{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,28]],"date-time":"2026-10-28T06:13:03Z","timestamp":1793167983954,"version":"4.5.0"},"reference-count":83,"publisher":"BMJ","issue":"6","license":[{"start":{"date-parts":[[2020,9,22]],"date-time":"2020-09-22T00:00:00Z","timestamp":1600732800000},"content-version":"unspecified","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["Frontline Gastroenterol"],"accepted":{"date-parts":[[2020,5,27]]},"published-print":{"date-parts":[[2021,11]]},"abstract":"<jats:p>The actual incidence of bile acid diarrhoea (BAD) is unknown, however, there is increasing evidence that it is misdiagnosed in up to 30% with diarrhoea-predominant patients with irritable bowel syndrome. Besides this, it may also occur following cholecystectomy, infectious diarrhoea and pelvic chemoradiotherapy.<\/jats:p>\n               <jats:p>BAD may result from either hepatic overproduction of bile acids or their malabsorption in the terminal ileum. It can result in symptoms such as bowel frequency, urgency, nocturnal defecation, excessive flatulence, abdominal pain and incontinence of stool. Bile acid synthesis is regulated by negative feedback loops related to the enterohepatic circulation, which are dependent on the farnesoid X receptor and fibroblast growth factor 19. Interruption of these feedback loops is thought to cause bile acid overproduction leading to BAD. This process may occur idiopathically or following a specific trigger such as cholecystectomy. There may also be an interplay with the gut microbiota, which has been reported to be significantly different in patients with severe BAD.<\/jats:p>\n               <jats:p>Patients with suspected BAD are investigated in various ways including radionucleotide imaging such as SeHCAT scans (though this is not available worldwide) and blood tests. However, other methods such as bile acid measurement in stool (either spot test or 48\u2009hours samples) and urine tests have been explored. Importantly, delay in diagnosis and treatment of BAD greatly affects patient\u2019s quality of life and may double the overall cost of diagnosis.<\/jats:p>","DOI":"10.1136\/flgastro-2020-101436","type":"journal-article","created":{"date-parts":[[2020,9,22]],"date-time":"2020-09-22T18:43:08Z","timestamp":1600800188000},"page":"500-507","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":39,"title":["Bile acid diarrhoea: pathophysiology, diagnosis and management"],"prefix":"10.1136","volume":"12","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-4366-9068","authenticated-orcid":false,"given":"Alexia","family":"Farrugia","sequence":"first","affiliation":[{"name":"Surgery, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK"},{"name":"Divison of Biomedical Sciences, University of Warwick, Warwick Medical School, Coventry, Coventry, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2231-3062","authenticated-orcid":false,"given":"Ramesh","family":"Arasaradnam","sequence":"additional","affiliation":[{"name":"Divison of Biomedical Sciences, University of Warwick, Warwick Medical School, Coventry, Coventry, UK"},{"name":"Gastroenterology, University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2020,9,22]]},"reference":[{"key":"2025090708344446000_12.6.500.1","doi-asserted-by":"publisher","DOI":"10.1136\/flgastro-2019-101301"},{"key":"2025090708344446000_12.6.500.2","doi-asserted-by":"crossref","first-page":"752","DOI":"10.1016\/S0016-5085(67)80140-9","article-title":"The syndrome of ileal disease and the broken enterohepatic circulation: cholerheic enteropathy","volume":"52","author":"Hofmann","year":"1967","journal-title":"Gastroenterology"},{"key":"2025090708344446000_12.6.500.3","doi-asserted-by":"publisher","DOI":"10.1016\/j.cgh.2009.04.024"},{"key":"2025090708344446000_12.6.500.4","doi-asserted-by":"publisher","DOI":"10.3109\/00365521.2011.574728"},{"key":"2025090708344446000_12.6.500.5","doi-asserted-by":"publisher","DOI":"10.1136\/gutjnl-2013-305965"},{"key":"2025090708344446000_12.6.500.6","doi-asserted-by":"publisher","DOI":"10.1136\/gut.35.1.90"},{"key":"2025090708344446000_12.6.500.7","doi-asserted-by":"publisher","DOI":"10.1097\/00002030-199610000-00011"},{"key":"2025090708344446000_12.6.500.8","first-page":"1852","article-title":"Post-Cholecystectomy diarrhea: evidence of bile acid malabsorption assessed by SeHCAT test","volume":"87","author":"Sciarretta","year":"1992","journal-title":"Am J Gastroenterol"},{"key":"2025090708344446000_12.6.500.9","first-page":"53","article-title":"Postinfective diarrhoea and bile acid malabsorption","volume":"31","author":"Niaz","year":"1997","journal-title":"J R Coll Physicians Lond"},{"key":"2025090708344446000_12.6.500.10","doi-asserted-by":"publisher","DOI":"10.5009\/gnl14397"},{"key":"2025090708344446000_12.6.500.11","doi-asserted-by":"publisher","DOI":"10.1177\/1756283X10377126"},{"key":"2025090708344446000_12.6.500.12","doi-asserted-by":"publisher","DOI":"10.1023\/A:1011927302076"},{"key":"2025090708344446000_12.6.500.13","doi-asserted-by":"crossref","first-page":"730","DOI":"10.1111\/codi.12932","article-title":"Are bile acid malabsorption and bile acid diarrhoea important causes of loose stool complicating cancer therapy?","volume":"17","author":"Phillips","year":"2015","journal-title":"Colorectal Dis"},{"key":"2025090708344446000_12.6.500.14","doi-asserted-by":"crossref","unstructured":"Takikawa H . Metabolism of Bile Acids. In: Tazuma S , Takikawa H , eds. Bile acids in gastroenterology: basic and clinical. Tokyo: Springer Japan, 2017: 3\u20138.","DOI":"10.1007\/978-4-431-56062-3_1"},{"key":"2025090708344446000_12.6.500.15","doi-asserted-by":"crossref","unstructured":"Honda A , Ikegami T , Matsuzaki Y . Intestinal Digestion and Absorption. In: Tazuma S , Takikawa H , eds. Bile acids in gastroenterology: basic and clinical. Tokyo: Springer Japan, 2017: 27\u201341.","DOI":"10.1007\/978-4-431-56062-3_3"},{"key":"2025090708344446000_12.6.500.16","doi-asserted-by":"publisher","DOI":"10.3748\/wjg.14.5630"},{"key":"2025090708344446000_12.6.500.17","doi-asserted-by":"crossref","first-page":"1233","DOI":"10.1053\/j.gastro.2018.11.069","article-title":"Current practice in the diagnosis of bile acid diarrhea","volume":"156","author":"Vijayvargiya","year":"2019","journal-title":"Gastroenterology"},{"key":"2025090708344446000_12.6.500.18","unstructured":"Harrison\u2019s Principles of Internal Medicine 14th ed 1998 McGraw Hill"},{"key":"2025090708344446000_12.6.500.19","doi-asserted-by":"publisher","DOI":"10.1136\/gut.25.4.405"},{"key":"2025090708344446000_12.6.500.20","doi-asserted-by":"crossref","first-page":"6757","DOI":"10.3748\/wjg.v22.i30.6757","article-title":"Mechanisms of triglyceride metabolism in patients with bile acid diarrhea","volume":"22","author":"Sagar","year":"2016","journal-title":"World J Gastroenterol"},{"key":"2025090708344446000_12.6.500.21","doi-asserted-by":"publisher","DOI":"10.1016\/j.steroids.2014.04.016"},{"key":"2025090708344446000_12.6.500.22","doi-asserted-by":"publisher","DOI":"10.1038\/nrgastro.2014.32"},{"key":"2025090708344446000_12.6.500.23","doi-asserted-by":"crossref","first-page":"725","DOI":"10.1016\/j.jcmgh.2016.08.004","article-title":"The farnesoid X receptor: good for bad","volume":"2","author":"Keely","year":"2016","journal-title":"Cell Mol Gastroenterol Hepatol"},{"key":"2025090708344446000_12.6.500.24","doi-asserted-by":"publisher","DOI":"10.1111\/j.1478-3231.2010.02361.x"},{"key":"2025090708344446000_12.6.500.25","doi-asserted-by":"crossref","unstructured":"Tazuma STH Se T , He T , eds. Bile acids in gastroenterology : basic and clinical. editors: Springer, 2017.","DOI":"10.1007\/978-4-431-56062-3"},{"key":"2025090708344446000_12.6.500.26","first-page":"661","article-title":"Effect of molecular structure on bile acid-induced alterations in absorptive function, permeability, and morphology in the perfused rabbit colon","volume":"94","author":"Chadwick","year":"1979","journal-title":"J Lab Clin Med"},{"key":"2025090708344446000_12.6.500.27","doi-asserted-by":"publisher","DOI":"10.1172\/JCI106644"},{"key":"2025090708344446000_12.6.500.28","doi-asserted-by":"publisher","DOI":"10.1152\/ajpgi.00194.2001"},{"key":"2025090708344446000_12.6.500.29","doi-asserted-by":"crossref","first-page":"423","DOI":"10.1038\/ajg.2015.424","article-title":"Characterizing factors associated with differences in FGF19 blood levels and synthesis in patients with primary bile acid diarrhea","volume":"111","author":"Johnston","year":"2016","journal-title":"Am J Gastroenterol"},{"key":"2025090708344446000_12.6.500.30","doi-asserted-by":"crossref","first-page":"1454","DOI":"10.1016\/0016-5085(81)90257-2","article-title":"Factors in the mechanism of diarrhea in bile acid malabsorption: fecal pH--a key determinant","volume":"80","author":"McJunkin","year":"1981","journal-title":"Gastroenterology"},{"key":"2025090708344446000_12.6.500.31","doi-asserted-by":"publisher","DOI":"10.1111\/j.1572-0241.2004.04139.x"},{"key":"2025090708344446000_12.6.500.32","doi-asserted-by":"publisher","DOI":"10.1136\/gut.28.8.970"},{"key":"2025090708344446000_12.6.500.33","doi-asserted-by":"publisher","DOI":"10.1111\/j.1365-2982.2011.01772.x"},{"key":"2025090708344446000_12.6.500.34","doi-asserted-by":"publisher","DOI":"10.1155\/2015\/317093"},{"key":"2025090708344446000_12.6.500.35","doi-asserted-by":"publisher","DOI":"10.1007\/s10620-013-2744-4"},{"key":"2025090708344446000_12.6.500.36","doi-asserted-by":"publisher","DOI":"10.1016\/j.cmet.2013.01.003"},{"key":"2025090708344446000_12.6.500.37","doi-asserted-by":"publisher","DOI":"10.1016\/j.nut.2013.11.018"},{"key":"2025090708344446000_12.6.500.38","doi-asserted-by":"publisher","DOI":"10.1007\/s11154-019-09512-0"},{"key":"2025090708344446000_12.6.500.39","doi-asserted-by":"crossref","first-page":"1016","DOI":"10.1053\/j.gastro.2019.11.301","article-title":"Differences in fecal Microbiomes and metabolomes of people with vs without irritable bowel syndrome and bile acid malabsorption","volume":"158","author":"Jeffery","year":"2020","journal-title":"Gastroenterology"},{"key":"2025090708344446000_12.6.500.40","doi-asserted-by":"crossref","first-page":"1602","DOI":"10.1016\/j.cgh.2016.05.033","article-title":"Similar fecal microbiota signatures in patients with diarrhea-predominant irritable bowel syndrome and patients with depression","volume":"14","author":"Liu","year":"2016","journal-title":"Clin Gastroenterol Hepatol"},{"key":"2025090708344446000_12.6.500.41","doi-asserted-by":"crossref","unstructured":"Sagar N , Duboc H , Kay G , et al . OWE-021\u2005Describing the gut microbiome and metabolomic changes in bile acid diarrhoea. Gut 2018;67.","DOI":"10.1136\/gutjnl-2018-BSGAbstracts.317"},{"key":"2025090708344446000_12.6.500.42","doi-asserted-by":"publisher","DOI":"10.1136\/gutjnl-2017-315909"},{"key":"2025090708344446000_12.6.500.43","first-page":"126","article-title":"Enterohepatic circulation in man of a gamma-emitting bile-acid conjugate, 23-selena-25-homotaurocholic acid (SeHCAT)","volume":"23","author":"Merrick","year":"1982","journal-title":"J Nucl Med"},{"key":"2025090708344446000_12.6.500.44","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.290.6469.665"},{"key":"2025090708344446000_12.6.500.45","unstructured":"NICE . SeHCAT (tauroselcholic [75 selenium] acid) for the investigation of diarrhoea due to bile acid malabsorption in people with diarrhoea-predominant irritable bowel syndrome (IBS-D) or Crohn\u2019s disease without ileal resection. DG7; 2012."},{"key":"2025090708344446000_12.6.500.46","doi-asserted-by":"publisher","DOI":"10.3310\/hta17370"},{"key":"2025090708344446000_12.6.500.47","doi-asserted-by":"publisher","DOI":"10.1136\/gutjnl-2015-309889"},{"key":"2025090708344446000_12.6.500.48","doi-asserted-by":"publisher","DOI":"10.1136\/gut.34.5.698"},{"key":"2025090708344446000_12.6.500.49","doi-asserted-by":"crossref","first-page":"449","DOI":"10.1097\/MNM.0b013e328351d516","article-title":"Bile acid malabsorption and SeHCAT: the 'Cinderella' will be going to the Nuclear Medicine Ball!","volume":"33","author":"Arasaradnam","year":"2012","journal-title":"Nucl Med Commun"},{"key":"2025090708344446000_12.6.500.50","doi-asserted-by":"crossref","first-page":"306","DOI":"10.1097\/MNM.0b013e32835e8989","article-title":"A survey of the clinical use of SeHCAT in the UK","volume":"34","author":"Smith","year":"2013","journal-title":"Nucl Med Commun"},{"key":"2025090708344446000_12.6.500.51","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/0016-5085(86)90431-2","article-title":"Use of 23-selena-25-homocholyltaurine to detect bile acid malabsorption in patients with illeal dysfunction or diarrhea","volume":"91","author":"Sciarretta","year":"1986","journal-title":"Gastroenterology"},{"key":"2025090708344446000_12.6.500.52","doi-asserted-by":"publisher","DOI":"10.1111\/j.1365-2036.2009.04081.x"},{"key":"2025090708344446000_12.6.500.53","doi-asserted-by":"publisher","DOI":"10.1155\/2011\/701287"},{"key":"2025090708344446000_12.6.500.54","doi-asserted-by":"publisher","DOI":"10.1111\/j.1572-0241.2002.05779.x"},{"key":"2025090708344446000_12.6.500.55","doi-asserted-by":"publisher","DOI":"10.1053\/j.gastro.2005.09.009"},{"key":"2025090708344446000_12.6.500.56","doi-asserted-by":"publisher","DOI":"10.1016\/0014-5793(91)80382-D"},{"key":"2025090708344446000_12.6.500.57","doi-asserted-by":"crossref","first-page":"96","DOI":"10.1016\/S0022-2275(20)39758-3","article-title":"Abnormal bile acid absorption in familial hypertriglyceridemia","volume":"36","author":"Duane","year":"1995","journal-title":"J Lipid Res"},{"key":"2025090708344446000_12.6.500.58","doi-asserted-by":"publisher","DOI":"10.1038\/ajg.2014.215"},{"key":"2025090708344446000_12.6.500.59","doi-asserted-by":"publisher","DOI":"10.1016\/j.cgh.2012.05.006"},{"key":"2025090708344446000_12.6.500.60","doi-asserted-by":"publisher","DOI":"10.1111\/apt.12466"},{"key":"2025090708344446000_12.6.500.61","doi-asserted-by":"publisher","DOI":"10.1111\/j.1365-2796.2006.01731.x"},{"key":"2025090708344446000_12.6.500.62","first-page":"408","article-title":"The role of fecal markers in the investigation of patients with chronic diarrhea","volume":"129","author":"Chandrapalan","year":"2019","journal-title":"Pol Arch Intern Med"},{"key":"2025090708344446000_12.6.500.63","doi-asserted-by":"publisher","DOI":"10.1016\/j.cgh.2013.04.020"},{"key":"2025090708344446000_12.6.500.64","doi-asserted-by":"publisher","DOI":"10.1194\/jlr.R001941"},{"key":"2025090708344446000_12.6.500.65","doi-asserted-by":"publisher","DOI":"10.1136\/gut.14.5.348"},{"key":"2025090708344446000_12.6.500.66","doi-asserted-by":"crossref","first-page":"S-774","DOI":"10.1016\/S0016-5085(19)38886-9","article-title":"Mo1542 \u2013 primary bile acids in a single fecal sample for the diagnosis of bile acid diarrhea: relationship to Sehcat testing","volume":"156","author":"Walters","year":"2019","journal-title":"Gastroenterology"},{"key":"2025090708344446000_12.6.500.67","unstructured":"Cancer Research UK . Bowel cancer diagnosis and treatment statistics, 2019. Available: https:\/\/www.cancerresearchuk.org\/health-professional\/cancer-statistics\/statistics-by-cancer-type\/bowel-cancer\/diagnosis-and-treatment"},{"key":"2025090708344446000_12.6.500.68","doi-asserted-by":"crossref","first-page":"11899","DOI":"10.3390\/s130911899","article-title":"Application of a novel tool for diagnosing bile acid diarrhoea","volume":"13","author":"Covington","year":"2013","journal-title":"Sensors"},{"key":"2025090708344446000_12.6.500.69","doi-asserted-by":"crossref","first-page":"489","DOI":"10.1080\/14737159.2020.1738928","article-title":"Urine as a biological modality for colorectal cancer detection","volume":"20","author":"Chandrapalan","year":"2020","journal-title":"Expert Rev Mol Diagn"},{"key":"2025090708344446000_12.6.500.70","doi-asserted-by":"publisher","DOI":"10.7861\/clinmedicine.15-3-252"},{"key":"2025090708344446000_12.6.500.71","doi-asserted-by":"publisher","DOI":"10.1136\/bmjgast-2016-000116"},{"key":"2025090708344446000_12.6.500.72","doi-asserted-by":"publisher","DOI":"10.1136\/flgastro-2018-101011"},{"key":"2025090708344446000_12.6.500.73","doi-asserted-by":"publisher","DOI":"10.1080\/003655299750026047"},{"key":"2025090708344446000_12.6.500.74","doi-asserted-by":"publisher","DOI":"10.1016\/j.cgh.2009.10.020"},{"key":"2025090708344446000_12.6.500.75","doi-asserted-by":"crossref","first-page":"1471","DOI":"10.1016\/j.crohns.2014.05.009","article-title":"Colesevelam for the treatment of bile acid malabsorption-associated diarrhea in patients with Crohn's disease: a randomized, double-blind, placebo-controlled study","volume":"8","author":"Beigel","year":"2014","journal-title":"Journal of Crohn's and Colitis"},{"key":"2025090708344446000_12.6.500.76","doi-asserted-by":"publisher","DOI":"10.1111\/apt.13065"},{"key":"2025090708344446000_12.6.500.77","doi-asserted-by":"crossref","first-page":"1132","DOI":"10.1111\/apt.13193","article-title":"Randomised clinical trial: colestyramine vs. hydroxypropyl cellulose in patients with functional chronic watery diarrhoea","volume":"41","author":"Fern\u00e1ndez-Ba\u00f1ares","year":"2015","journal-title":"Aliment Pharmacol Ther"},{"key":"2025090708344446000_12.6.500.78","doi-asserted-by":"publisher","DOI":"10.1111\/apt.12999"},{"key":"2025090708344446000_12.6.500.79","doi-asserted-by":"publisher","DOI":"10.7861\/clinmedicine.15-6-536"},{"key":"2025090708344446000_12.6.500.80","doi-asserted-by":"publisher","DOI":"10.7861\/clinmedicine.17-5-412"},{"key":"2025090708344446000_12.6.500.81","first-page":"2881","article-title":"Outcomes from treating bile acid malabsorption using a multidisciplinary approach","volume":"23","author":"Gupta","year":"2015","journal-title":"Support Care Cancer"},{"key":"2025090708344446000_12.6.500.82","doi-asserted-by":"crossref","first-page":"1193","DOI":"10.1016\/S0140-6736(77)90436-6","article-title":"Bacterial overgrowth syndrome without \"blind loop\": A cause for malnutrition in the elderly","volume":"2","author":"Roberts","year":"1977","journal-title":"Lancet"},{"key":"2025090708344446000_12.6.500.83","doi-asserted-by":"publisher","DOI":"10.1111\/j.1365-2036.2006.03168.x"}],"container-title":["Frontline Gastroenterology"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/flgastro-2020-101436","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,9,7]],"date-time":"2025-09-07T15:34:56Z","timestamp":1757259296000},"score":1,"resource":{"primary":{"URL":"https:\/\/fg.bmj.com\/lookup\/doi\/10.1136\/flgastro-2020-101436"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2020,9,22]]},"references-count":83,"journal-issue":{"issue":"6","published-online":{"date-parts":[[2021,10,7]]},"published-print":{"date-parts":[[2021,11]]}},"alternative-id":["10.1136\/flgastro-2020-101436"],"URL":"https:\/\/doi.org\/10.1136\/flgastro-2020-101436","relation":{},"ISSN":["2041-4137","2041-4145"],"issn-type":[{"value":"2041-4137","type":"print"},{"value":"2041-4145","type":"electronic"}],"subject":[],"published":{"date-parts":[[2020,9,22]]}}}