Introduction Current BSG guidelines for chronic diarrhoea recommend that patients aged < 45 with diarrhoea suggestive of functional disease (ie > 3 months duration, no weight loss, no nocturnal symptoms, intermittent symptoms) and normal basic investigations, do not require further investigation and have IBS1. This potentially disadvantages a population who might in fact suffer with idiopathic BAM. NICE guidelines however feature abdominal pain as one of the key symptoms for diagnosing IBS2. In this observational study we aim to assess whether abdominal pain can distinguish idiopathic BAM from IBS-D.
Methods All patients who underwent SeHCAT scan over a 30 month period January 2009-June 2012 were identified. Patient records and blood results/radiological imaging/endoscopy procedures performed prior to SeHCAT scan were reviewed.
Results A total of 112 patients were identified. 4 patients were excluded due to the unavailability of patient records. 53 patients (49%) had abnormal bile acid retention on SeHCAT (defined by < 8% retention). Of these 53 patients, 72% were female (n = 38) with a median age of 52 years (range 26–80) and average stool frequency of 7 times/day. 27 of the 53 patients (51%) had no known risk factors for BAM and the other 26 patients had risk factors (eg terminal ileal disease/ileal resection/post-cholecystectomy). Of the 55 patients classified as having normal bile acid retention ( > 8% retention), 39 of the 55 (71%) had no known risk factors for BAM.
Of the 39 patients who had suspected idiopathic BAM but normal SeHCAT, excluding 12 patients where there was no clear mention of abdominal pain in the notes, 78% had abdominal pain as a prominent symptom (21/27) and 22% had no pain. Of the 27 patients who had suspected idiopathic BAM and abnormal SeHCAT, excluding 7 patients where there was no mention of abdominal pain in the notes, only 40% had abdominal pain (8/20) whereas 60% had no pain (Chi-squared, p = 0.008).
20 of the 53 patients with BAM were aged < 45 years old. 6 of these 20 had known risk factors for Type I BAM due to history of terminal ileal disease but the remaining 14 patients had no risk factors, fit criteria for functional disease, and could easily have been labelled as IBS-D.
Conclusion Our results highlight that a significant proportion of patients with chronic diarrhoea suffer from BAM. Younger patients cannot be assumed to have ‘functional’ symptoms and though the population is small, it does seem that idiopathic BAM patients might be distinguishable from IBS-D patients in that they usually do not experience abdominal pain.
Disclosure of Interest None Declared.
Thomas PD et al., Gut 2003; 52 (Suppl V): v1-v15 – Guidelines for the investigation of chronic diarrhoea, 2nd edition
NICE guidelines on Irritable Bowel Syndrome (CG61) 2008
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