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Diagnosis and management of bile acid diarrhoea: a survey of UK expert opinion and practice
  1. Julian R F Walters1,2,
  2. Ramesh Arasaradnam3,
  3. H Jervoise N Andreyev4,5
  4. for the UK Bile Acid Related Diarrhoea Network
    1. 1Department of Gastroenterology, Imperial College Healthcare NHS Trust, London, UK
    2. 2Division of Digestive Diseases, Imperial College London, London, UK
    3. 3Department of Gastroenterology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
    4. 4Department of Gastroenterology, Lincoln County Hospital, Lincoln, UK
    5. 5School of Medicine, University of Nottingham, Nottingham, United Kingdom
    1. Correspondence to Professor Julian R F Walters, Gastroenterology, Imperial College Healthcare NHS Trust, London, UK; julian.walters{at}


    Objective Bile acid diarrhoea (BAD), which includes bile acid malabsorption, causes a variety of digestive symptoms. Diagnostic rates and management vary considerably. We conducted a survey of current practice to review expert opinion and provide guidance on diagnosis and management.

    Design/method An online survey was conducted of clinical members of the UK Bile Acid Related Diarrhoea Network, who had all published research on BAD (n=21). Most were National Health Service consultants who had diagnosed over 50 patients with the condition.

    Results The preferred terminology was to use BAD, with primary and secondary to classify causes. A wide range of presenting symptoms and associated conditions were recognised. SeHCAT (tauroselcholic acid) was the preferred diagnostic test, and 50% of respondents thought general practitioners should have access to this. Patients who met the Rome IV diagnostic criteria for functional diarrhoea, irritable bowel syndrome (IBS) with predominant diarrhoea or postcholecystectomy diarrhoea were usually investigated by SeHCAT, which was used sometimes in other types of IBS. Treatment with a bile acid sequestrant was offered to patients with low SeHCAT values, with expected response rates >70% in the most severe. Colestyramine was the usual sequestrant, starting between 2 g and 8 g daily; colesevelam was an alternative. In patients who had an incomplete response, increasing the dose, changing to an alternative sequestrant, use of loperamide and a low fat diet were suggested. Recommendations for follow-up and to improve the overall patient experience were made.

    Conclusion This expert survey indicates current best practice in the diagnosis and management of BAD.

    • chronic diarrhoea
    • functional bowel disorder
    • irritable bowel syndrome
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    • Collaborators Members of UK Bile Acid Related Diarrhoea Network: Ayesha Akbar; Jervoise Andreyev; Richard Appleby; Ramesh Arasaradnam; Matthew Brookes; Anton Emmanuel; Adam Farmer; Alastair Forbes; Alex Ford; Subrata Ghosh; John Green; Ian Johnston; Matthew Kurien; John McLaughlin; Charlie Murray; Iain Murray; Jonathan Nolan; Sanjeev Pattni; David Sanders; Nidhi Sagar; and Julian Walters.

    • Contributors All authors designed the survey; JRFW: data collection and analysis; all authors: critical revision of the manuscript.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests JRFW reports grants and personal fees from GE healthcare, grants from Novartis, personal fees from Pendopharm, personal fees from Prometheus, grants from Intercept, grants from ENYO, outside the submitted work. RA has received renumerations from GE healthcare for delivery of educational talks. HJNA has received remunerations as a member of advisory boards for GE Healthcare and Sanofi Aventis and has been provided by GE Healthcare with free SeHCAT capsules for completed and planned studies.

    • Patient consent for publication Not required.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data availability statement Data are available on reasonable request.

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