Physiology of bile acid diarrhoea

Professor Julian R.F. Walters

Consultant Gastroenterologist and Professor of Gastroenterology, Imperial College London, London, UK

Bile acid diarrhoea (BAD) is a common but under-recognised cause of chronic functional diarrhoea, accounting for up to a third of patients who otherwise would be labelled as diarrhoea-predominant irritable bowel syndrome (IBS-D).1,2

Bile acids normally undergo an enterohepatic circulation. This starts with the hepatic synthesis of bile acids from cholesterol, and then conjugation with glycine or taurine.3

The conjugated bile acids are then secreted via the bile ducts into the intestine, where they solubilise lipids into micelles to aid in their absorption. Bile acids undergo reabsorption, with active absorption of conjugated bile acids in the ileum. Uptake of bile acids by the hepatocytes then occurs, and they are subsequently resecreted.3 If bile acids enter the colon, diarrhoea can result.2

In BAD, an excess of bile acids is found in the colon, either because they are not absorbed in the small intestine, or due to overproduction.1 Bacterial metabolism changes bile acids, producing stimulation of colon secretions with watery diarrhoea, and increased motility.1

Methods that have been used for diagnosing BAD include measuring faecal bile acids, the tauroselcholic...

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Job number: JB57410GBl(1) Date of Preparation: June 2020

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How common is bile acid diarrhoea (BAD)?
Professor David S. Sanders 

How common is bile acid diarrhoea (BAD)?
Professor David S. Sanders 

Professor Sanders argues that many patients presenting with irritable bowel syndrome (IBS) have underlying diseases. He explores a series of studies that suggest approximately 25% of patients presenting with IBS symptoms have BAD as the underlying cause. 

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