Assuntos
Ácidos e Sais Biliares , Diarreia , Diarreia/diagnóstico , Diarreia/etiologia , Fezes , HumanosRESUMO
When first described in 1976, primary bile acid diarrhea (BADâType 1) was regarded as a very rare cause of chronic diarrhea. Today, the incidence is estimated as >â1â%. Availability of diagnostic tools varies widely and, in Germany, there is no generally consented recommendation for their use. BADâis still widely underdiagnosed.Since the beginning of the '90âs, we have added a therapeutic trial with cholestyramine to our diagnostic approach of chronic diarrhea. Patients with a positive test were offered a Selenium-homocholic acid taurine (SeHCAT) test for confirmation of bile-acid-diarrhea (BAD), using a 7-day-retention of 20â% as cut-off value.From April 1991 to March 2017, after exclusion of other relevant causes for chronic diarrhea like IBD, celiac disease or microscopic colitis, 70 patients with a positive trial treatment of cholestyramine were identified for evaluation. Sixty of them had a SeHCAT test. Patients with BADâType 1 and Type 3 were excluded, except for cholecystectomy.85â% (35/41) of patients with BADâType 1 needed continued medical treatment (median follow-up time 8.3 (1â-â23.6) years). Among them, 68.6â% (24/35) took cholestyramine, 31.4â% (11/35) loperamide or another antidiarrheal treatment. 14.6â% (6/41) of patients reported a spontaneous remission after median 2.9 (0.7â-â5.7) years.In the group of patients with BADâafter cholecystectomy, 82â% (8/11) still needed treatment after median 7.7 (1â-â24.5) years; 8 having taken cholestyramine, one patient nothing and two with spontaneous remissions.All (8/8) patients with a normal SeHCAT test (7-day retention >â20â%) had spontaneous relief after median 3.6 (1.2â-â6.3) months.Also, 70â% (7/10) of patients who had not been confirmed by the SeHCAT test still needed treatment after median 4.3 (3.7â-â18.3) years.Based on a trial treatment alone, diagnosis of BADâis possible but not assured. Due to its ubiquitous availability, it should be used consequently if other methods are not available. Despite the well-known shortcomings of cholestyramine, a therapeutic trial should be used more consequently. According to the current literature, using the SeHCAT test in the first place will give significantly better results and unnecessary follow-up examinations can be avoided. However, therapeutic consequences might be modest due to the well-known limitations of cholestyramine. A well-tolerated and licensed alternative to cholestyramine is urgently needed.