A source for healthcare professionals to access the latest data and information on the diagnosis, treatment and management of patients with gut related disorders


How common is diarrhoea caused by bile acids?

Professor David S. Sanders

Consultant Gastroenterologist and Professor, Royal Hallamshire Hospital and the University of Sheffield, Sheffield, UK

Diarrhoea caused by excess bile acids reaching the colon or bile acid diarrhoea (BAD), which has historically been referred to as bile acid malabsorption (BAM), is not a new disorder. In fact, the first reports of this disease appeared in the 1960s. The diseases in which BAD can be observed are chronic diarrhoea, cholecystectomy, microscopic colitis and irritable bowel syndrome (IBS).

A study published in 2007 conducted in patients with functional diarrhoea observed that diarrhoea was caused by BAD in 45% of the cases, while only 16% of the study patients had gluten sensitivity problems.1 A more recent review conducted in more than 1,000 patients with chronic diarrhoea and IBS symptoms, measured the tauroselcholic (75selenium) acid (SeHCAT) retention of these patients and concluded that approximately 30% of the patients presented with BAD.2 This review found that an extremely high percentage of patients responded to treatment with cholestyramine (96% of patients with SeHCAT retention <5, 80% with a retention of <10% and 70% with a retention of <15%).2

There is clinical confusion between chronic diarrhoea and diarrhoea-predominant IBS. Although there are fixed definitions for both conditions, the discriminatory feature appears to be the presence or absence of abdominal pain.3 However, patients do not always perfectly sit within these research based constructs. One example of this overlap is a recent study that clarified the possible causes of chronic diarrhoea in 89 patients. The investigators found that the main cause of diarrhoea was IBS, while diarrhoea caused by bile acids was the fourth leading cause.4 Two themes emerge from the existing body of literature. The first is that patients with IBS-type symptoms can have underlying undetected BAD. The second theme is the delay in diagnosis for patients with BAD. Our UK based study demonstrated that the diagnosis of BAD was made at a mean of 248 days from presentation, compared with 35 days for the diagnosis of coeliac disease.4

The association between cholecystectomy and BAD relates to the storage and recirculation of bile acids. Bile acids are produced by the liver and then stored in the gall bladder. If a cholecystectomy is performed then loss of bile acids occurs with the potential for subsequent gastrointestinal symptoms.5 Moreover, studies assessing BAD in patients with functional diarrhoea have observed that 23% of these patients had previously undergone cholecystectomy.6

Another of the causes of chronic diarrhoea is microscopic colitis. The incidence of this disease has increased in recent years and is related to BAD. Budesonide is a good therapeutic option for microscopic colitis as the drug is associated with an increase in bile acid absorption.7 An association between lymphocytic colitis and diarrhoea due to BAD has also been observed.8


Professor David S. Sanders is Professor of Gastroenterology at The University of Sheffield and an NHS consultant based in The Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK. He is the current Chair of the Coeliac UK Health Advisory Council, BSG Council Member and President of the International Society for the Study of Coeliac Disease (ISSCD). He is a medical doctor, international researcher and author.


1. Fernández-Bañares F et al. Am J Gastroenterol 2007;102:2520–2528.
2. Wedlake L et al. Aliment Pharmacol Ther 2009;30:707–717.
3. Lacy BE et al. Gastroenterology 2016;150:1393–1407.
4. Kurien M et al. Aliment Pharmacol Ther. 2014;40:215.
5. Sauter GH et al. Am J Gastroenterol 2002;97:1732–1725
6. Maisterra S et al. Bile acid malabsorption in the diagnosis of chronic diarrhea. Digestive Disease Week Congress 2011; May 19–22; San Diego, CA, USA. Sa1305.
7. Bajor A et al. Aliment Pharmacol Ther. 2006;24:1643–1649.
8. Fernández-Bañares F et al. Am J Gastroenterol 2009;104:1189–1198.

Job number: JB57410GBm Date of Preparation: June 2019

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