Bile Acid Diarrhea: When, Why, How?

Presented in 13th World Gastroenterology, IBD & Hepatology Conference in Holiday Inn Dubai, Al Barsha, UAE & Virtual from December 15-17, 2023. 

Speaker Name: Dr. Cuckoo Choudhary
Biography: MD, FACP, AGAF, Associate Professor of Medicine Division of Gastroenterology and Hepatology, Thomas Jefferson University ( UAS)

Global Journal of Gastroenterology & Hepatology Research [GJGHR]

Bile Acid Diarrhea: 

  • Several diarrheal diseases have a component of bile acid diarrhea
  • Epidemiology & pathophysiology (why and when)
  • Clinical presentations (how)
  • Diagnosis (how)
  • Management (how)

Synthesis, Secretion, and Enterohepatic Circulation of Bile salts

Synthesis, secretion, Enterohepatic circulation

  • Bile acids are synthesized from cholesterol in the liver; stored in the gall bladder
  • Primary bile acids: Chenodeoxycholic acid (CDOA) and Cholic acid (CA)
  • Released into the small intestines after meals: help in fat digestion
  • 95% of the bile acids that enter the ileum are actively re-absorbed there; of the 5% that go into the colon, most reabsorbed there passively
  • bile acids are deconjugated and dehydroxylated in the colon to deoxycholic acid and lithocholic acid; Ursodeoxycholic acid also produced in the colon


  • 25-50% of patients with functional diarrhea (IBS-D) will have a component of bile acid diarrhea (BAD)
  • 4% of our population has IBS
  • Therefore,1% of our population has bile acid diarrhea
  • Remember that 1% of population has celiac!!!
    • Just like we think about Celiac and have a low threshold to screen for Celiac, we should have a low threshold to think about and screen for BAD

Different Types of BAD: Pathophysiology

Idiopathic Bile Acid Diarrhea

  • FGF-19 is a protein that functions as a hormone and regulates bile production
  • Studies from Dr. Walters have shown that the production of FGF-19 in the ileum of patients with idiopathic BAD is reduced
  • Low FGF-19 stimulates liver to produce bile
  • When ileal enterocytes absorb bile, they stimulate the receptors in the enterocytes to produce FGF-19
  • If ileum diseased, absorption decreases, less production of FGF-19, and more production of bile by liver (enterohepatic circulation)

Clinical Symptoms

  • Increased frequency of liquid, watery stools
  • Abdominal pain
  • Urgency
  • Fecal incontinence

Bile Acid Diarrhea: Quality of Life


Diagnosis of BAD

The diagnosis is largely clinical for most of us

  • SehCat retention test
  • 48 hours fecal bile acids
  • Fasting serum C4
  • Combination of fasting serum C4 and bile acids in a random stool sample
  • (which we think will be the future)

SeHCat is an artificial bile acid that has Selenium

  • Measures the capacity of the ileum to reabsorb the artificial bile acid
  • Ingested; on the 7th day the retention is measured with a gamma camera
  • If the retention is < 5%, test positive, and patients thought to have BAD
  • NA in the US

Measurement of 48 hour fecal bile acids, level of primary bile acids and see of they are 4% or 10% of the total


     A Simpler test for Diagnosis?

C4 measurements vs 48 hours fecal bile acids: validation



  • Combining the serum test with the fecal primary bile acids in a random stool sample
  • Diagnosis of BAD is made if the C4 level > 52.5 ng/ml PLUS the percentage of primary bile acids in the stool sample> 10% of the total fecal bile acid
  • 63 % sensitivity and 90% specificity
  • Might be the future

          Benefits of early Testing in BAD

Ten Reasons to Think of BAD in IBD patients

       Is it the chicken vs egg situation?

      Other GI Conditions Associated with BAD

  • Neuro endocrine tumors (carcinoid)
  • Pancreatic insufficiency, bile salt diarrhea, SIBO
  • Post cholecystectomy state
  • Lasts for weeks, but definitely can last longer

Crohn’s and Colitis Journals | Gastroenterology & Hepatology Journals | Gastroenterology Journals | Research Gastroenterology and Hepatology Journals | Clinical and Experimental Gastroenterology Journals | Gastrointestinal Endoscopy Journals | Therapeutic Advances in Gastroenterology Journals | Colorectal Disease: clinical and molecular gastroenterology and surgery Journals | Inflammatory Bowel Diseases Journals | Expert Review of Gastroenterology & Hepatology Journals | Clinical Colorectal Journals | Cancer Gut Journals | Endoscopy Journals | Hepatitis B Annual Journals | Hepato-biliary-Pancreatic Sciences Journals | Medical Bulletin Journals 

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