Canadian Association of Gastroenterology Clinical Practice Guideline on the Management of Bile Acid Diarrhea

Daniel C. Sadowski, Michael Camilleri, William D. Chey, Grigorios I. Leontiadis, John K. Marshall, Eldon A. Shaffer, Frances Tse, Julian R.F. Walters

Research output: Contribution to journalArticle

1 Citation (Scopus)

Abstract

Background & Aims: Chronic diarrhea affects about 5% of the population overall. Altered bile acid metabolism is a common but frequently undiagnosed cause. Methods: We performed a systematic search of publication databases for studies of assessment and management of bile acid diarrhea (BAD). The certainty (quality) of evidence and strength of recommendations were rated according to the Grading of Recommendation Assessment, Development and Evaluation approach. Patient population, intervention, comparator, and outcome questions were developed through an iterative process and were voted on by a group of specialists. Results: The certainty of evidence was generally rated as very low. Therefore, 16 of 17 recommendations are conditional. In patients with chronic diarrhea, consideration of risk factors (terminal ileal resection, cholecystectomy, or abdominal radiotherapy), but not additional symptoms, was recommended for identification of patients with possible BAD. The group suggested testing using 75selenium homocholic acid taurine (where available) or 7α-hydroxy-4-cholesten-3-one, including patients with irritable bowel syndrome with diarrhea, functional diarrhea, and Crohn's disease without inflammation. Testing was suggested over empiric bile acid sequestrant therapy (BAST). Once remediable causes are managed, the group suggested cholestyramine as initial therapy, with alternate BAST when tolerability is an issue. The group suggested against BAST for patients with extensive ileal Crohn's disease or resection and suggested alternative antidiarrheal agents if BAST is not tolerated. Maintenance BAST should be given at the lowest effective dose, with a trial of intermittent, on-demand administration, concurrent medication review, and reinvestigation for patients whose symptoms persist despite BAST. Conclusions: Based on a systematic review, BAD should be considered for patients with chronic diarrhea. For patients with positive results from tests for BAD, a trial of BAST, initially with cholestyramine, is suggested.

Original languageEnglish (US)
Pages (from-to)24-41.e1
JournalClinical Gastroenterology and Hepatology
Volume18
Issue number1
DOIs
StatePublished - Jan 2020

Fingerprint

Bile Acids and Salts
Practice Guidelines
Diarrhea
Cholestyramine Resin
Therapeutics
Crohn Disease
Concurrent Review
Ileal Diseases
Antidiarrheals
Irritable Bowel Syndrome
Taurine
Cholecystectomy
Population
Publications
Radiotherapy
Maintenance
Databases
Inflammation

Keywords

  • C4
  • FGF19
  • Fibroblast Growth Factor 19
  • IBS
  • SeHCAT

ASJC Scopus subject areas

  • Hepatology
  • Gastroenterology

Cite this

Canadian Association of Gastroenterology Clinical Practice Guideline on the Management of Bile Acid Diarrhea. / Sadowski, Daniel C.; Camilleri, Michael; Chey, William D.; Leontiadis, Grigorios I.; Marshall, John K.; Shaffer, Eldon A.; Tse, Frances; Walters, Julian R.F.

In: Clinical Gastroenterology and Hepatology, Vol. 18, No. 1, 01.2020, p. 24-41.e1.

Research output: Contribution to journalArticle

Sadowski, Daniel C. ; Camilleri, Michael ; Chey, William D. ; Leontiadis, Grigorios I. ; Marshall, John K. ; Shaffer, Eldon A. ; Tse, Frances ; Walters, Julian R.F. / Canadian Association of Gastroenterology Clinical Practice Guideline on the Management of Bile Acid Diarrhea. In: Clinical Gastroenterology and Hepatology. 2020 ; Vol. 18, No. 1. pp. 24-41.e1.
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