Bile Acid Diarrhoea – Causes, Symptoms and Treatment
Bile acid diarrhoea is a chronic diarrhoeal condition caused by excess bile acids reaching the colon. It commonly occurs after small bowel surgery or in association with conditions such as Crohn's disease.
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Bile acid diarrhoea is a chronic diarrhoeal condition caused by excess bile acids reaching the colon. It commonly occurs after small bowel surgery or in association with conditions such as Crohn's disease.
What is Bile Acid Diarrhoea?
Bile acid diarrhoea (also known as bile acid malabsorption or bile salt diarrhoea) is a form of chronic diarrhoea that occurs when excess bile acids pass into the large intestine (colon). Under normal circumstances, bile acids are reabsorbed in the final section of the small intestine (terminal ileum) and recycled by the body. When this process is disrupted, the excess bile acids irritate the lining of the colon and stimulate fluid secretion, resulting in watery diarrhoea.
Causes
Bile acid diarrhoea can be triggered by a variety of medical conditions and surgical procedures:
- Surgical resection of the terminal ileum: for example in Crohn's disease or colorectal cancer, removing the segment responsible for bile acid reabsorption
- Crohn's disease: a chronic inflammatory bowel disease that can affect the ileum and impair its function
- Cholecystectomy: removal of the gallbladder, after which bile acids flow continuously into the intestine rather than being stored
- Idiopathic bile acid malabsorption: occurring without an identifiable underlying cause, often overlapping with irritable bowel syndrome (IBS)
- Pelvic radiotherapy, which can damage the ileum
- Coeliac disease or other conditions causing damage to the small intestinal mucosa
Symptoms
Typical symptoms of bile acid diarrhoea include:
- Watery, often yellow-coloured diarrhoea
- Sudden and urgent need to defecate
- Abdominal cramps and bloating
- Frequent bowel movements, including at night
- In severe cases: weight loss and nutritional deficiencies
Diagnosis
Several methods can be used to diagnose bile acid diarrhoea:
- SeHCAT test (selenium-75 homocholic acid taurine test): a nuclear medicine scan in which a radiolabelled bile acid is swallowed and its retention is measured over seven days. Low retention values indicate bile acid malabsorption.
- Serum C4 levels (7-alpha-hydroxy-4-cholesten-3-one): elevated levels indicate increased bile acid synthesis and suggest malabsorption.
- Stool bile acid measurement
- Exclusion of other causes through colonoscopy and laboratory tests
Treatment
Treatment depends on the underlying cause and the severity of symptoms:
Medication
- Bile acid sequestrants (anion exchange resins): First-line treatments include cholestyramine, colesevelam, and colestipol. These medications bind excess bile acids in the intestine, preventing them from irritating the bowel lining.
- Budesonide: A locally acting corticosteroid that may be used in cases where microscopic colitis is a concurrent diagnosis.
Dietary Adjustments
- A low-fat diet may help, as dietary fat stimulates bile acid production
- Smaller, more frequent meals are often better tolerated
- Adequate fluid intake to compensate for fluid losses
Treatment of the Underlying Condition
In cases related to Crohn's disease or other underlying conditions, treating the root cause is an essential part of management. Close collaboration with a gastroenterologist is recommended.
References
- Walters, J. R. F. (2014): Bile acid diarrhoea and FGF19: new views on diagnosis, pathogenesis and therapy. Nature Reviews Gastroenterology and Hepatology, 11(7), 426-434.
- Wedlake, L. et al. (2009): Systematic review: the prevalence of idiopathic bile acid malabsorption as diagnosed by SeHCAT scanning in patients with diarrhoea-predominant irritable bowel syndrome. Alimentary Pharmacology and Therapeutics, 30(7), 707-717.
- National Institute for Health and Care Excellence (NICE): Bile acid malabsorption -- diagnosis and management. NICE guideline evidence review (2023).
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