Published online Jun 7, 2018. doi: 10.3748/wjg.v24.i21.2320
Peer-review started: January 22, 2018
First decision: February 26, 2018
Revised: March 8, 2018
Accepted: March 31, 2018
Article in press: March 31, 2018
Published online: June 7, 2018
A 32-year-old woman with chronic diarrhea that had multiple potential causes including bile acid diarrhea, Crohn’s disease, and medications for epilepsy and depression.
Bile acid diarrhea (BAD), diagnosed by selenium homotaurocholic acid test scintigraphy with 0 bile acid retention after seven days.
Persistently low plasma levels of sodium and potassium and undetectable 24-h urine sodium excretion, indicating intestinal failure with dependency of intravenous fluid support.
Normal duodenal, jejunal, ileal, and colonic biopsies, indicating quiescent Crohn’s disease. Positive Clostridium difficile toxin PCR test indicating Clostridium difficile colitis.
Clostridium difficile colitis was treated with vancomycin followed by fecal microbiota transplantation. Bile acid diarrhea was refractory to conventional treatments including colestyramine and colesevelam, and oral obeticholic acid treatment was commenced at 10 mg per day, increasing to 25 mg per day. Upon this, the patient’s bowel habits and quality of life improved.
Obeticholic is licensed for primary biliary cholangitis and has been used in non-alcoholic steatohepatitis. It was recently reported that obeticholic acid may improve bile acid diarrhea through induction of fibroblast growth factor 19 that inhibits hepatic bile production.
BAD–bile acid diarrhea, resulting from excess hepatic production and/or deficient ileal reabsorption of bile acids, which in turn induces colonic fluid and electrolyte secretion and leads to chronic secretory diarrhea.
In patients with chronic diarrhea, a thorough and systematic diagnostic workup may help to differentiate between potential causes of diarrhea. Some patients with bile acid diarrhea are refractory to conventional treatments. Obeticholic acid may be of clinical benefit in these patients.