Prevalence of, and predictors of, bile acid diarrhea in outpatients with chronic diarrhea: A follow‐up study

Abstract

Background 23‐seleno‐25‐homo‐tauro‐cholic acid (SeHCAT) scanning to rule out bile acid diarrhea (BAD) in patients with chronic diarrhea has a high yield. Our previous study showed that patients with terminal ileal (TI) Crohn's disease, TI resection, or cholecystectomy were highly likely to have an abnormal scan. As a result, we encouraged clinicians to use a therapeutic trial of a bile acid sequestrant in these patients, instead of scanning. This may have reduced diagnostic yield of the test, so we examined this issue, as well as factors predicting an abnormal scan, in a large cohort of patients referred subsequently. Methods We retrospectively identified 1,071 consecutive patients with chronic diarrhea undergoing SeHCAT scanning at Leeds Teaching Hospitals Trust from 2012 to 2016. We reviewed electronic patient records to obtain information on presenting gastrointestinal symptoms and any proposed risk factors for BAD. BAD was categorized according to subtype and severity. Key Results As expected, indications for scanning changed between 2012 and 2016, with a significant reduction in referrals with TI Crohn's disease or resection year‐on‐year (P < 0.001). Despite this, 457 (42.7%) patients had BAD and there was no downward trend in yield of SeHCAT during the 5 year period (P = 0.39). Overall, 51.6% had type II BAD, 36.1% type III, and 12.3% type I. BAD was mild in 31.7%, moderate in 34.4%, and severe in 33.9%. In total, 653 (61.0%) patients had no known risk factors, other than chronic diarrhea, but 233 (35.7%) of these individuals had BAD, and in 143 (61.4%), this was moderate or severe. Conclusions and Inferences Despite reduced referrals for SeHCAT scanning in those with clear risk factors for BAD, the yield remained > 40%. One‐third of those without known risk factors had BAD.

Prevalence of irritable bowel syndrome-type symptoms in patients with inflammatory bowel disease in remission: a systematic review and meta-analysis

“…(47,48) In addition, small bowel disease increases the risk of bacterial overgrowth, and terminal ileal CD may be associated with bile acid diarrhoea, particularly in those who have undergone prior ileal resection. (49)(50)(51) Delays in diagnosis of small bowel CD may also lead to a prolonged inflammatory insult, potentially increasing the risk of fibrosis, stricturing, and mechanical dysfunction of the gastrointestinal tract. (16,39) These associated conditions can mimic IBS-type symptoms and could explain the increased prevalence observed in CD.…”

Prevalence and clinical features of bile acid diarrhea in patients with chronic diarrhea

“…Dark gray slices: number and percentage of patients affected by organic forms of chronic diarrhea, including four with Crohn's disease, four with drug-induced diarrhea (metformin in two, olmesartan in one, mycophenolate in one), two with celiac disease, one each of microscopic colitis, hyperthyroidism, metastatic neuroendocrine tumor, ulcerative colitis, salmonellosis, small intestinal bacterial overgrowth prevalence of BAD in patients with chronic diarrhea. [13][14][15][16][17][18] These studies, performed in tertiary referrals and with SeHCAT test, reported a prevalence of BAD of between 6% and 50%. [13][14][15][16][17][18] Although our results were based on a therapeutic trial of cholestyramine, they parallel the findings obtained with the SeHCAT test.…”

“…[13][14][15][16][17][18] These studies, performed in tertiary referrals and with SeHCAT test, reported a prevalence of BAD of between 6% and 50%. [13][14][15][16][17][18] Although our results were based on a therapeutic trial of cholestyramine, they parallel the findings obtained with the SeHCAT test. Therefore, clinical response to a therapeutic trial of cholestyramine could be adopted as an alternative diagnostic strategy for BAD, not only in everyday clinical practice but also in research and epidemiological studies.…”

“…[10][11][12] So far, only a few studies have systematically evaluated the prevalence and clinical features of BAD in patients with chronic diarrhea, and only recently specific guidelines for the diagnosis and management of BAD have been developed. 9,[13][14][15][16][17][18][19][20] Therefore, the aim of this study was to evaluate the prevalence and clinical features of BAD in a cohort of patients consecutively assessed for chronic diarrhea in a single Outpatient Gastroenterology Clinic. While those who initially responded to cholestyramine but reported persistent well-being 6 months after last taking cholestyramine were not considered to be affected by BAD.…”

Effect of cholecystectomy on bile acid diarrhoea biomarkers: A prospective clinical study

“…Chronic watery diarrhoea is a common complaint after cholecystectomy, with an estimated cumulative incidence of 9%, 1 and bile acid diarrhoea may account for 66% of this. [1][2][3] Bile acid diarrhoea is caused by excess bile acids spilling over from the small intestine to the large intestine, triggering secretion and peristalsis. 4 Ultimately this leads to diarrhoea that may be socially debilitating.…”