The Good the BAD and the Ugly Dr Matthew Kurien Academic Clinical Lecturer in Gastroenterology University of Sheffield Conflict of Interest Good or BAD Ben Age 4 Sam Age 2 Chenodeoxycholic ID: 528233
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Slide1
Bile Acids:
The Good, the BAD and the Ugly
Dr Matthew Kurien
Academic Clinical Lecturer in Gastroenterology, University of SheffieldSlide2
Conflict of Interest: Good or BAD?
Ben, Age - 4
Sam, Age - 2Slide3
Chenodeoxycholic
acid
Deoxycholic
acid
Cholic
acid
Bile Acids
Lithocholic
acid
What are Bile Acids?
“Digestive Detergents”
Important role in absorbing Fats Slide4
Bile Acids: What do they do?
TI absorption reduced
Excess BA spills into colon
Reduces calcium-mediated water & electrolyte absorption:
Net fluid loss
Watery diarrhoea
Courtesy of KD
Bardhan
, Emeritus Professor,
Rotherham
Released into the small intestine
After function performed – recycled back to the liver
97%
Gallbladder
Liver
Ileum
3%
Released into the small intestine
After function performed – recycled back to the liverSlide5
TI absorption reduced
Excess BA spills into colon
Reduces calcium-mediated water & electrolyte absorption:
Net fluid loss
Watery diarrhoea
Role in Fat Digestion
Secreted into the small intestine
After function performed – recycled back to the liver
Reabsorption
reduced
Excess BA spills into colon
Watery diarrhoea
Salt and Water Secretion
<<97%
Gallbladder
Liver
Courtesy of KD
Bardhan
, Emeritus Professor,
Rotherham
Diarrhoea
Bile Acid Malabsorption (BAM)
Active inflammation of the Terminal Ileum (Crohn’s)
Surgically removed
Ileum
>>3%
Problems with Bile AcidsSlide6
More than BAM
Seen :After gallbladder surgery (cholecystectomy)After radiation treatment (Radiation enteritis)
With Microscopic Colitis/ Coeliac Disease
40% is idiopathic
BILE ACID DIARRHOEA (BAD)
Excessive Bile Acids
Increased Gut Movements Slide7
Diarrhoea – Bread & Butter
One of the commonest reasons for referral to a Gastroenterologist
Estimated that 4-5% of the general population have chronic diarrhoea
Associated with reduced quality of life. Slide8
Causes of Diarrhoea
Inflammatory bowel diseaseCoeliac disease
Colorectal cancer
Microscopic colitis
Pancreatic insufficiency
GI infections and infestationsBacterial overgrowthLactose intolerance
Functional diarrhoeaDiarrhoea-predominant irritable bowel syndrome (IBS-D)Drugs (including laxative abuse)Bile
Acid Diarrhoea (BAD)Slide9Slide10
How common is Bile
Acid
Diarrhoea
in the UK?
1:100,000
1:10,000
1:1,000
1:100Slide11
Wheat Field with Sheaves, 1888 Vincent Van Gogh
Coeliac Disease – 1%Slide12
Guidelines on Diarrhoea
British Society of Gastroenterology Guidelines, 2003Slide13
Diagnosis of BAD
In the UK, Europe and Canada
23-Seleno-25-homo-tauro-cholic acid (SeHCAT) scanning.
Uses 370KBq capsule of
75
Se
homocholyltaurine
Normal - ≥15% retention at day 7
15 CXRs
However, limited access in some centres, and in the USA, SeHCAT scanning is not available
Other potential methods include:
Serum 7
α
-hydroxy-4cholesten-3-one (also known as C4)
Faecal bile acid measurement
Trial of a bile acid sequestrant, with response used as a positive test for BAMSlide14
Not just chronic diarrhoeaSlide15
When Judith’s three daughters were young she often had to leave them unattended in the pram outside a public toilet because she was caught short.
‘This is one of my nightmare images of my illness,’ says Judith.
‘I hated leaving them on their own but I had no alternative — such was the urgency that I needed the toilet.’Slide16
Under-recognised and Under-utilised
Survey of 436 UK Gastroenterologists:
34% of all new patients seen had chronic diarrhoea
BAM was considered as a possible cause in only 22%
72% of Gastroenterologists only considered after other investigations negative
Estimated 184 new diagnoses of BAM per month
Equates to 5 cases per Gastroenterologist per year 50% of all SeHCAT scans in the UK come from 10 hospitals<80 of the 250 departments in the UK equipped to perform SeHCAT do so
Khalid
et al.
C
lin Medicine 2010;10:124-126Slide17
Testing may be improving
Proportion of patients with a positive test in each year did not vary significantly
(χ
2
for trend = 1.46, P = 0.96
)
Gracie
et al.
Neurogastroenterol Motil 2012;24:983-e538Slide18
Coeliac Disease
1988: 273 publications1993: 332 publications
1998: 470 publications
2003: 658 publications
2008: 908 publications
2013: 972
publications
Bile Acid
Malabsorption
1988: 27 publications
1993: 18 publications
1998: 31 publications
2003: 26 publications
2008: 11 publications
2013: 23 publications
SeHCAT = 87 in totalWhy the difference between coeliac disease and bile acid malabsorption?
?!!Slide19
Take Home Messages
BAD is common and under-recognised
Diagnosing BAD can reduce misdiagnosis, inappropriate treatments and potentially improve quality of life
Growing research
a
rea in the UK
Professor Julian Walters
Professor KD
Bardhan
Professor
Jervoise
Andreyev