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Canadian Journal of Gastroenterology
Volume 27, Issue 11, Pages 653-659

Bile Acid Malabsorption in Chronic Diarrhea: Pathophysiology and Treatment

Alan Barkun,1 Jonathan Love,2 Michael Gould,3 Henryk Pluta,4 and A Hillary Steinhart5

1Division of Gastroenterology, McGill University, Montreal, Quebec, Canada
2Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
3Toronto Digestive Disease Associates Inc, Toronto, Ontario, Canada
4Gastroenterology and Hepatology Clinic, Abbotsford, British Columbia, Canada
5Division of Gastroenterology, Mount Sinai Hospital and the University Health Network, Toronto, Ontario, Canada

Received 24 January 2013; Accepted 26 August 2013

Copyright © 2013 Hindawi Publishing Corporation. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


BACKGROUND: Bile acid malabsorption (BAM) is a common but frequently under-recognized cause of chronic diarrhea, with an estimated prevalence of 4% to 5%.

METHODS: The published literature for the period 1965 to 2012 was examined for articles regarding the pathophysiology and treatment of BAM to provide an overview of the management of BAM in gastroenterology practice.

RESULTS: BAM is classified as type 1 (secondary to ileal dysfunction), type 2 (idiopathic) or type 3 (secondary to gastrointestinal disorders not associated with ileal dysfunction). The estimated prevalence of BAM is >90% in patients with resected Crohn disease (CD) and 11% to 52% of unresected CD patients (type 1); 33% in diarrhea-predominant irritable bowel syndrome (type 2); and is a frequent finding postcholecystectomy or postvagotomy (type 3). Investigations include BAM fecal bile acid assay, 23-seleno-25-homo-tauro-cholic acid (SeHCAT) testing and high-performance liquid chromatography of serum 7-α-OH-4-cholesten-3-one (C4), to determine the level of bile acid synthesis. A less time-consuming and expensive alternative in practice is an empirical trial of the bile acid sequestering agent cholestyramine. An estimated 70% to 96% of chronic diarrhea patients with BAM respond to short-course cholestyramine. Adverse effects include constipation, nausea, borborygmi, flatulence, bloating and abdominal pain. Other bile acid sequestering agents, such as colestipol and colesevelam, are currently being investigated for the treatment of BAM-associated diarrhea.

CONCLUSIONS: BAM is a common cause of chronic diarrhea presenting in gastroenterology practice. In accordance with current guidelines, an empirical trial of a bile acid sequestering agent is warranted as part of the clinical workup to rule out BAM.