Systematic review: the prevalence of idiopathic bile acid malabsorption as diagnosed by SeHCAT scanning in patients with diarrhoea‐predominant irritable bowel syndrome

Abstract

Summary Background Recurrent, watery diarrhoea affects one‐third of patients diagnosed with irritable bowel syndrome (‘IBS‐D’). Idiopathic bile acid malabsorption (‘I‐BAM’) may be the cause. Aim To determine the prevalence of I‐BAM in patients suffering from IBS‐D. Methods A systematic search was performed of publications reporting patients presenting with IBS‐D type symptoms, who were subsequently confirmed as having I‐BAM by SeHCAT scanning. Results Eighteen relevant studies, 15 prospective, comprising 1223 patients were identified. Five studies (429 patients) indicated that 10% (CI: 7–13) patients had severe bile acid malabsorption (SeHCAT 7 day retention <5% of baseline value). 17 studies (1073 patients) indicated that 32% (CI: 29–35) patients had moderate bile acid malabsorption (SeHCAT <10%). 7 studies (618 patients) indicated that 26% (CI: 23–30) patients had mild (SeHCAT <15%) bile acid malabsorption. Pooled data from 15 studies showed a dose‐response relationship according to severity of malabsorption to treatment with a bile acid binder: response to colestyramine occurred in 96% of patients with <5% retention, 80% at <10% retention and 70% at <15% retention. Conclusions Idiopathic adult‐onset bile acid malabsorption is not rare. International guidelines for the management of irritable bowel syndrome need to be revised so that clinicians become more aware of this possibility.

High Prevalence of Idiopathic Bile Acid Diarrhea Among Patients With Diarrhea-Predominant Irritable Bowel Syndrome Based on Rome III Criteria

“…Nevertheless, other studies have demonstrated a beneficial response to open treatment, particularly in those with moderate to severe BAD. 17,23 A systematic review noted that response to colestyramine occurred in 96% of patients with 75 SeHCAT retention <5%, 80% with 75 SeHCAT retention <10%, and 70% with 75 SeHCAT retention <15%. 23 In our study, of those that had BAD, 28.6% were mild, 28.6% moderate and 42.8% severe.…”

“…17,23 A systematic review noted that response to colestyramine occurred in 96% of patients with 75 SeHCAT retention <5%, 80% with 75 SeHCAT retention <10%, and 70% with 75 SeHCAT retention <15%. 23 In our study, of those that had BAD, 28.6% were mild, 28.6% moderate and 42.8% severe. This suggests that making a positive diagnosis will be of clinical benefit, and serves as a mandate for randomized placebo-controlled trials of bile acid sequestrants in D-IBS.…”

“…23 However, many of the included studies were either retrospective in nature, did not use symptom-based criteria to define D-IBS, or included patients with chronic functional diarrhea. Nevertheless, a recent prospective evaluation has shown that 23% of patients with D-IBS have a 75…”

Validation of the Rome III Criteria for the Diagnosis of Irritable Bowel Syndrome in Secondary Care

“…7 Individuals with IBS are more likely to consume health care resources than healthy individuals, 8 with up to 80% of sufferers consulting their primary care physician as a result of symptoms. 9,10 Diagnosing IBS can be challenging due to overlap between the symptoms that sufferers report and those of organic GI conditions such as celiac disease, [11][12][13] small intestinal bacterial overgrowth, 14 bile acid diarrhea, 15,16 exocrine pancreatic insufficiency, 17 or inflammatory bowel disease. 18 Partly as a result of this uncertainty, symptom-based diagnostic criteria were developed for use by physicians consulting with patients with suspected IBS as early as the 1970s, with Manning et al reporting six symptoms that were commoner among individuals found ultimately to have IBS after investigation.…”

Therapeutic strategies for functional dyspepsia and irritable bowel syndrome based on pathophysiology

“…Recent studies on the prevalence of bile acid malabsorption suggest this may be a common cause of IBS-D symptoms (up to one in four cases), and targeted therapeutic intervention with a bile acid binder (e.g. cholestyramine) may be warranted [21,22].…”