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Bile acid diarrhea

Definition
BAD is a form of chronic diarrhea characterized by impaired reabsorption of bile acids in the small intestine.
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Pathophysiology
In BAD, the acids recirculation between the liver and small intestine in the enterohepatic recirculation is disrupted, leading to an overabundance of bile acids in the colon, which can cause water and electrolyte secretion and result in diarrhea.
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Epidemiology
The prevalence of BAD is estimated at 28.1% in patients with chronic diarrhea.
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Disease course
Clinically, patients with BAD typically present with chronic watery diarrhea. Other symptoms may include urgency, bloating, and abdominal pain. The severity of symptoms can vary, with some patients experiencing mild to moderate diarrhea that responds well to treatment, while others may have more severe diarrhea and steatorrhea, which may not respond to treatment.
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Prognosis and risk of recurrence
The prognosis of BAD can vary depending on the underlying cause and the effectiveness of treatment. Patients with mild to moderate bile acid malabsorption generally respond very well to treatment with bile acid binders. However, patients with more severe bile acid malabsorption may not benefit from such treatment and may require dietary modifications.
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Key sources
The following summarized guidelines for the evaluation and management of bile acid diarrhea are prepared by our editorial team based on guidelines from the Canadian Association of Gastroenterologists (CAG 2020).
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Guidelines

1.Diagnostic investigations

Clinical evaluation
Ask about risk factors (history of terminal ileal resection, cholecystectomy, or abdominal radiotherapy) in the initial assessment of patients presenting with chronic non-bloody diarrhea to identify possible BAD.
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Do not use presenting symptoms in the initial assessment in patients presenting with chronic non-bloody diarrhea to identify possible BAD.
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  • Laboratory testing

2.Medical management

Bile acid sequestrants, choice of agent: consider administering cholestyramine for induction of clinical response in patients with BAD.
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More topics in this section

  • Bile acid sequestrants (dosing)

  • Bile acid sequestrants (monitoring)

  • Anti-diarrheal agents

  • Management of secondary causes

3.Follow-up and surveillance

Follow-up: obtain diagnostic reevaluation in patients with BAD and recurrent or worsening symptoms despite stable bile acid sequestrant therapy.
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