Patients with bile acid malabsorption typically present with chronic, watery diarrhea. Bile acids recirculate between the liver and small intestine in the enterohepatic circulation. They are reabsorbed in the distal small intestine, and normally only a small fraction of the bile acid pool is lost to the colon during each cycle. In patients with bile acid malabsorption, a larger amount of bile acids is spilled into the colon, where the acids stimulate electrolyte and water secretion, which results in loose to watery stools. The common causes of bile acid malabsorption are ileal resection and diseases of the terminal ileum (Crohn’s disease and radiation enteritis), which result in a loss of bile acid transporters and, consequently, diminished reabsorption. Bile acid malabsorption also has been documented in a small group of patients with chronic, watery diarrhea who have no demonstrable ileal disease (idiopathic bile acid malabsorption). The amount of bile acid loss to the colon determines the clinical presentation. Patients with mild to moderate bile acid malabsorption present with watery diarrhea and generally respond very well to treatment (with abolishment of diarrhea) with bile acid binders such as cholestyramine. Patients with more severe bile acid malabsorption have both diarrhea and steatorrhea. Treatment with cholestyramine is of no benefit in this group of patients and may, in fact, worsen steatorrhea. These patients are best treated with a low-fat diet supplemented with medium-chain triglycerides.
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References and Recommended Reading
Shneider BL: Intestinal bile acid transport: biology, physiology, and pathophysiology. J Pediatr Gastroenterol Nutr 2001, 32:407–417.
Hofmann AF: The continuing importance of bile acids in liver and intestinal disease. Arch Intern Med 1999, 159:2647–2658.
Hofmann AF, Poley JR: Cholestyramine treatment of diarrhea associated with ileal resection. N Engl J Med 1969, 281:397–402.
Hofmann AF, Poley JR: Role of bile acid malabsorption in pathogenesis of diarrhea and steatorrhea in patients with ileal resection. 1. Response to cholestyramine or replacement of dietary long chain triglyceride by medium chain triglyceride. Gastroenterology 1972, 62:918–934.
Thaysen EH, Pederson L: Idiopathic bile acid catharsis. Gut 1976, 17:965–970.
van Tilburg AJ, de Rooij FW, van den Berg JW, van Blankenstein M: Primary bile acid malabsorption: a pathophysiologic and clinical entity? Scand J Gastroenterol Suppl 1992, 194:66–70.
Oelkers P, Kirby LC, Heubi JE, Dawson PA: Primary bile acid malabsorption caused by mutations in the ileal sodium-dependent bile acid transporter gene (SCL10A2). J Clin Invest 1997, 99:1880–1887.
Montagnani M, Love MW, Rossel P, et al.: Absence of dysfunctional ileal sodium-bile acid cotransporter gene mutations in patients with adult-onset idiopathic bile acid malabsorption. Scand J Gastroenterol 2001, 36:1077–1080.
al-Hadrani A, Lavelle-Jones M, Kennedy N, et al.: Bile acid malabsorption in patients with post-vagotomy diarrhea. Ann Chir Gynaecol 1992, 81:351–353.
Sciarretta G, Furno A, Mazzoni M, Malaguti P: Post-cholecystectomy diarrhea: evidence of bile acid malabsorption assessed by SeHCAT test. Am J Gastroenterol 1992, 87:1852–1854.
Sauter GH, Moussavian AC, Meyer G, et al.: Bowel habits and bile acid malabsorption in the months after cholecystectomy. Am J Gastroenterol 2002, 97:1732–1735.
Niaz SK, Sandrasegaran K, Renny FH, Jones BJ: Postinfective diarrhoea and bile acid malabsorption. J R Coll Physicians Lond 1997, 31:53–56.
Ung KA, Gillberg R, Kilander A, Abrahamsson H: Role of bile acids and bile acid binding agents in patients with collagenous colitis. Gut 2000, 46:170–175.
Fernandez-Banares F, Esteve M, Salas A, et al.: Bile acid malabsorption in microscopic colitis and in previously unexplained functional chronic diarrhea. Dig Dis Sci 2001, 46:2231–2238.
Otte JJ, Andersen JR: The clinical value of faecal bile acid determination in patients with chronic diarrhea of unknown origin. Scand J Gastroenterol 1986, 21:585–588.
Schiller LR, Hogan RB, Morawski SG, et al.: Studies of the prevalence and significance of radiolabeled bile acid malabsorption in a group of patients with idiopathic chronic diarrhea. Gastroenterology 1987, 92:151–160.
Schiller LR, Bilhartz LE, Santa Ana CA, Fordtran JS: Comparison of endogenous and radiolabeled bile acid excretion in patients with idiopathic chronic diarrhea. Gastroenterology 1990, 98:1036–1043.
Ford GA, Preece JD, Davies IH, Wilkinson SP: Use of the SeHCAT test in the investigation of diarrhoea. Postgrad Med J 1992, 68:272–276.
Nyhlin H, Merrick MV, Eastwood MA: Bile acid malabsorption in Crohn’s disease and indications for its assessment using SeHCAT. Gut 1994, 35:90–93.
Smith MJ, Cherian P, Raju GS, et al.: Bile acid malabsorption in persistent diarrhoea. J R Coll Physicians Lond 2000, 34:448–451.
Wildt S, Norby Rasmussen S, Lysgard Madsen J, Rumessen JJ: Bile acid malabsorption in patients with chronic diarrhoea: clinical value of SeHCAT test. Scand J Gastroenterol 2003, 38:826–830.
Muller M, Willen R, Stotzer PO: Colonoscopy and SeHCAT for investigation of chronic diarrhea. Digestion 2004, 69:211–218.
Merrick MV, Eastwood MA, Ford MJ: Is bile acid malabsorption underdiagnosed? An evaluation of accuracy of diagnosis by measurement of SeHCAT retention. Br Med J (Clin Res Ed) 1985, 290:665–668.
Sciarretta G, Vicini G, Faglioli G, et al.: Use of 23-selena-25 homocholytaurine to detect bile acid malabsorption in patients with ileal dysfunction or diarrhea. Gastroenterology 1986, 91:1–9.
Williams AJ, Merrick MV, Eastwood MA: Idiopathic bile acid malabsorption—a review of clinical presentation, diagnosis, and response to treatment. Gut 1991, 32:1004–1006.
Eusufzai S: Bile acid malabsorption: mechanisms and treatment. Dig Dis 1995, 13:312–321.
Sinha L, Liston R, Testa HJ, Moriarty KJ: Idiopathic bile acid malabsorption: qualitative and quantitative clinical features and response to cholestyramine. Aliment Pharmacol Ther 1998, 12:839–844.
Luman W, Williams AJ, Merrick MV, Eastwood MA: Idiopathic bile acid malabsorption: long-term outcome. Eur J Gastroenterol Hepatol 1995, 7:641–645.
Rossel P, Sortsoe Jensen H, Qvist P, Arveschoug A: Prognosis of adult-onset idiopathic bile acid malabsorption. Scand J Gastroenterol 1999, 34:587–590.
Jung D, Fantin AC, Scheurer U, et al.: Human ileal bile acid transporter gene ASBT (SLC10A2) is transactivated by the glucocorticoid receptor. Gut 2004, 53:78–84.
Kwon RS, Carey MC: Do steroids ameliorate bile acid malabsorption in Crohn’s disease? Gut 2004, 53:10–11.
Lillienau J, Schteingart CD, Hofmann AF: Physicochemical and physiological properties of cholylsarcosine. A potential replacement detergent for bile acid deficiency states in the small intestine. J Clin Invest 1992, 89:420–431.
Schmassmann A, Fehr HF, Locher J, et al.: Cholylsarcosine, a new bile acid analogue: metabolism and effect on biliary secretion in humans. Gastroenterology 1993, 104:1171–1181.
Gruy-Kapral C, Little KH, Fordtran JS, et al.: Conjugated bile acid replacement therapy for short-bowel syndrome. Gastroenterology 1999, 116:15–21.
Heydorn S, Jeppesen PB, Mortensen PB: Bile acid replacement therapy with cholylsarcosine for short-bowel syndrome. Scand J Gastroenterol 1999, 34:818–823.
Popovic OS, Jojic N, Necic D: Cholylsarcosine for bile acid deficiency caused by ileal resection. Dig Dis Sci 1999, 44:1931–1932.
Aldridge MA, Ito MK: Colesevelam hydrochloride: a novel bile acid-binding resin. Ann Pharmacother 2001, 35:898–907.
Wong NN: Colesevelam: a new bile acid sequestrant. Heart Dis 2001, 3:63–70.
Steinmetz KL: Colesevelam hydrochloride. Am J Health Syst Pharm 2002, 59:932–939.
Puleston J, Morgan H, Andreyev J: New treatment for bile salt malabsorption. Gut 2005, 54:441–442.
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Westergaard, H. Bile acid malabsorption. Curr Treat Options Gastro 10, 28–33 (2007). https://doi.org/10.1007/s11938-007-0054-7
- Bile Acid
- Watery Diarrhea