Pathophysiology and Clinical Management of Bile Acid Diarrhea

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.

A case for screening real‐world data for collateral drug benefits: Glucagon‐like peptide 1 receptor agonists and bile acid diarrhea

“…The current mainstay of treatment for BAD is bile acid sequestrants (BAS) 5 . In addition to treatment of bile acid associated diarrhea, BAS are also used as cholesterol‐lowering treatment, but owing to high cost and low palatability, they are not used much for this indication 5 . Since patients who incidentally are treated with GLP1‐RA are already effectively treated for BAD, we would expect a lower‐than‐expected rate of BAS initiations among its users, that is, an inverse association between GLP1‐RA and BAS initiation.…”

“…The current mainstay of treatment for BAD is bile acid sequestrants (BAS) 5 . In addition to treatment of bile acid associated diarrhea, BAS are also used as cholesterol‐lowering treatment, but owing to high cost and low palatability, they are not used much for this indication 5 .…”

Das Reizdarmsyndrom aus Sicht der Naturheilkunde

“…Eine weitaus seltenere Ursache von RDS-Symptomen ist das Gallensäureverlustsyndrom 3 . Es äußert sich mit Durchfällen, Blähungen, Fettstühlen und der Malabsorption fettlöslicher Vitamine.…”

Management of Irritable Bowel Syndrome With Diarrhea

“…11 The pathophysiology of IBS includes several factors such as dysbiosis, increased intestinal permeability, mucosal immune activation, altered intestinal motor function, visceral hypersensitivity, and altered processing of information in the central nervous system. 2,[12][13][14][15][16] IBS is defined by symptom-based diagnostic criteria, known as the "Rome criteria," derived by consensus from a multinational group of experts, currently in their IV update which is reported in Table 1. 2 Patients are categorized according to predominant stool pattern by the use of the Bristol Stool Form Scale.…”

“…IBS development, likely in genetically predisposed subjects, 5 can be triggered by a number of events, such as antibiotic exposure or other disruptors of gut physiology and microbiota such as an acute bout of gastrointestinal infection, 6–10 menses, diet, and psychological factors 11 . The pathophysiology of IBS includes several factors such as dysbiosis, increased intestinal permeability, mucosal immune activation, altered intestinal motor function, visceral hypersensitivity, and altered processing of information in the central nervous system 2,12–16 . IBS is defined by symptom-based diagnostic criteria, known as the “Rome criteria,” derived by consensus from a multinational group of experts, currently in their IV update which is reported in Table 1 2 .…”