among patients with different IBS symptom subtypes. Fecal metabolome profiles could discriminate patients with IBS from control individuals. Urine metabolomes also differed significantly between patients with IBS and control individuals, but most discriminatory metabolites were related to diet or medications. Fecal metabolomes, but not microbiomes, could distinguish patients with IBS with vs those without BAM. CONCLUSIONS Despite the heterogeneity of IBS, patients have significant differences in urine and fecal metabolomes and fecal microbiome vs control individuals, independent of symptom-based subtypes of IBS. Fecal metabolome analysis can be used to distinguish patients with IBS with vs those without BAM. These findings might be used for developing microbe-based treatments for these disorders.
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Affiliation(s)
- Ian B Jeffery
- 4D pharma Cork Limited, Cavanagh Pharmacy Building, University College Cork, National University of Ireland, Cork, Ireland
| | - Anubhav Das
- 4D pharma Cork Limited, Cavanagh Pharmacy Building, University College Cork, National University of Ireland, Cork, Ireland
| | - Eileen O'Herlihy
- 4D pharma Cork Limited, Cavanagh Pharmacy Building, University College Cork, National University of Ireland, Cork, Ireland
| | - Simone Coughlan
- 4D pharma Cork Limited, Cavanagh Pharmacy Building, University College Cork, National University of Ireland, Cork, Ireland
| | - Katryna Cisek
- 4D pharma Cork Limited, Cavanagh Pharmacy Building, University College Cork, National University of Ireland, Cork, Ireland
| | - Michael Moore
- Department of Radiology, Cork University Hospital, Cork, Ireland
| | - Fintan Bradley
- Medical Physics Department, Cork University Hospital, Cork, Ireland
| | - Tom Carty
- Medical Physics Department, Cork University Hospital, Cork, Ireland
| | - Meenakshi Pradhan
- 4D pharma Cork Limited, Cavanagh Pharmacy Building, University College Cork, National University of Ireland, Cork, Ireland
| | - Chinmay Dwibedi
- 4D pharma Cork Limited, Cavanagh Pharmacy Building, University College Cork, National University of Ireland, Cork, Ireland
| | - Fergus Shanahan
- 4D pharma Cork Limited, Cavanagh Pharmacy Building, University College Cork, National University of Ireland, Cork, Ireland; APC Microbiome Ireland, University College Cork, Ireland
| | - Paul W O'Toole
- 4D pharma Cork Limited, Cavanagh Pharmacy Building, University College Cork, National University of Ireland, Cork, Ireland; APC Microbiome Ireland, University College Cork, Ireland; School of Microbiology, University College Cork, Ireland.
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19
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Adio J, Burch J. Chronic diarrhoea due to bile salt malabsorption: nurse-led assessment, medical treatment and dietary management. ACTA ACUST UNITED AC 2020. [DOI: 10.12968/gasn.2020.18.1.26] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Bile salt malabsorption (BSM) occurs when bile salts, which are secreted in the small bowel to aid digestion of fats and vitamins, are not sufficiently re-absorbed in the terminal ileum. Consequently, an excess of bile salts enters the colon, causing chronic explosive diarrhoea, associated with abdominal cramps, flatulence and urgent, frequent and unpredictable bowel habits. BSM affects around 1% of the population, often occuring in ileal Crohn's disease or after ileal resection. Diagnosis begins with a nurse-led assessment, including blood and stool tests, to exclude other potential organic causes of chronic diarrhoea. BSM can then be confirmed and classified with a75Se-homocholic acid taurine (SeHCAT) scan. BSM can be treated medically with bile salt sequestrants, including colestyramine sachets, which are approved but have an unpleasant taste, and colesevelam tablets, which are more tolerable but more expensive and not yet approved. However, long-term sequestrant use can impact absorption of vitamins and other medications. BSM can also be managed with a low-fat diet, which is cost-effective and can reduce the amount of bile secreted. Nurses should provide patient education to ensure adherence and safe use.
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Affiliation(s)
- Jitka Adio
- Inflammatory Bowel Disease Nurse Specialist
| | - Jennie Burch
- Head of Gastrointestinal Nurse Education, both at St Mark's Hospital, London
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20
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Sadowski DC, Camilleri M, Chey WD, Leontiadis GI, Marshall JK, Shaffer EA, Tse F, Walters JRF. Canadian Association of Gastroenterology Clinical Practice Guideline on the Management of Bile Acid Diarrhea. Clin Gastroenterol Hepatol 2020; 18:24-41.e1. [PMID: 31526844 DOI: 10.1016/j.cgh.2019.08.062] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 08/28/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Chronic diarrhea affects about 5% of the population overall. Altered bile acid metabolism is a common but frequently undiagnosed cause. METHODS We performed a systematic search of publication databases for studies of assessment and management of bile acid diarrhea (BAD). The certainty (quality) of evidence and strength of recommendations were rated according to the Grading of Recommendation Assessment, Development and Evaluation approach. Patient population, intervention, comparator, and outcome questions were developed through an iterative process and were voted on by a group of specialists. RESULTS The certainty of evidence was generally rated as very low. Therefore, 16 of 17 recommendations are conditional. In patients with chronic diarrhea, consideration of risk factors (terminal ileal resection, cholecystectomy, or abdominal radiotherapy), but not additional symptoms, was recommended for identification of patients with possible BAD. The group suggested testing using 75selenium homocholic acid taurine (where available) or 7α-hydroxy-4-cholesten-3-one, including patients with irritable bowel syndrome with diarrhea, functional diarrhea, and Crohn's disease without inflammation. Testing was suggested over empiric bile acid sequestrant therapy (BAST). Once remediable causes are managed, the group suggested cholestyramine as initial therapy, with alternate BAST when tolerability is an issue. The group suggested against BAST for patients with extensive ileal Crohn's disease or resection and suggested alternative antidiarrheal agents if BAST is not tolerated. Maintenance BAST should be given at the lowest effective dose, with a trial of intermittent, on-demand administration, concurrent medication review, and reinvestigation for patients whose symptoms persist despite BAST. CONCLUSIONS Based on a systematic review, BAD should be considered for patients with chronic diarrhea. For patients with positive results from tests for BAD, a trial of BAST, initially with cholestyramine, is suggested.
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Affiliation(s)
- Daniel C Sadowski
- Division of Gastroenterology, Royal Alexandra Hospital, Edmonton, Alberta, Canada.
| | - Michael Camilleri
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - William D Chey
- Division of Gastroenterology, University of Michigan Health System, Ann Arbor, Michigan
| | - Grigorios I Leontiadis
- Division of Gastroenterology, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - John K Marshall
- Division of Gastroenterology, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Eldon A Shaffer
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
| | - Frances Tse
- Division of Gastroenterology, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Julian R F Walters
- Division of Digestive Diseases, Imperial College London, London, United Kingdom
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21
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Sadowski DC, Camilleri M, Chey WD, Leontiadis GI, Marshall JK, Shaffer EA, Tse F, Walters JRF. Canadian Association of Gastroenterology Clinical Practice Guideline on the Management of Bile Acid Diarrhea. J Can Assoc Gastroenterol 2019; 3:e10-e27. [PMID: 32010878 PMCID: PMC6985689 DOI: 10.1093/jcag/gwz038] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background and Aims Chronic diarrhea affects about 5% of the population overall. Altered bile acid metabolism is a common but frequently undiagnosed cause. Methods We performed a systematic search of publication databases for studies of assessment and management of bile acid diarrhea (BAD). The certainty (quality) of evidence and strength of recommendations were rated according to the Grading of Recommendation Assessment, Development and Evaluation approach. Patient population, intervention, comparator and outcome questions were developed through an iterative process and were voted on by a group of specialists. Results The certainty of evidence was generally rated as very low. Therefore, 16 of 17 recommendations are conditional. In patients with chronic diarrhea, consideration of risk factors (terminal ileal resection, cholecystectomy or abdominal radiotherapy), but not additional symptoms, was recommended for identification of patients with possible BAD. The group suggested testing using 75selenium homocholic acid taurine (where available) or 7α-hydroxy-4-cholesten-3-one, including patients with irritable bowel syndrome with diarrhea, functional diarrhea and Crohn's disease without inflammation. Testing was suggested over empiric bile acid sequestrant therapy (BAST). Once remediable causes are managed, the group suggested cholestyramine as initial therapy, with alternate BAST when tolerability is an issue. The group suggested against BAST for patients with extensive ileal Crohn's disease or resection and suggested alternative antidiarrheal agents if BAST is not tolerated. Maintenance BAST should be given at the lowest effective dose, with a trial of intermittent, on-demand administration, concurrent medication review and reinvestigation for patients whose symptoms persist despite BAST. Conclusions Based on a systematic review, BAD should be considered for patients with chronic diarrhea. For patients with positive results from tests for BAD, a trial of BAST, initially with cholestyramine, is suggested.
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Affiliation(s)
- Daniel C Sadowski
- Division of Gastroenterology, Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - Michael Camilleri
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - William D Chey
- Division of Gastroenterology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Grigorios I Leontiadis
- Division of Gastroenterology, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - John K Marshall
- Division of Gastroenterology, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Eldon A Shaffer
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
| | - Frances Tse
- Division of Gastroenterology, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
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22
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Walters JRF, Arasaradnam R, Andreyev HJN. Diagnosis and management of bile acid diarrhoea: a survey of UK expert opinion and practice. Frontline Gastroenterol 2019; 11:358-363. [PMID: 32879719 PMCID: PMC7447276 DOI: 10.1136/flgastro-2019-101301] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Revised: 08/16/2019] [Accepted: 09/02/2019] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE Bile acid diarrhoea (BAD), which includes bile acid malabsorption, causes a variety of digestive symptoms. Diagnostic rates and management vary considerably. We conducted a survey of current practice to review expert opinion and provide guidance on diagnosis and management. DESIGN/METHOD An online survey was conducted of clinical members of the UK Bile Acid Related Diarrhoea Network, who had all published research on BAD (n=21). Most were National Health Service consultants who had diagnosed over 50 patients with the condition. RESULTS The preferred terminology was to use BAD, with primary and secondary to classify causes. A wide range of presenting symptoms and associated conditions were recognised. SeHCAT (tauroselcholic acid) was the preferred diagnostic test, and 50% of respondents thought general practitioners should have access to this. Patients who met the Rome IV diagnostic criteria for functional diarrhoea, irritable bowel syndrome (IBS) with predominant diarrhoea or postcholecystectomy diarrhoea were usually investigated by SeHCAT, which was used sometimes in other types of IBS. Treatment with a bile acid sequestrant was offered to patients with low SeHCAT values, with expected response rates >70% in the most severe. Colestyramine was the usual sequestrant, starting between 2 g and 8 g daily; colesevelam was an alternative. In patients who had an incomplete response, increasing the dose, changing to an alternative sequestrant, use of loperamide and a low fat diet were suggested. Recommendations for follow-up and to improve the overall patient experience were made. CONCLUSION This expert survey indicates current best practice in the diagnosis and management of BAD.
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Affiliation(s)
- Julian R F Walters
- Department of Gastroenterology, Imperial College Healthcare NHS Trust, London, UK,Division of Digestive Diseases, Imperial College London, London, UK
| | - Ramesh Arasaradnam
- Department of Gastroenterology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - H Jervoise N Andreyev
- Department of Gastroenterology, Lincoln County Hospital, Lincoln, UK,School of Medicine, University of Nottingham, Nottingham, United Kingdom
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23
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Fernandes DCR, Poon D, White LL, Andreyev HJN. What is the cost of delayed diagnosis of bile acid malabsorption and bile acid diarrhoea? Frontline Gastroenterol 2019; 10:72-76. [PMID: 30651961 PMCID: PMC6319159 DOI: 10.1136/flgastro-2018-101011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 06/20/2018] [Accepted: 07/09/2018] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION 75Selenium taurocholic acid (SeHCAT) scanning diagnoses bile acid malabsorption/bile acid diarrhoea (BAM/BAD) and defines optimal treatment. Approximately 2% of the population have BAM/BAD. AIM To evaluate the cost of delayed diagnosis of BAM/BAD. METHODS Patients' notes who underwent SeHCAT scanning in three hospitals over a 1-year period were reviewed retrospectively. Scan results and treatment response were recorded. Package-of-care costs were calculated using costing tools from the National Institute for Health and Care Excellence and from United Lincolnshire Hospitals Trust business unit. RESULTS Between June 2016 and May 2017, 19 men and 37 women (median age 58 (range 19-83)) of 3860 new patients seen in gastroenterology clinics were referred for SeHCAT scanning. Sixty-four per cent of scans were abnormal: 13 demonstrated severe (<5% 7-day SeHCAT retention), 13 moderate (5%-10%), 5 mild (10%-15%) and 5 borderline (15%-20%) BAD/BAM. Likely causes included primary BAD (n=16), cholecystectomy (n=13), inflammatory bowel disease (n=4) and other (n=3). If SeHCAT scanning was ordered at first consultation (n=11), patients reported 24 months (median) of symptoms (range 6-360) and the median diagnostic package-of-care cost was £811.40 (95% CI £625.59 to £1508.20). If SeHCAT scanning was booked later (n=25), patients reported symptoms for 30 months (median, range 0.5-360) and the cost was £1568.31 (95% CI £1200.55 to £1713.18). Following diagnosis, treatment led to symptom improvement (n=24), no change/deterioration (n=3) and not reported (n=9). CONCLUSIONS SeHCAT is underused. Late diagnosis leads to unnecessary demands for other services and treatment delay. Early diagnosis achieves health benefits while reducing costs.
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Affiliation(s)
| | - Dennis Poon
- Department of Gastroenterology, Lincoln County Hospital, Lincoln, UK
| | - Laura L White
- Department of Medical Diagnostics, Lincoln County Hospital, Lincoln, UK
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24
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Damsgaard B, Dalby HR, Krogh K, Jørgensen SMD, Arveschough AK, Agnholt J, Dahlerup JF, Jørgensen SP. Letter: long-term treatment of severe bile acid diarrhoea-obeticholic acid can normalise SeHCAT retention. Authors' reply. Aliment Pharmacol Ther 2018; 48:1034-1035. [PMID: 30318688 DOI: 10.1111/apt.14996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Brian Damsgaard
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Helene R Dalby
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Klaus Krogh
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Simon M D Jørgensen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Jørgen Agnholt
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Jens Frederik Dahlerup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Søren Peter Jørgensen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
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25
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Yde J, Larsen HM, Laurberg S, Krogh K, Moeller HB. Chronic diarrhoea following surgery for colon cancer-frequency, causes and treatment options. Int J Colorectal Dis 2018; 33:683-694. [PMID: 29589108 DOI: 10.1007/s00384-018-2993-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/21/2018] [Indexed: 02/04/2023]
Abstract
PURPOSE The growing population of survivors after colon cancer warrants increased attention to the long-term outcome of surgical treatment. The change in bowel anatomy after resection disrupts normal gastrointestinal function and may cause symptoms. Thus, many patients surviving colon cancer have to cope with bowel dysfunction for the rest of their lives. We here aim to provide an overview of the literature on this topic. METHODS We review long-term functional outcomes of surgical treatment for colon cancer, the underlying pathology, and treatment options. RESULTS Common symptoms include constipation, urge for defecation and diarrhoea. Causes of diarrhoea after colon cancer surgery are sparsely studied, but they probably include bile acid malabsorption, small intestinal bacterial overgrowth and disruption of the ileal brake. Specific diagnosis should be made to allow individual treatment based on the underlying pathology. Studies on treatment of functional problems after surgery for colon cancer are extremely few, but some lessons can be drawn from the treatment of other patient groups having undergone colon surgery. CONCLUSION Diarrhoea is likely a common long-term complication after colon cancer surgery. Attention to this complication and a specific diagnosis will aid the targeted treatment of patients suffering from this complication.
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Affiliation(s)
- Jonathan Yde
- Department of Biomedicine, Aarhus University, Wilhelm Meyers Alle 3, Building 1233, 8000, Aarhus, Denmark
| | - Helene M Larsen
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark.,Danish Cancer Society Centre for Research and Late Adverse Effects After Cancer in the Pelvic Organs, Aarhus University Hospital, Aarhus, Denmark
| | - Søren Laurberg
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark.,Danish Cancer Society Centre for Research and Late Adverse Effects After Cancer in the Pelvic Organs, Aarhus University Hospital, Aarhus, Denmark
| | - Klaus Krogh
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark.,Danish Cancer Society Centre for Research and Late Adverse Effects After Cancer in the Pelvic Organs, Aarhus University Hospital, Aarhus, Denmark
| | - Hanne B Moeller
- Department of Biomedicine, Aarhus University, Wilhelm Meyers Alle 3, Building 1233, 8000, Aarhus, Denmark.
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26
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Damsgaard B, Dalby HR, Krogh K, Jørgensen SMD, Arveschough AK, Agnholt J, Dahlerup JF, Jørgensen SP. Long-term effect of medical treatment of diarrhoea in 377 patients with SeHCAT scan diagnosed bile acid malabsorption from 2003 to 2016; a retrospective study. Aliment Pharmacol Ther 2018; 47:951-957. [PMID: 29368342 DOI: 10.1111/apt.14533] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 10/13/2017] [Accepted: 01/03/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Excessive amounts of bile acids entering the colon due to bile acid malabsorption cause chronic bile acid diarrhoea. Diagnosis is possible by measuring the retention fraction of orally ingested 75 Selenium homotaurocholic acid (SeHCAT). The knowledge of long-term effects of medical treatment is sparse. AIM To describe diarrhoea, adherence to treatment, treatment effects and quality of life in a large, well-defined cohort of patients with bile acid diarrhoea. METHODS A retrospective survey was performed among 594 patients with bile acid malabsorption verified by SeHCAT scans at our unit between 2003 and 2016. Questionnaires about medical history, diarrhoea, use of medication, and quality of life scores were mailed to all patients. RESULTS Among 594 patients 377 (69%) responded. Among respondents, 121 (32%) had bile acid diarrhoea due to ileal disease or resection (type 1), 198 (52%) idiopathic bile acid diarrhoea (type 2) and 58 (16%) bile acid diarrhoea due to other non-ileal disease, mainly cholecystectomy (type 3). At follow-up, half of the patients, 184 (50%), reported improvement of diarrhoea. However, 273 patients (74%) still reported diarrhoea and 234 (62%) regularly used anti-diarrhoeal medication. In spite of treatment, 235 (64%) considered reduced quality of life by diarrhoea and 184 (50%) reported that diarrhoea was unaltered or worse than before established diagnosis. CONCLUSION Many patients with bile acid diarrhoea continue to have bothersome diarrhoea in spite of correct diagnosis and treatment.
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Affiliation(s)
- B Damsgaard
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - H R Dalby
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - K Krogh
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - S M D Jørgensen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - A K Arveschough
- Department of Nuclear Medicine & PET-centre, Aarhus University Hospital, Aarhus, Denmark
| | - J Agnholt
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - J F Dahlerup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - S P Jørgensen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
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27
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Jackson A, Lalji A, Kabir M, Muls A, Gee C, Vyoral S, Shaw C, Andreyev HJN. The efficacy of a low-fat diet to manage the symptoms of bile acid malabsorption - outcomes in patients previously treated for cancer. Clin Med (Lond) 2017; 17:412-418. [PMID: 28974589 PMCID: PMC6301937 DOI: 10.7861/clinmedicine.17-5-412] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Dietary fat ingestion triggers bile secretion into the gastrointestinal tract. Bile acid malabsorption affects >1% of the population, causing loose stool and other gastrointestinal symptoms. The diagnosis is frequently missed. Treatments are often considered ineffective. We evaluated low-fat diets for managing gastrointestinal symptoms in these patients. All patients reporting type 6 or 7 stool were offered a selenium-75 homocholic acid taurine (SeHCAT) scan. Prospective data in patients with 7-day scan retention <20% were analysed. -Patients requiring a bile acid sequestrant were given this before receiving dietary advice. Patients completed a 7-day food diary before dietetic consultations. Personalised dietary interventions, providing 20% of daily energy from fat, were prescribed. Symptoms were assessed using a modified gastrointestinal symptom rating scale questionnaire before and 4-12 weeks after dietary intervention. A total of 114 patients (49 male, median age 64 years, median body mass index 27 kg/m2) were evaluated. 44% of these patients were taking colesevelam. After dietary intervention, there was statistically significant improvement in abdominal pain and nocturnal defecation (0.2% alpha, p=0.001). Improvement in bowel frequency, urgency, flatulence, belching, borborygmi and stool consistency were seen, but did not reach statistical significance (p≤0.004-0.031). Dietary intervention is an effective treatment option for patients with symptomatic bile acid malabsorption and should be routinely considered.
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Affiliation(s)
- Amy Jackson
- GI unit, Royal Marsden NHS Foundation Trust, London and Sutton, UK
| | - Amyn Lalji
- GI unit, Royal Marsden NHS Foundation Trust, London and Sutton, UK
| | - Mohammed Kabir
- Department of Research and Development, Royal Marsden NHS Foundation Trust, London and Sutton, UK
| | - Ann Muls
- GI unit, Royal Marsden NHS Foundation Trust, London and Sutton, UK
| | - Caroline Gee
- GI unit, Royal Marsden NHS Foundation Trust, London and Sutton, UK
| | - Susan Vyoral
- Royal Marsden NHS Foundation Trust, London and Sutton, UK
| | - Clare Shaw
- Royal Marsden NHS Foundation Trust, London and Sutton, UK
| | - H Jervoise N Andreyev
- GI unit, United Licolnshire Hospitals NHS Trust, Lincoln County Hospital, Lincoln, UK
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28
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Abstract
PURPOSE OF REVIEW Our objective was to review advances in bile acids in health and disease published in the last 2 years. Bile acid diarrhea (BAD) is recognized as a common cause of chronic diarrhea, and its recognition has been facilitated by development of new screening tests. RECENT FINDINGS Primary BAD can account for 30% of cases of chronic diarrhea. The mechanisms leading to BAD include inadequate feedback regulation by fibroblast growth factor 19 (FGF-19) from ileal enterocytes, abnormalities in synthesis or degradation of proteins involved in FGF-19 regulation in hepatocytes and variations as a function of the bile acid receptor, TGR5 (GPBAR1). SeHCAT is the most widely used test for diagnosis of BAD. There has been significant validation of fasting serum FGF-19 and 7 α-hydroxy-cholesten-3-one (C4), a surrogate measure of bile acid synthesis. Bile acid sequestrants are the primary treatments for BAD; the farnesoid X-receptor-FGF-19 pathway provides alternative therapeutic targets for BAD. Bile acid-stimulated intestinal mechanisms contribute to the beneficial effects of bariatric surgery on obesity, glycemic control and the treatment of recurrent Clostridium difficile infection. SUMMARY Renewed interest in the role of bile acids is leading to novel management of diverse diseases besides BAD.
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