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IntroductionBile acid malabsorption (BAM) is a socially debilitating disease characterised by high stool frequency and urgency caused by a spillover of bile acids into the colon. Bile acid sequestrants (BASs) have limited therapeutic effect but represent the only available treatment option. Cases reporting total remission of BAM-related symptoms after treatment with liraglutide, a glucagon-like peptide 1 analogue, prompted us to design a clinical trial investigating the therapeutic effect of this compound in patients with BAM.Methods and analysisFifty adult individuals with moderate or severe BAM as assessed by the 75selenium-homotaurocholic acid test (SeHCAT) will, after a run-in period of 10 days with no BAM treatment, be randomised to either treatment with the BAS colesevelam or liraglutide (double blinded) for 6 weeks. Daily symptom diaries and questionnaires will be filled in. Blood and faecal samples will be collected and SeHCAT will be performed at baseline, after week 3 and at end of trial. The primary endpoint is change in daily stool frequency. Secondary endpoints include changes from baseline in questionnaires, biochemistry, SeHCAT and faecal bile acid content and microbial composition.Ethics and disseminationThe study complies with Danish and European Union legislation and is approved by the Danish Medicines Agency, the Regional Scientific Ethics Committee of the Capital Region of Denmark and the Danish Data Protection Agency. The study is monitored by the Capital Region of Denmark’s good clinical practice unit. All results, positive, negative and inconclusive, will be disseminated at national and/or international scientific meetings and in peer-reviewed scientific journals.Trial registration numberEudraCA: 2018-003575-34; Pre-results.

Background & aimsPatients with Crohn's disease (CD) often have bile acid diarrhea (BAD), due to bile acid malabsorption following ileal resection (IR). Bile acid malabsorption increases production of 7α-hydroxy-4-cholesten-3-one (C4), a bile acid precursor. We investigated relationships between serum concentrations of C4 and BAD in patients with CD.MethodsWe collected demographic data, serum samples, and information on the presence of diarrhea (>3 liquid bowel movements/day), as well as clinical, endoscopic, and histologic scores from 26 patients with CD and IR, 21 patients with CD without IR, and 37 patients with ulcerative colitis (UC). We compared serum concentrations of C4 and fibroblast growth factor 19 (FGF19) between groups. We performed area under the receiver operating characteristic curve (AUROC) analysis to identify the optimal cutoff C4 concentrations for the diagnosis of diarrhea attributable to bile acid malabsorption (BAD), defined as diarrhea and a serum concentration of FGF19

Background A limited number of small-sized studies suggest that bile acid diarrhoea is frequent in patients with chronic watery diarrhoea and previous cholecystectomy. Aim To perform a systematic review and meta-analysis to assess the prevalence of bile acid diarrhoea in patients with chronic watery diarrhoea and previous cholecystectomy, and their response to colestyramine, including a new consecutive series of patients. Methods MEDLINE and EMBASE were searched up to January 2018. Selected studies included patients with previous cholecystectomy and chronic watery diarrhoea assessed by the 23-seleno-25-homotaurocholic acid (SeHCAT) test. We calculated the pooled rate of bile acid diarrhoea using the inverse double arcsine square root method. Additionally, the medical records of 291 consecutive patients with chronic watery diarrhoea in whom a SeHCAT test was performed were retrospectively reviewed and 74 with previous cholecystectomy were included in the meta-analysis. Results The search strategy identified eight relevant studies, which, together with the data of the present series, comprise 361 individuals. The pooled bile acid diarrhoea rate was 70% (95% CI 56%-82%), and was similar when using cut-offs of 10% or 15%. There was substantial heterogeneity (I2 = 84%). Five studies comprising 166 patients evaluated the effect of colestyramine in patients with bile acid diarrhoea. The pooled colestyramine response rate was 79% (95% CI 63%-91%) with substantial heterogeneity (I2 = 73%). Conclusions Two-thirds of patients with chronic watery diarrhoea and previous cholecystectomy have bile acid diarrhoea. Response to colestyramine in these patients is good.

Introduction Worldwide 1,470,900 women are diagnosed yearly with a gynaecological cancer. Some women develop long-term changes in bowel function following treatment severely impacting on quality of life. Methods A service evaluation collecting prospective data was approved by the organisation’s R and D department. Intestinal symptoms were measured using a modified GSRS and impact on QoL assessed by VAS score (0=worst QoL, 10=best QoL). The McNemar Chi-square and Wilcoxon signed rank tests were used to analyse changes in symptom burden between initial assessment to discharge from the service. Results From April 2013 to March 2016, 235 women treated for gynaecological cancers attended the clinic, representing a fifth of those using the service. Fifteen declined further intervention and were excluded, leaving 220 for analysis. Women had been treated for cancer of the cervix (50%), endometrium (28%), ovary (15%), vagina or vulva (7%) cancer. Most women received multi-modal therapies: chemoradiation (28%), surgery +radiotherapy (27%), surgery +chemoradiation (22%), surgery +chemotherapy (10%). Median age was 57 years (range: 24–83). The median time between cancer diagnosis and referral to service was 4 years and 10 months (range: 6 m–47.5 y). Most troublesome symptoms at assessment were bowel frequency of 4 or more times a day (88%), type 6 or 7 stool consistency (36%), urgency to defaecate (31%), faecal incontinence (21%) and fatigue (25%). Some women also reported urinary problems (17%) and sexual concerns (12%). Following a published algorithm, a median of 8 investigations were requested (range: 1–14): blood screen (97%), gastroscopy (75%), glucose hydrogen methane breath test (77%), SeHCAT scan (71%), faecal elastase (69%), flexible sigmoidoscopy (52%), colonoscopy (25%) and abdominal Xray (18%). A median of four factors contributing to symptoms were found (range: 1–9) and 68% of women had more than three. The most common diagnoses were vitamin D deficiency (60%), treated with replacement; SIBO (54%), treated with antibiotics and bile acid malabsorption (52%), treated with bile acid sequestrants and low fat diet. The median number of consultations was 4 (range: 1–17). Median quality of life improved from 4 at first assessment to 6 at discharge (p Conclusions Bowel symptoms after cancer treatment affect many women. They can be discharged with symptom improvement using a systematic investigational and treatment approach. Earlier referral to specialist services is recommended.

Introduction NICE guidelines in 2012 have recommended SeHCAT to be used in research in order to collect more information in its usefulness in the diagnosis and treatment of BAM. A previous study has identified a lack of consistent cut-off threshold values for abnormal SeHCAT results. The aim of this study is to determine whether there is any relationship between the severity of BAM and treatment response. Methods Medical records of 492 patients who had a SeHCAT scan at Aberdeen Royal Infirmary between 23/7/2013 to 9/6/2017 were retrospectively reviewed. Mild, moderate and severe BAM were defined as 10.1%–15%, 5.1%–10% and Results 492 scans were performed and 51% (252/492) of patients had abnormal SeHCAT results ( 20% (50/252) of these patients had a prior diagnosis of IBS and 27% (67/252) patients had previous cholecystectomy. 17% (44/252) had type 1 BAM, 53% (134/252) had type 2 BAM and 29% (74/252) had type 3 BAM. The mean SeHCAT retention percentage was 2.59% for type 1 BAM, 7.45% for type 2 BAM and 5.63% for type 3 BAM. The difference was statistically significant (p 52% (132/252) of patients had treatment response documented following their scans and 13% (17/132) of these patients stopped treatment due to side effects. For the remaining 115 patients, 71% (12/17) of patients with mild BAM had good response to bile acid binder compared to 77% (23/30) with moderate BAM and 78% (55/68) with severe BAM. The difference was not statistically significant (p 15 out of 90 patients who responded to colesevelam previously found cholestyramine ineffective or intolerance of it. Conclusions In our study, the mean SeHCAT retention level was significantly lower for BAM type 1 compared to BAM types 2 and 3. There was an overall good therapeutic response to bile acid binders in patients with a positive SeHCAT scan. However, there was no statistically significant difference between severity of BAM and theurapeutic response. Further prospective study using larger sample size is required to assess the accuracy and cut-offs of the SeHCAT test in diagnosing BAM as determined by theurapeutic response to BAS treatment.

Introduction Bile acid malabsorption (BAM) is accurately diagnosed using a 75 selenium taurocholic acid (SeHCAT) scan which also defines treatments patients require. BAM causes chronic, often debilitating symptoms including loose stool, faecal incontinence and abdominal pain. Primary BAM affects 1% of Britons yet is frequently misdiagnosed as IBS. A further 1% have BAM secondary to other conditions. The 2012 NICE DG7 review of SeHCAT included a cost-effectiveness evaluation based on assumptions without supporting evidence. Our aim was to evaluate the cost of delayed diagnosis of BAM. Methods The notes of all patients undergoing SeHCAT scanning in our Trust over a one-year period were reviewed retrospectively. The number of abnormal scans and patient response to treatment were recorded. Costs of additional clinics/tests/procedures performed before the diagnosis of BAM were calculated using NICE costing templates. Results 1.5% of 3860 new patients seen in our gastroenterology clinics between June 2016-May 2017, 19 men and 37 women, median age 58 (range 19–83) were referred for SeHCAT scanning. Of these, 64% were abnormal: 13 demonstrated severe ( Conclusions In our Trust, SeHCAT scanning is enormously underused. Late diagnosis of BAM is associated with markedly increased costs, unnecessary demands for other services and treatment delay for patients. National data on SeHCAT usage suggest that our findings will apply to most other Trusts. More emphasis to ensure early diagnosis of BAM, a frequent, unpleasant and treatable condition would bring the unusual but highly desirable result of significant health benefits while substantially reducing healthcare costs.

Introduction The diagnosis of bile acid diarrhoea (BAD) is often missed or misdiagnosed for irritable bowel syndrome – diarrhoea predominant (IBS-D) as these conditions have a similar clinical presentation. The principal hindrance to diagnosis of BAD is limited access to the diagnostic SeHCAT scan. Mechanisms of aetiology underlying BAD have not been fully elucidated but it has been accepted that bile acids (BAs) are metabolised by the gut microbiota, therefore their role as signalling molecules in regulating intestinal homeostasis is influenced primarily by the gut commensals. The aim was to profile the gut microbiome in BAD and investigate the mechanisms of how bacterial metabolic products may influence the development of disease. Methods 157 patients participated in the study after having a SeHCAT scan to either diagnose BAD or IBS-D (the latter with a negative scan). Exclusion criteria included recent use of antibiotics/probiotics and the diagnoses of coeliac disease, colorectal cancer and active inflammatory bowel disease (unremarkable levels of C-reactive protein and/or faecal calprotectin were required) in type 1 BAD patients. To examine the gut microbiome, 16S ribosomal RNA gene analysis was undertaken. Bacterial metabolites (short chain fatty acids-SCFAs and volatile organic compounds-VOCs) and BAs were measured using gas and liquid chromatography, mass and ion mobility spectrometry. Results Intestinal dysbiosis with reduced bacterial diversity was observed in patients with BAD compared with IBS-D (p=0.01). A greater total concentration of SCFAs (p=0.17) with increases in the concentrations of acetate (p=0.14) and propionate (p=0.08) were observed in BAD compared to IBS-D. An increase in the concentrations of faecal primary BAs (p=0.05) and serum CDCA (p=0.05) was observed in BAD compared to IBS-D. Conclusions Intestinal dysbiosis with altered fermentation and resultant BA dysmetabolism were observed in BAD. The metabolic output of the microbiota rather than abundance of specific bacterial taxa appears to be more important in the aetiology of BAD.

Introduction75Selenium taurocholic acid (SeHCAT) scanning diagnoses bile acid malabsorption/bile acid diarrhoea (BAM/BAD) and defines optimal treatment. Approximately 2% of the population have BAM/BAD.AimTo evaluate the cost of delayed diagnosis of BAM/BAD.MethodsPatients’ notes who underwent SeHCAT scanning in three hospitals over a 1-year period were reviewed retrospectively. Scan results and treatment response were recorded. Package-of-care costs were calculated using costing tools from the National Institute for Health and Care Excellence and from United Lincolnshire Hospitals Trust business unit.ResultsBetween June 2016 and May 2017, 19 men and 37 women (median age 58 (range 19–83)) of 3860 new patients seen in gastroenterology clinics were referred for SeHCAT scanning. Sixty-four per cent of scans were abnormal: 13 demonstrated severe (ConclusionsSeHCAT is underused. Late diagnosis leads to unnecessary demands for other services and treatment delay. Early diagnosis achieves health benefits while reducing costs.

Bile acid malabsorption (BAM) causing chronic diarrhea may be due to organic as well as functional disorders, and some of them were included under the general label of diarrheic-type irritable bowel syndrome (IBS-D). The 75-selenium homocholic acid taurine (SeHCAT) test is a nuclear medicine investigation considered to be the gold standard for the diagnosis of bile acid malabsorption (BAM). Many studies demonstrate that it could be effective in the clinical workout of chronic diarrhea due to different conditions. The SeHCAT test provides a quantitative assessment to estimate the severity of BAM and the possible response to therapy with bile acid sequestrants (BASs). However, there is no general agreement regarding its cutoff value and the test is not widely available. The aim of this review is to discuss the advantages and disadvantages of the SeHCAT test in clinical practice.

There is no universally available laboratory test to diagnose bile acid diarrhoea (BAD). Objective To conduct a systematic review and meta-analysis to identify a biomarker for idiopathic BAD in patients with functional bowel disorder (FBD) with diarrhoea. Design We searched multiple databases through 15 May 2015. Data were only available to estimate the diagnostic yield of each test (the prevalence of a positive test). Estimates were pooled across studies using the random effects model. Results We included 36 studies, enrolling 5028 patients (24 using 75 selenium homotaurocholic acid test ( 75 SeHCAT) retention of 75 SeHCAT retention ( Conclusions Overall, the test with the highest diagnostic yield conducted in the largest number of studies was 75 SeHCAT retention, which is not widely available in many countries outside Europe and Canada. Using different diagnostic tests, 25% (average) of patients with lower FBD with diarrhoea has evidence of idiopathic BAD. These tests serve to identify idiopathic BAD among patients with FBD with diarrhoea. Further studies are required to appraise the performance characteristics of tests for idiopathic BAD.

The classical definition of chronic diarrhoea is ≥3 defecations/day, with a stool weight of more than 200 g and duration of ≥4 weeks. However, with this definition many patients with substantial symptoms and pathology will be excluded from further investigations. As a consequence other definitions have been proposed, mainly based on evaluation of the stool form.To evaluate the accuracy of the classic criteria for diarrhoea in comparison with a definition based on stool consistency, using the Bristol Stool Form Scale.All patients were investigated with laboratory tests, upper and lower gastrointestinal endoscopy with biopsies, and SeHCAT test. They were asked to complete a diary recording stool frequency and consistency during a week, as well as other gastrointestinal symptoms (pain, bloating and gas).One hundred and thirty-nine subjects were eligible for analysis. Ninety-one had an organic cause of diarrhoea. Fifty-three patients had ≥3 loose stools/day, whereas 86 reported3 stools/day. Ninety had a median stool consistency that was mushy or loose and 49 had harder stools. A higher proportion of subjects with an organic cause of their diarrhoea compared with subjects with a functional bowel disorder had ≥3 loose stools/day, 43/91 (47%) vs. 10/48 (21%) (p 0.01). Similarly, more subjects with an organic cause of their diarrhoea versus patients with a functional bowel disorder had a median stool consistency that was mushy or watery, 73/91 (80%) vs. 17/48 (35%), p 0.0001. When diarrhoea was defined according to stool form, more patients were classified correctly as having a functional disorder or organic disorder, compared with the classical definition (p 0.05).Loose stools defined according to the Bristol Stool Form scale seem to be the best predictor of having an organic cause of the diarrhoea.

Although recognised as a cause of chronic diarrhoea for over forty years, diagnostic tests and treatments for bile acid malabsorption (BAM) remain controversial. Recent National Institute for Health and Care Excellence (NICE) guidelines highlighted the lack of evidence in the field, and called for further research. This retrospective study explores the BAM subtype and severity, the use and response to bile acid sequestrants (BAS) and the prevalence of abnormal colonic histology. 264 selenium-75-labelled homocholic acid conjugated taurine (SeHCAT)-tested patient records were reviewed and the severity and subtype of BAM, presence of colonic histopathology and response to BAS were recorded. 53% of patients tested had BAM, with type-2 BAM in 45% of patients with presumed irritable bowel syndrome. Colonic histological abnormalities were similar overall between patients with (29%) or without (23%) BAM (p = 0.46) and between BAM subtypes, with no significant presence of inflammatory changes. 63% of patients with BAM had a successful BAS response which showed a trend to decreased response with reduced severity. Colestyramine was unsuccessful in 44% (38/87) and 45% of these (17/38) were related to medication intolerance, despite a positive SeHCAT. 47% (7/15) of colestyramine failures had a successful colesevelam response. No patient reported colesevelam intolerance. Quantifying severity of BAM appears to be useful in predicting BAS response. Colesevelam was better tolerated than colestyramine and showed some efficacy in colestyramine failures. Colestyramine failure should not be used to exclude BAM. Colonic histology is of no relevance.

Background: Irritable bowel syndrome is a widespread disorder with a marked socioeconomic burden. Previous studies support the proposal that a subset of patients with features compatible with diarrhoea-predominant IBS (IBS-D) have bile acid malabsorption (BAM). Aims: To perform a systematic review and meta-analysis to assess the prevalence of BAM in patients meeting the accepted criteria for IBS-D. Methods: MEDLINE and EMBASE were searched up to March 2015. Studies recruiting adults with IBS-D, defined by the Manning, Kruis, Rome I, II or III criteria and which used 23-seleno-25-homotaurocholic acid (SeHCAT) testing for the assessment of BAM were included. BAM was defined as 7 day SeHCAT retention of

Despite bile acid malabsorption affecting >1 % of the population, the outcomes of treatment are largely unreported. This study evaluated the effectiveness of a structured intervention for this condition. This was a retrospective evaluation of prospectively recorded patient reported outcome measures in a consecutive cohort of patients diagnosed with bile acid malabsorption seen in a cancer centre gastroenterology clinic. Every patient completed a 7-day food diary, a gastrointestinal symptom rating scale questionnaire and Bristol stool chart before the first clinic appointment and the symptom questionnaire and Bristol stool chart before all subsequent appointments. Patients who reported any episodes of type 6 or 7 stool were referred for a 75Selenium (Se) homocholic acid taurine scan. Abnormal gastrointestinal symptoms were investigated and treated systematically using a peer reviewed management algorithm. Between 2011 and 2013, 136 men, 146 women, median age 66 years (range 19–89) underwent a scan. 143 (51 %) had 7-day isotope retention of ≤20 %. 105 (73 %) had previously undergone pelvic radiotherapy and 67 (47 %) GI surgery. 123 (86 %) were treated with low-fat diets, 79 (55 %) with a bile acid sequestrant, 73 (51 %) both. On discharge, 100 (70 %) patients reported an overall symptom improvement (mean −4.2 points, p

It was previously demonstrated that patients with bile acid (BA) diarrhea have low fasting serum levels of the ileal hormone--fibroblast growth factor-19 (FGF-19). In this paper, the authors demonstrate a positive correlation between ileal transcripts of FGF-19 and (75)SeHCAT retention, providing further evidence of FGF-19 deficiency as an explanation for BA diarrhea. Variants in KLB and FGFR4 genes (that determine the functional re-uptake of BA in the portal circulation by hepatocytes) are also demonstrated to be associated with (75)SeHCAT retention, confirming a second potential mechanism for the development of BA diarrhea.

BackgroundExcessive amounts of bile acids entering the colon due to bile acid malabsorption cause chronic bile acid diarrhoea. Diagnosis is possible by measuring the retention fraction of orally ingested 75Selenium homotaurocholic acid (SeHCAT). The knowledge of long-term effects of medical treatment is sparse.AimTo describe diarrhoea, adherence to treatment, treatment effects and quality of life in a large, well-defined cohort of patients with bile acid diarrhoea.MethodsA retrospective survey was performed among 594 patients with bile acid malabsorption verified by SeHCAT scans at our unit between 2003 and 2016. Questionnaires about medical history, diarrhoea, use of medication, and quality of life scores were mailed to all patients.ResultsAmong 594 patients 377 (69%) responded. Among respondents, 121 (32%) had bile acid diarrhoea due to ileal disease or resection (type 1), 198 (52%) idiopathic bile acid diarrhoea (type 2) and 58 (16%) bile acid diarrhoea due to other non-ileal disease, mainly cholecystectomy (type 3). At follow-up, half of the patients, 184 (50%), reported improvement of diarrhoea. However, 273 patients (74%) still reported diarrhoea and 234 (62%) regularly used anti-diarrhoeal medication. In spite of treatment, 235 (64%) considered reduced quality of life by diarrhoea and 184 (50%) reported that diarrhoea was unaltered or worse than before established diagnosis.ConclusionMany patients with bile acid diarrhoea continue to have bothersome diarrhoea in spite of correct diagnosis and treatment. BACKGROUND: Excessive amounts of bile acids entering the colon due to bile acid malabsorption cause chronic bile acid diarrhoea. Diagnosis is possible by measuring the retention fraction of orally ingested75Selenium homotaurocholic acid (SeHCAT). The knowledge of long-term effects of medical treatment is sparse.AIM: To describe diarrhoea, adherence to treatment, treatment effects and quality of life in a large, well-defined cohort of patients with bile acid diarrhoea.METHODS: A retrospective survey was performed among 594 patients with bile acid malabsorption verified by SeHCAT scans at our unit between 2003 and 2016. Questionnaires about medical history, diarrhoea, use of medication, and quality of life scores were mailed to all patients.RESULTS: Among 594 patients 377 (69%) responded. Among respondents, 121 (32%) had bile acid diarrhoea due to ileal disease or resection (type 1), 198 (52%) idiopathic bile acid diarrhoea (type 2) and 58 (16%) bile acid diarrhoea due to other non-ileal disease, mainly cholecystectomy (type 3). At follow-up, half of the patients, 184 (50%), reported improvement of diarrhoea. However, 273 patients (74%) still reported diarrhoea and 234 (62%) regularly used anti-diarrhoeal medication. In spite of treatment, 235 (64%) considered reduced quality of life by diarrhoea and 184 (50%) reported that diarrhoea was unaltered or worse than before established diagnosis.CONCLUSION: Many patients with bile acid diarrhoea continue to have bothersome diarrhoea in spite of correct diagnosis and treatment.

Introduction Dietary fat ingestion triggers bile secretion into the gastrointestinal (GI) tract. Bile acid diarrhoea (BAD) or malabsorption (BAM) affects 1%–2% of the population. Affected individuals suffer a wide range of GI symptoms in addition to loose stool. The diagnosis is often missed and treatments are often reported to be ineffective. In this study we used SEHCAT scanning to determine treatment options and evaluated the impact of low-fat diets on GI symptoms in these patients. Method This study analysed prospectively collected data in patients with 7 day 75selenium homocholic acid taurine (SeHCAT) scan retention Results Between January 2014 to March 2016, 114 patients, 49 men and 65 women, median age of 64 years, median BMI of 27 kg/m2 were evaluated. 50% had previously undergone GI surgery and 45% had additional GI disorders. 44% were taking Colesevelam. After dietary intervention, the frequency with which patients experienced GI symptoms decreased, with a significant reduction in troublesome urgency, flatulence, abdominal pain, nocturnal defaecation, belching and borborygmi (p≤0.01). Stool consistency and stool frequency also improved. Conclusion Dietary intervention is an effective treatment option for patients with symptomatic bile acid malabsorption/diarrhoea and should be routinely considered. The exact fat restriction which is effective, requires further study. Disclosure of Interest None Declared

Introduction Bile acid malabsorption (BAM) is diagnosed by a reduced day 7 retention of bile acid at tauroselcholic [75selenium] acid (SeHCAT) scan. Currently there is little consensus on its use in the diagnosis of BAM in patients with unexplained diarrhoea [1]. At our site, we have adopted a “test and treat” strategy rather than empirical therapy with bile acid sequestrants in patients with unexplained diarrhoea. In this retrospective study, we have examined the diagnostic yield of SeHCAT in our clinical practice. Method Patients who underwent SeHCAT scans between December 2012 to March 2016 were included in the study. Patients who had incomplete scans were excluded.≤15% bile acid retention at day 7 was regarded as mild BAM, ≤10% retention as moderate BAM, and ≤5% retention as severe BAM. Clinic letters were subsequently reviewed to ascertain causes of BAM. Results SeHCAT scans were performed on 332 patients during the study period. One patient was excluded due to incomplete scan. Of the remaining 331 patients, 174 (53%) patients had normal scans, and 157 (47%) were diagnosed with BAM (63 severe, 43 moderate, 51 mild). Of the 157 patients who were diagnosed with BAM, 93 (59%) were type 2 (Idiopathic), followed by 39 (25%) type 1 (Terminal ileal pathology) and 25 (16%) type 3 (Other GI causes). Because of the size of the subgroups, further analysis was not possible. Conclusion A high proportion (47%) of those who underwent SeHCAT scan were diagnosed with BAM. This exceeds the recently published meta-analysis data on the prevalence of BAM (16.9%>35.3%, pooled rate 28.1%) [2]. This may be because of a higher than usual pre-test probability since all patients had already undergone comprehensive investigations for other causes of chronic diarrhoea. Type 2 BAM predominated (60%) and the majority had mild or moderate malabsorption. Anecdotally, response rates to therapy in this group are variable and we have noticed that diagnostic confidence may increase patient compliance and satisfaction with treatment. This retrospective data seems to support a “test and treat” strategy in the management of bile acid diarrhoea. References . NICE diagnostic guidance DG7 (Nov 2012, reviewed Nov 2015)- SeHCAT for the investigation of diarrhoea due to bile acid malabsorption in people with diarrhoea-predominant irritable bowel syndrome (IBD-D) or Crohn’s disease without ileal resection. . Slattery SA, et al. Systematic review with meta-analysis: The prevalence of bile acid malabsorption in the irritable bowel syndrome with diarrhoea. Alimentary Pharmacology and Therapeutics, 2015Jul;42(1):3–11. Disclosure of Interest None Declared

Introduction Emerging evidence in the literature has suggested fibroblast growth factor 19 (FGF19) and the farnesoid X receptor (FXR) are integral in bile acid synthesis, glucose and lipid metabolism. Reduced level of FGF19 and reduced feedback via the FXR are associated with idiopathic bile acid malabsorption (BAM) and non-alcoholic fatty liver disease (NAFLD), leading to the research and development of FXR agonists as potential treatment. In this retrospective case control study, we examined the correlation between BAM and NAFLD in the district general hospital population in light of recent findings in the literature. Method Patients who had tauroselcholic [ 75selenium] acid (SeHCAT) scan (Defined as Results BAM subgroup analysis- 93 type 2 (idiopathic), 39 type 1 (Terminal ileal pathology), 25 type 3 (Other GI causes). Further subgroup analysis was not possible, but the majority of the included patients had Type 2 BAM. Conclusion Our study has shown that in patients with BAM who subsequently had liver imaging, 34% were also diagnosed with NAFLD. In comparison only 11.96% in the control group were diagnosed with NAFLD (p=0.0003, OR=3.8). It is likely that patients with Type 2 BAM are over represented, but that is reflective of our clinical experience. An expanded bile acid pool in these patients may be mechanistic by increasing LDL cholesterol and reducing HDL cholesterol. A number of other factors have recognised influences on hepatic fat metabolism and the progressive impact of bile acid sequestration on the hepatic bile acid pool and subsequent hepatic fat load is uncertain. In summary, the increased prevalence of NAFLD in patients with BAM may indicate clinical value in screening these malabsorptive patients with hepatic ultrasound. Bile acid sequestration may have little impact on reducing hepatic fat, but there may be benefit from addressing lifestyle factors such as exercise and weight loss. Disclosure of Interest None Declared

Introduction SeHCAT (tauroselcholic [75 selenium] acid) can be used to investigate diarrhoea due to bile acid malabsorption (BAM). It is predominantly used in patients with diarrhoea-predominant irritable bowel syndrome (IBS-D) and Crohn’s disease (CD). Historically these patients have been treated with bile acid sequestrants without a diagnosis however treatment is known to be poorly tolerated. NICE concluded in 2012 that SeHCAT is potentially useful, but that there is not enough evidence to demonstrate value for money. Method A database of 53 patients who had undergone a SeHCAT scan at Bedford Hospital between June 2014 and June 2016 were retrospectively reviewed. BAM was defined as less than 15% retention of SeHCAT after one week. Data was subsequently analysed to look at severity and type of BAM, and treatment methods were reviewed. Results Of the 53 patients, 28 were diagnosed with BAM following scanning with SeHCAT. The average age was 45 years old, with 75% being female. 10 of the 28 patients had type 1 BAM (9 with CD without ileal resection, and 1 with an ileal resection for ischaemic bowel). 10 of the 28 patients had type 2 BAM (idiopathic) whilst the remaining 8 had other GI pathology and were diagnosed with type 3 BAM. 13 of the 28 patients had 0%–5% retention indicating severe BAM, and 8 of the 13 had a diagnosis of Type 1 BAM. 3 patients who were started on colestyramine did not find it useful, and 6 could not tolerate the medication. 6 patients were subsequently trialled on colesevelam with no positive response. Dietetic manipulation was found to be the most successful treatment, with 6 patients responding to a diet low in FODMAP. However, these patients all had IBS-D rather than CD. Conclusion Interestingly, 10 out of 13 CD patients (77%) were diagnosed with BAM, and 8 of them were diagnosed with severe BAM (SeHCAT retention Colestyramine costs £730 a year on average (based on a dose of 2–3 sachets per day at a cost of £31.84 for 50 sachets). Colesevelam is more expensive, and costs £1170 a year on average (based on a cost of £96.10 for 180 capsules). SeHCAT scanning costs £436–486 according to NICE. Adherence and reported response to treatment are poor. This study highlights that formal diagnosis is more financially desirable than blind treatment. As medications are poorly tolerated and long term dietary manipulation may be the best treatment for BAM Type 2, especially for IBS-D patients, a diagnosis is crucial. Reference . NICE guidleines 2012- https://www.nice.org.uk/guidance/dg7 Disclosure of Interest None Declared

Introduction Following pelvic radiotherapy up to 50% of patients have a permanent change in bowel habit which will affect their quality-of-life. Malnourishment is common prior to treatment and bile acid malabsorption (BAM), lactose intolerance and small bowel bacterial overgrowth (SBBO) can occur during treatment. It was hypothesised that patients who receive a gastrointestinal (GI) care bundle during chemoradiotherapy for pelvic malignancy will have improved GI symptoms and Health-Related Quality-of-Life (HRQL). Method This pilot feasibility randomised controlled trial (RCT) included patients with cervical and bladder carcinoma who were undergoing radical chemoradiotherapy. Questionnaire and anthropometric data were collected. The intervention patients received individualised dietary counselling and when they developed lower GI symptoms hydrogen methane breath testing was arranged to detect lactose intolerance and SBBO and a SeHCAT to detect BAM. Treatment was given. Results Fifty patients were recruited between December 2012 and January 2015, 24 were randomised to the intervention group and 26 to the control group. All trial patients completed 20 fractions of external beam pelvic radiotherapy. Figure 1 demonstrates the mean bowel scores reported by patients at baseline, 6 weeks, 12 weeks and 52 weeks. As in Table 1 the median bowel score of each group increased at 6 weeks and decreased thereafter. The control group score was higher than the intervention group score at 6 weeks however this study was not powered for hypothesis testing. Abstract PWE-140 Table 1 The median bowel score of each group at each time point. The mean HRQL in the control group fell by 0.14 (0.91 at baseline to 0.77 at 52 weeks) compared to 0.06 in the intervention group (0.89 at baseline to 0.83 at 52 weeks) (see figure 2). This relative difference was in part driven by the increased mortality observed in the control arm. All patients developed GI symptoms. It was possible to perform 57/72 (79%) intervention tests. Conclusion It was feasible to recruit to and deliver an RCT of GI intervention in patients undergoing pelvic chemoradiotherapy. There was a trend for a lower median bowel score in the intervention group at 6 weeks. This needs testing in a larger RCT. Disclosure of Interest None Declared

Chronic diarrhoea is a common condition, resulting from a number of different disorders. Bile acid diarrhoea, occurring in about a third of these patients, is often undiagnosed. We hypothesised that a positive diagnosis of bile acid diarrhoea would reduce the need for subsequent investigations for alternative diagnoses. METHODS: Patients previously recruited to a study of chronic diarrhoea who had selenium homocholic acid taurine (SeHCAT) testing and subsequent follow-up at our institution were identified. In a retrospective analysis, the numbers of defined investigations undertaken from the first 3 months after SeHCAT in the following 5 years were compared. RESULTS: 90 patients were identified with primary bile acid diarrhoea (SeHCAT retention 15%, n=54). Follow-up had been performed on 29 and 39 subjects, respectively, with no differences in previous investigations or the last contact date. In the follow-up period, the proportions of these patients who had undergone endoscopic procedures (gastroscopy, colonoscopy and sigmoidoscopy) were the same. However, there was a higher proportion of patients in the SeHCAT-negative group who had other investigations, including imaging, physiological tests and blood tests (p=0.037). The use of cross-sectional imaging was significantly higher in this group (p=0.015) with greater proportions having CT (0.44 vs 0.10) and MRI (0.26 vs 0.07). Ultrasound use and the number of blood tests were higher in the SeHCAT-negative group whereas the SeHCAT-positive group attended more clinic appointments (p=0.013). CONCLUSION: A positive diagnosis of bile acid diarrhoea, made by a SeHCAT test, resulted in reduced use of diagnostic investigations over the subsequent 5 years.

BackgroundIn 2012, the National Institute for Health and Care Excellence (NICE) assessed guidance (DG7) on the use of tauroselcholic (75selenium) acid (also known as SeHCAT) for the investigation of diarrhoea due to bile acid malabsorption (BAM) in patients with IBS-D and in patients with Crohn’s disease who have not had an ileal resection. NICE concluded that tauroselcholic (75selenium) acid was recommended for use in research only. NICE will be reviewing the decision to update the guidance for tauroselcholic (75selenium) acid, for these populations, in March 2017.AimOur aim is to summarise advances in BAM, also known as bile acid diarrhoea (BAD), and encourage clinicians to re-evaluate their understanding of this disorder.ApproachWe review the prevalence, diagnosis and treatment of BAD/BAM. We describe the new evidence available since the original NICE review in 2012, and discuss the economic issues associated with failure to diagnose or to treat BAD/BAM accurately.Evidence updateThere is new and compelling evidence available since DG7, which shows that tauroselcholic (75selenium) acid scanning is a powerful tool in the diagnosis of BAD/BAM. We summarise published prevalence data (approximately 1% prevalence in the UK, as suggested by clinical practice diagnosis rates), and highlight that the true prevalence of BAD/BAM could be far greater than this.ConclusionWe present evidence that challenges current opinion about this disorder, and we commend both clinicians and health technology assessment (HTA) agencies for being open to arguments and new evidence in any future HTAs.

Bile acids malabsorption (BAM) is encountered in numerous gastrointestinal pathologies and is a good example of a treatable cause of watery diarrhea after ileal resection. The gold standard for diagnosing BAM is the selenium homocholic acid taurine test (SeHCAT), an expensive and complex analysis. An alternative method is the quantification of 7α-hydroxy-4-cholesten-3-one (C4). Here, we present a simple, ultra high-performance liquid chromatography–tandem mass spectrometry method to measure C4 in human serum. To avoid time consuming sample preparation (e.g., derivatization, solid phase extraction), we used absorption chemistry-based extraction plates. This method demonstrates a lower limit of quantification of 5 ng/mL and is linear over a concentration range from 5 to 300 ng/mL (R2 = 0.9977). Inaccuracy and imprecision were less than 15%. The validated method is currently used for routine measurement of C4 from serum in patients to confirm BAM diagnosis.

Measurements of SeHCAT (tauroselcholic [75selenium] acid) retention have been used to diagnose bile acid malabsorption for a number of years. In current UK practice the vast majority of centres calculate uptake using an uncollimated gamma camera. Because of ever-increasing demands on gamma camera time, a new 'probe' detector was designed, assembled and commissioned. To validate the system, nine patients were scanned at day 0 and day 7 with both the new probe detector and an uncollimated gamma camera. Commissioning results were largely in line with expectations. Spatial resolution (full-width 95% of maximum) at 1 m was 36.6 cm, the background count rate was 24.7 cps and sensitivity at 1 m was 720.8 cps/MBq. The patient comparison study showed a mean absolute difference in retention measurements of 0.8% between the probe and uncollimated gamma camera, and SD of ± 1.8%. The study demonstrated that it is possible to create a simple, reproducible SeHCAT measurement system using a commercially available scintillation detector. Retention results from the probe closely agreed with those from the uncollimated gamma camera.

Chronic diarrhoea induced by bile acids is common and the underlying mechanisms are linked to homeostatic regulation of hepatic bile acid synthesis by fibroblast growth factor 19 (FGF19). Increasing evidence, including that from several large case series using SeHCAT (selenium homocholic acid taurine) tests for diagnosis, indicates that bile acid diarrhoea (BAD) accounts for a sizeable proportion of patients who would otherwise be diagnosed with IBS. Studies of other approaches for diagnosis of BAD have shown increased bile acid synthesis, increased faecal levels of primary bile acids, dysbiosis and different urinary volatile organic compounds when compared with healthy controls or with other diseases. The role of the ileal hormone FGF19 in BAD has been strengthened: a prospective clinical study has confirmed low FGF19 levels in BAD, and so a test to measure these levels could be developed for diagnosis. In animal models, FGF19 depletion by antibodies produces severe diarrhoea. Bile acids affect colonic function through farnesoid X receptor (FXR) and TGR5 receptors. As well as these effects in the colon, FXR-dependent stimulation of ileal FGF19 production could be a logical mechanism to provide therapeutic benefit in BAD. Further studies of FGF19 in humans hold promise in providing novel treatments for this cause of chronic diarrhoea.

Background: Bile acid malabsorption (BAM) is a common, yet under-recognised, cause of chronic diarrhoea, with limited guidance available on the appropriate management of patients with BAM. Aim: To summarise the evidence supporting different treatments available for patients with bile acid malabsorption, noting their impact on clinical outcomes, tolerability and associated side effects. Methods: A literature search was conducted through PubMed, the Cochrane Database of Systematic Reviews and Scopus. Relevant articles studied patients who had been diagnosed with BAM and were clinically assessed before and after therapy. Results: A total of 30 relevant publications (1241 adult patients) were identified, which investigated the clinical response to drugs, including colestyramine, colestipol, colesevelam, aluminium hydroxide and obeticholic acid. The most commonly used diagnostic test of bile acid malabsorption was the SeHCAT test (24 studies). Colestyramine treatment was by far the most studied of these agents, and was successful in 70% of 801 patients (range: 63–100%). Conclusions: Colestyramine and colestipol are generally effective treatments of gastrointestinal symptoms from BAM, but may be poorly tolerated and reduce the bioavailability of co-administered agents. Alternative therapies (including colesevelam and aluminium hydroxide) as well as dietary intervention may also have a role, and the promising results of the first proof-of-concept study of obeticholic acid suggest that its novel approach may have an exciting future in the treatment of this condition. Future trials should employ accurate diagnostic testing and be conducted over longer periods so that the long-term benefits and tolerability of these different approaches can be evaluated.

To evaluate the cost of delayed diagnosis of bile acid malabsorption (BAM). The notes of all patients undergoing selenium-75 taurocholic acid (SeHCAT) scanning in our trust over a 1-year period were reviewed retrospectively. The number of abnormal scans and patient response to treatment were

Altered concentrations of bile acid (BA) in the colon can cause diarrhea or constipation. More than 25% of patients with irritable bowel syndrome with diarrhea or chronic diarrhea in Western countries have BA malabsorption (BAM). As BAM is increasingly recognized, proper diagnostic methods are needed to help direct the most effective course of treatment for the chronic bowel dysfunction. We review the methodologies, advantages, and disadvantages of tools that directly measure BAM: the 14 C-glycocholate breath and stool test, the 75 selenium homotaurocholic acid test (SeHCAT), and measurements of 7 α-hydroxy-4-cholesten-3-one (C4) and fecal BAs. The 14 C-glycocholate test is laborious and no longer widely used. The 75 SeHCAT has been validated but is not available in the United States. Measurement of serum C4 is a simple and accurate method that can be used for most patients but requires further clinical validation. Assays to quantify fecal BA (total and individual levels) are technically cumbersome and not widely available. Regrettably, none of these tests are routinely available in the United States; assessment of the therapeutic effects of a BA binder is used as a surrogate for diagnosis of BAM. Recent data indicate the advantages to studying fecal excretion of individual BAs and their role in BAM; these could support the use of the fecal BA assay, compared with other tests. Measurement of fecal BA levels could become a routine addition to the measurement of fecal fat in patients with unexplained diarrhea. Availability ultimately determines whether the C4, SeHCAT, or fecal BA test is used; more widespread availability of such tests would enhance clinical management of these patients.

TauroH-23-(75Se) selena-25-homocholic acid retention values are used in the diagnosis of bile acid malabsorption. The standard method for measuring values is with an uncollimated gamma camera, which can create some logistic difficulties, with other background sources of activity, which are irrelevant when a collimator is used, becoming significant. In this study we compare the retention values obtained with a collimated and an uncollimated gamma camera in phantoms and in 23 patients. Bland–Altman plots were created using the data, which showed a mean bias in retention of 0.10% in the phantom study and 0.55% in the patient study between methods. A Wilcoxon signed-rank test with the null hypothesis of zero median difference between uncollimated and collimated methods was not statistically significant to P values less than 0.05 in the patient and phantom studies. In the patient study, on using a fixed boundary of retention (10%) between positive and negative status, the status of one patient was changed from negative (12%) to positive (9%). We conclude that measurement of retention with a collimated gamma camera is similar but not identical to that of uncollimated values. The clinical significance of this shift is unclear, as the threshold of significance and the method of integrating this measure with other clinical factors into management remain unclear.

Objective A clinical diagnosis of bile acid malabsorption (BAM) can be confirmed using SeHCAT (tauroselcholic (75selenium) acid), a radiolabelled synthetic bile acid. However, while BAM can be the cause of chronic diarrhoea, it is often overlooked as a potential diagnosis. Therefore, we investigated the use of SeHCAT for diagnosis of BAM in UK hospitals. Design A multicentre survey was conducted capturing centre and patient-level information detailing patient care-pathways, clinical history, SeHCAT results, treatment with bile acid sequestrants (BAS), and follow-up in clinics. Eligible data from 38 centres and 1036 patients were entered into a validated management system. Results SeHCAT protocol varied between centres, with no standardised patient positioning, and differing referral systems. Surveyed patients had a mean age of 50 years and predominantly women (65%). The mean SeHCAT retention score for all patients was 19% (95% CI 17.8% to 20.3%). However, this differed with suspected BAM type: type 1: 9% (95% CI 6.3% to 11.4%), type 2: 21% (95% CI 19.2% to 23.0%) and type 3: 22% (95% CI 19.6% to 24.2%). Centre-defined ‘abnormal’ and ‘borderline’ results represented over 50% of the survey population. BAS treatment was prescribed to only 73% of patients with abnormal results. Conclusions The study identified a lack of consistent cut-off/threshold values, with differing centre criteria for defining an ‘abnormal’ SeHCAT result. BAS prescription was not related in a simple way to the SeHCAT result, nor to the centre-defined result, highlighting a lack of clear patient care-pathways. There is a clear need for a future diagnostic accuracy study and a better understanding of optimal management pathways.

Bile acid malabsorption (BAM) is a frequently unrecognized and misdiagnosed cause of chronic diarrhea. It is characterized by the disruption of normal enterohepatic circulation modifying bile acids (BAs) production, reabsorption and/or transportation. The level in which the abnormality appears gives BAM classification. Type 1 BAM is accounted to small bowel dysfunction, Type 2 to a primary affection or idiopathic, Type 3 to other gastrointestinal disorders and a fourth type may be related to hepatic BAs hyperproduction. BAM predominant symptom is chronic watery diarrhea. The 75 selenium homotaurocholic acid taurine (SeHCAT) retention test is considered the gold standard but it has a lot of practice limitations. The serum 7 ?-hydroxy-4-cholesten-3-one (C4) concentration is next in line due to its simplicity and high sensitivity and specificity. Treatment is based on bile acid sequestrants.

Background: Bile acid malabsorption (BAM) is one possible explanation for chronic diarrhea. BAM may be idiopathic, or result from ileal resection or inflammation including Crohn’s disease, or may be secondary to other conditions, including cholecystectomy, peptic ulcer surgery, and chronic pancreatitis. No “gold standard” exists for clinical diagnosis of BAM, but response to treatment with a bile acid sequestrant (BAS) is often accepted as confirmation. The SeHCAT (tauroselcholic [selenium-75] acid) test uses a radiolabeled synthetic bile acid and provides a diagnostic test for BAM, but its performance against “trial of treatment” is unknown. Fibroblast growth factor 19 (FGF-19) and 7-alpha-hydroxy-4-cholesten-3-one (C4) also offer potential new biomarkers of BAM.Objective: This protocol describes a multicenter prospective study to evaluate the diagnostic accuracy of SeHCAT and 2 biomarkers in predicting BAM as assessed by trial of treatment.Methods: Participating gastroenterology centers should have a minimum workload of 30 SeHCAT patients per annum. Patients should not be pregnant, on medication that could confound follow-up, or have any severe comorbidity. All eligible patients attending a gastrointestinal appointment will be invited to participate. On attending the SeHCAT test, blood and fecal samples will be collected for analysis of FGF-19 by enzyme-linked immunosorbent assay and for C4 and fractionated bile acids by liquid chromatography–mass spectrometry. A capsule containing radiolabeled SeHCAT will be administered orally and a scan performed to measure SeHCAT activity. Patients will return on day 7 to undergo a second scan to measure percentage SeHCAT retention. The test result will be concealed from clinicians and patients. BAS will be dispensed to all patients, with a follow-up gastroenterologist appointment at 2 weeks for clinical assessment of treatment response and adherence. Patients responding positively will continue treatment for a further 2 weeks and all patients will have a final follow-up at 8 weeks. The diagnostic accuracy of the SeHCAT test and biomarkers will be analyzed at different thresholds using sensitivity, specificity, positive and negative predictive value, likelihood ratios, and area under the curve in a sample of 600 patients. Multivariable logistic regression models will be used to assess the association between presence of BAM and continuous SeHCAT retention levels after adjustment for confounders.Results: Funding is being sought to conduct this research.Conclusions: The SeHCAT test for diagnosis of BAM has been in common use in the United Kingdom for more than 30 years and an evidence-based assessment of its accuracy is overdue. The proposed study has some challenges. Some forms of BAS treatment are unpleasant due to the texture and taste of the resin powder, which may negatively affect recruitment and treatment adherence. Trial of treatment is not as “golden” a standard as would be ideal, and itself warrants further study.

OBJECTIVE Bile-acid diarrhoea (BAD) is a recognized cause of chronic diarrhoea; however, its detection remains suboptimal. Currently, there is a paucity of follow-up studies evaluating BAD. This work evaluates the natural history of BAD by examining individuals diagnosed with BAD [7 days of Se-homocholic acid taurine (SeHCAT) retention

This study evaluates the efficacy of low-fat dietary interventions in the management of gastrointestinal (GI) symptoms due to bile acid malabsorption. In total, 40 patients with GI symptoms and a 7-day (75)selenium homocholic acid taurine (SeHCAT) scan result of

TauroH-23-((75)Se)selena-25-homocholic acid (SeHCAT) retention has been used for the diagnosis of bile acid malabsorption since the early 1980s. Bile acid malabsorption has been increasingly recognized as an important cause of severe chronic diarroea with subsequent increase in the number of referrals for the SeHCAT test. In this study, we review and discuss the standard techniques for the measurement of SeHCAT retention and describe a simple and modified technique using a noncollimated whole-body scanner, suitable for most modern dual-headed cameras.

Aim To evaluate the usefulness of the 75 SeHCAT abdominal retention (AR) measurement in the early diagnosis of diarrhea syndrome (DS). Methods Thirty-seven patients with diarrhea syndrome within the first month of evolution were prospectively evaluated. The 75 Se-SeHCAT abdominal retention was measured 4 and 7 days post-administration of 0.01 mCi of 75 SeHCAT. The test was performed prior to treatment and at 3 months when the baseline study was positive. The test was considered positive if the RA was Results Group A: The AR of 75 Se-SEHCAT was normal in 21 patients. Six were diagnosed of colonic diverticulosis, 8 of irritable bowel syndrome, 1 of lymphocytic colitis, 1 of post-gastroenteritis syndrome, 1 of celiac disease and 1 of stenosis of the cardia. Four are still under study. Group B: The AR of 75 Se-SEHCAT decreased in 16 patients. All showed abnormal AR at day 7 and all but 1 at day 4. Following administration of cholestyramine resin, 8 (50%) presented partial response and 8 presented (50%) complete response. At 3 months, AR had increased at day 4 and 9 at day 7. Conclusion The measurement of 75 SEHCAT abdominal retention allows the early diagnosis of bile acid malabsorption in 43% of the patients with DS. Measurement at 7 days seems more accurate than that at 4 days.

Introduction The terminal ileum (TI) is important for the active reabsorption of bile salts and is the site of allograft rejection; disruption of enterohepatic circulation (EHC) may give insights to inflammatory and other physiologic processes at the TI. Subjects and methods Four children aged 5 to 12 years who had received small bowel transplantation (SBTx), 3 recovering from post-transplant lymphoproliferative disease (PTLD) and 1 with acute rejection, were studied. Two of the 4 had stoma reversal. Another child (15 years) with progressive familial intrahepatic cholestasis (PFIC) and pruritus, despite liver transplantation and biliary diversion, was studied. Selenium homocholic acid taurocholate scanning (75SeHCAT) capsule was given orally (n = 3) or via introducer during endoscopy (n = 2); a baseline whole-body gamma camera scan was done 4 hours later and on days 1 to 5. Results The normal 3-day bile salt retention is 30% to 70% of baseline and normal adult biological half-life, t½ is 62 ± 17 hours. The results in children with a stoma were very low (0.1% at 7.6 hours; 5% at 17 hours). The children with reversed stoma had retention and t½ closer to the reference range (18% at 29 hours; 22% at 33 hours). The child with PFIC + biliary diversion had an initial very high gamma emission from the stoma bag suggesting excellent reabsorption of bile salts from his TI, but retention was 0.6% and t½ 9.8 hours, demonstrating efficient biliary diversion. Conclusion These results confirm children with stomas malabsorb bile acids, which can be ameliorated after stoma closure. SeHCAT demonstrated that the biliary diversion was working well and may be helpful in preoperative assessment of abnormal EHC. The role of SeHCAT in SBTx requires further evaluation.

Introduction: Bile acid malabsorption (BAM) is a syndrome of chronic watery diarrhoea with excess faecal bile acids. Disruption of the enterohepatic circulation of bile acids following surgical resection is a common cause of BAM. The condition is easily diagnosed by the selenium homocholic acid taurine (SeHCAT) test and responds to bile acid sequestrants. Idiopathic BAM (IBAM, primary bile acid diarrhoea) is the condition where no definitive cause for low SeHCAT retention can be identified. Sources of data: Review of PubMed and major journals. Areas of agreement: Evidence is accumulating that BAM is more prevalent than first thought. Management of chronic diarrhoea involves excluding secondary causes. Treatment of the condition is with bile acid binders. Areas of controversy: SeHCAT testing is not widely performed, limiting awareness of how common this condition can be. The underlying mechanism for IBAM has been unclear. Growing points: Increasing awareness of the condition is important. Alternative mechanisms of IBAM have been suggested which involve an increased bile acid pool size and reduced negative feedback regulation of bile acid synthesis by FGF19. New sequestrants are available. Areas timely for developing research: Further research into the precise mechanism of IBAM is needed. Improvements in the recognition of the condition and optimization of treatment are required.

Summary Background Recurrent, watery diarrhoea affects one-third of patients diagnosed with irritable bowel syndrome (‘IBS-D’). Idiopathic bile acid malabsorption (‘I-BAM’) may be the cause. Aim To determine the prevalence of I-BAM in patients suffering from IBS-D. Methods A systematic search was performed of publications reporting patients presenting with IBS-D type symptoms, who were subsequently confirmed as having I-BAM by SeHCAT scanning. Results Eighteen relevant studies, 15 prospective, comprising 1223 patients were identified. Five studies (429 patients) indicated that 10% (CI: 7–13) patients had severe bile acid malabsorption (SeHCAT 7 day retention