Introduction Bile acid diarrhoea (BAD), including bile acid malabsorption (BAM), causes a variety of digestive symptoms and is increasingly recognised, although diagnostic rates and management vary considerably. The UK Bile Acid Related Diarrhoea Network (UK-BARDN), established in 2017, conducted a survey of current practice to provide a review of expert opinion and guidance on diagnosis and management.
Methods An on-line survey was sent at the end of 2018 to 21 clinical members of UK-BARDN, who had all published research on BAD.
Results A response rate of 100% was obtained. 95% were NHS Consultants; 85% estimated they had diagnosed over 50 patients with the condition. BAD was the terminology preferred by 57%, with another 29% using BAD or BAM depending on the clinical circumstances. Primary and secondary were the preferred terms to classify the different causes.
A wide range of presenting symptoms and associated conditions were recognised. SeHCAT was the preferred diagnostic test, with a therapeutic trial the second choice. Access to SeHCAT by GPs was thought appropriate by 50%, with greater availability of specific blood tests in hospitals. SeHCAT would usually be requested (>70%) in patients who met the diagnostic criteria for functional diarrhoea, IBS-D, or post-cholecystectomy diarrhoea, and sometimes be requested (>30%) in other types of IBS, and in Crohn’s disease with ileal resection and negative inflammatory markers, where a therapeutic trial was also commonly used.
Treatment with a bile acid sequestrant (BAS) would always be given if SeHCAT was <5%, usually if 5–15%, and sometimes if 15–20%. Expected response rates were >70%, falling to 30% in these groups. Colestyramine was the usual first line BAS, with starting doses varying between 2 g od and 4 g bd. Colesevelam was also used. There was a slight preference to give the drug at bedtime. Warnings about drug interactions were usual. In patients who had an incomplete response, increasing the dose, changing to an alternative BAS, increasing use of drugs such as loperamide, and advice on a low fat (40 g/d) diet were commonly recommended. During follow-up, annual review by a specialist or GP, patient support groups, dietetic and pharmacist review, and monitoring of blood vitamins and lipids were given varying importance. To improve the overall patient experience, greater recognition by various professional groups and in the popular press, with improved diagnosis and drugs, were considered important.
Conclusions This expert consensus provides a basis for current best practice in the diagnosis and management of patients with BAD.
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