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Patel HM, Kaur MR, Haris Ali M, Hadi Z, Parikh A, Khan SH, Kamireddy M, Faiz H, Kamani YG, Agarwal A, Al Hasibuzzaman M. Evaluation of non-invasive diagnostic tools for diarrhea: a systematic review of point-of-care tests and biomarkers. Ann Med Surg (Lond) 2024; 86:2951-2962. [PMID: 38694383 PMCID: PMC11060204 DOI: 10.1097/ms9.0000000000001946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 03/02/2024] [Indexed: 05/04/2024] Open
Abstract
Background Diarrhea is a prevalent condition affecting millions worldwide. However, current standard diagnostic methods have many drawbacks. This review examines various non-invasive point-of-care (POC) tests and biomarkers aiding rapid diagnosis of diarrhea from different causes. Methods PubMed, PubMed Central, ScienceDirect, Cochrane Library, and Google Scholar were searched from 2013 to present for relevant literature. Two reviewers independently assessed included studies' quality using the Critical Appraisal Skills Programme (CASP) checklist. Results The search yielded 1453 studies, of which 39 were included after screening and applying eligibility criteria. Polymerase chain reaction (PCR) was the POC test in 25 studies, providing consistent sensitivity and specificity. For biomarkers, C-reactive protein (CRP), fecal calprotectin, and procalcitonin offered high sensitivity and specificity for conditions like acute pediatric diarrhea, microscopic colitis, and inflammatory diarrhea, respectively. Conclusion PCR proved the ideal POC test for rapid diarrhea diagnosis, while the procalcitonin biomarker helps differentiate inflammatory from non-inflammatory diarrhea. Other reviewed tools also demonstrated promising diagnostic performance, though improvements in sensitivity, specificity, and usability are still needed.
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Affiliation(s)
| | | | - Mohammad Haris Ali
- Shaikh Khalifa Bin Zayed Al-Nahyan Medical and Dental College, Lahore, Punjab
| | | | | | | | | | - Haseeb Faiz
- Department of Medicine, Jinnah Hospital, Lahore
| | - Yashkumar G. Kamani
- Cagayan State University College of Medicine, Tuguegarao, Cagayan Valley, Philippines
| | | | - Md. Al Hasibuzzaman
- Institute of Nutrition and Food Science, University of Dhaka, Dhaka
- Med Research Hub, Panchagarh, Bangladesh
- The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang Province, People’s Republic of China
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2
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Yang D, Lyu C, He K, Pang K, Guo Z, Wu D. Bile Acid Diarrhea: From Molecular Mechanisms to Clinical Diagnosis and Treatment in the Era of Precision Medicine. Int J Mol Sci 2024; 25:1544. [PMID: 38338820 PMCID: PMC10855108 DOI: 10.3390/ijms25031544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/18/2024] [Accepted: 01/25/2024] [Indexed: 02/12/2024] Open
Abstract
Bile acid diarrhea (BAD) is a multifaceted intestinal disorder involving intricate molecular mechanisms, including farnesoid X receptor (FXR), fibroblast growth factor receptor 4 (FGFR4), and Takeda G protein-coupled receptor 5 (TGR5). Current diagnostic methods encompass bile acid sequestrants (BAS), 48-h fecal bile acid tests, serum 7α-hydroxy-4-cholesten-3-one (C4), fibroblast growth factor 19 (FGF19) testing, and 75Selenium HomotauroCholic acid test (75SeHCAT). Treatment primarily involves BAS and FXR agonists. However, due to the limited sensitivity and specificity of current diagnostic methods, as well as suboptimal treatment efficacy and the presence of side effects, there is an urgent need to establish new diagnostic and treatment methods. While prior literature has summarized various diagnostic and treatment methods and the pathogenesis of BAD, no previous work has linked the two. This review offers a molecular perspective on the clinical diagnosis and treatment of BAD, with a focus on FXR, FGFR4, and TGR5, emphasizing the potential for identifying additional molecular mechanisms as treatment targets and bridging the gap between diagnostic and treatment methods and molecular mechanisms for a novel approach to the clinical management of BAD.
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Affiliation(s)
- Daiyu Yang
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China; (D.Y.); (K.P.); (Z.G.)
| | - Chengzhen Lyu
- State Key Laboratory of Complex Severe and Rare Diseases, Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China; (C.L.); (K.H.)
| | - Kun He
- State Key Laboratory of Complex Severe and Rare Diseases, Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China; (C.L.); (K.H.)
| | - Ke Pang
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China; (D.Y.); (K.P.); (Z.G.)
| | - Ziqi Guo
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China; (D.Y.); (K.P.); (Z.G.)
| | - Dong Wu
- State Key Laboratory of Complex Severe and Rare Diseases, Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China; (C.L.); (K.H.)
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3
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Lupianez-Merly C, Dilmaghani S, Camilleri M. Recent developments in diagnosing bile acid diarrhea. Expert Rev Gastroenterol Hepatol 2023; 17:1185-1195. [PMID: 38086533 DOI: 10.1080/17474124.2023.2293814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 12/08/2023] [Indexed: 01/19/2024]
Abstract
INTRODUCTION Bile acid diarrhea (BAD) commonly causes chronic diarrhea. Symptoms may be mistaken for disorders of gut brain interaction. Due to the lack of widely available diagnostic tests and poor recognition of BAD, there is a delay in diagnosis leading to increased healthcare system burden and decreased patient quality of life. AREAS COVERED A thorough review of the literature was conducted using PubMed for articles on the biological functions of bile acids, pathophysiology and management of BAD, but focusing on diagnostic testing including 75SeHCAT retention, 7αC4, FGF-19, fecal bile acids, and single stool tests. This narrative review discusses available modalities focusing on noninvasive stool and serum testing that are more widely available and show good sensitivity and specificity for diagnosis of BAD. 75SeHCAT retention is not available in many countries. Alternative diagnostic tests include total and primary fecal bile acid (BA) excretion in 48-hour collection or a single stool sample, serum7αC4 >46 or 52.5 ng/mL, and combination of single stool and serum 7αC4 ±watery stools (Bristol Stool Form Scale 6-7). EXPERT OPINION Given the ease of serum and single stool sample acquisition and diagnostic advances, clinical practice should embrace positive diagnosis, rather than BAS therapeutic trial. BAD needs to be considered in diverse gastrointestinal diseases.
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Affiliation(s)
- Camille Lupianez-Merly
- Division of Gastroenterology and Hepatology, Mayo Clinic, Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Rochester, MN, USA
| | - Saam Dilmaghani
- Division of Gastroenterology and Hepatology, Mayo Clinic, Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Rochester, MN, USA
| | - Michael Camilleri
- Division of Gastroenterology and Hepatology, Mayo Clinic, Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Rochester, MN, USA
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4
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Dunleavy KA, Cross RK, Raffals LE. Causes, Diagnostic Testing, and Treatment of Residual Symptoms in Patients With IBD With Quiescent Disease. Am J Gastroenterol 2023; 118:1909-1914. [PMID: 36988311 DOI: 10.14309/ajg.0000000000002267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 03/23/2023] [Indexed: 03/30/2023]
Affiliation(s)
- Katie A Dunleavy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
- Division of Gastroenterology and Hepatology, University of Maryland, Baltimore, Maryland, USA
| | - Raymond K Cross
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
- Division of Gastroenterology and Hepatology, University of Maryland, Baltimore, Maryland, USA
| | - Laura E Raffals
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
- Division of Gastroenterology and Hepatology, University of Maryland, Baltimore, Maryland, USA
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Wu X, Li P, Wang W, Xu J, Ai R, Wen Q, Cui B, Zhang F. The Underlying Changes in Serum Metabolic Profiles and Efficacy Prediction in Patients with Extensive Ulcerative Colitis Undergoing Fecal Microbiota Transplantation. Nutrients 2023; 15:3340. [PMID: 37571277 PMCID: PMC10421017 DOI: 10.3390/nu15153340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 07/18/2023] [Accepted: 07/24/2023] [Indexed: 08/13/2023] Open
Abstract
(1) Background: Fecal microbiota transplantation (FMT) is an effective treatment for ulcerative colitis (UC). Metabolomic techniques would assist physicians in clinical decision-making. (2) Methods: Patients with active UC undergoing FMT were enrolled in the study and monitored for 3 months. We explored short-term changes in the serum metabolic signatures of groups and the association between baseline serum metabolomic profiles and patient outcomes. (3) Results: Forty-four eligible patients were included in the analysis. Of them, 50.0% and 29.5% achieved clinical response and clinical remission, respectively, 3 months post-FMT. The top two significantly altered pathways in the response group were vitamin B6 metabolism and aminoacyl-tRNA biosynthesis. Both the remission and response groups exhibited an altered and enriched pathway for the biosynthesis of primary bile acid. We found a clear separation between the remission and non-remission groups at baseline, characterized by the higher levels of glycerophosphocholines, glycerophospholipids, and glycerophosphoethanolamines in the remission group. A random forest (RF) classifier was constructed with 20 metabolic markers selected by the Boruta method to predict clinical remission 3 months post-FMT, with an area under the curve of 0.963. (4) Conclusions: FMT effectively induced a response in patients with active UC, with metabolites partially improving post-FMT in the responsive group. A promising role of serum metabolites in the non-invasive prediction of FMT efficacy for UC demonstrated the value of metabolome-informed FMT in managing UC.
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Affiliation(s)
- Xia Wu
- Department of Microbiota Medicine, Medical Center for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing 210011, China; (X.W.); (P.L.); (W.W.); (J.X.); (R.A.); (Q.W.); (B.C.)
- Key Lab of Holistic Integrative Enterology, Nanjing Medical University, Nanjing 210011, China
| | - Pan Li
- Department of Microbiota Medicine, Medical Center for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing 210011, China; (X.W.); (P.L.); (W.W.); (J.X.); (R.A.); (Q.W.); (B.C.)
- Key Lab of Holistic Integrative Enterology, Nanjing Medical University, Nanjing 210011, China
| | - Weihong Wang
- Department of Microbiota Medicine, Medical Center for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing 210011, China; (X.W.); (P.L.); (W.W.); (J.X.); (R.A.); (Q.W.); (B.C.)
- Key Lab of Holistic Integrative Enterology, Nanjing Medical University, Nanjing 210011, China
| | - Jie Xu
- Department of Microbiota Medicine, Medical Center for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing 210011, China; (X.W.); (P.L.); (W.W.); (J.X.); (R.A.); (Q.W.); (B.C.)
- Key Lab of Holistic Integrative Enterology, Nanjing Medical University, Nanjing 210011, China
| | - Rujun Ai
- Department of Microbiota Medicine, Medical Center for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing 210011, China; (X.W.); (P.L.); (W.W.); (J.X.); (R.A.); (Q.W.); (B.C.)
- Key Lab of Holistic Integrative Enterology, Nanjing Medical University, Nanjing 210011, China
| | - Quan Wen
- Department of Microbiota Medicine, Medical Center for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing 210011, China; (X.W.); (P.L.); (W.W.); (J.X.); (R.A.); (Q.W.); (B.C.)
- Key Lab of Holistic Integrative Enterology, Nanjing Medical University, Nanjing 210011, China
| | - Bota Cui
- Department of Microbiota Medicine, Medical Center for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing 210011, China; (X.W.); (P.L.); (W.W.); (J.X.); (R.A.); (Q.W.); (B.C.)
- Key Lab of Holistic Integrative Enterology, Nanjing Medical University, Nanjing 210011, China
| | - Faming Zhang
- Department of Microbiota Medicine, Medical Center for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing 210011, China; (X.W.); (P.L.); (W.W.); (J.X.); (R.A.); (Q.W.); (B.C.)
- Key Lab of Holistic Integrative Enterology, Nanjing Medical University, Nanjing 210011, China
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6
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Liu H, Xu M, He Q, Wei P, Ke M, Liu S. Untargeted serum metabolomics reveals specific metabolite abnormalities in patients with Crohn's disease. Front Med (Lausanne) 2022; 9:814839. [PMID: 36160171 PMCID: PMC9492954 DOI: 10.3389/fmed.2022.814839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 08/19/2022] [Indexed: 11/18/2022] Open
Abstract
Crohn's disease (CD) is a subtype of inflammatory bowel disease (IBD) characterized by skip intestinal lesions that can occur in any part of the gastrointestinal tract. Currently, the diagnosis of CD is based on clinical history, physical examination and complementary diagnostic tests. It is challenging for physicians to make a definitive diagnosis. This study aimed to analyze the variation in metabolites in CD serum and identify potential predictive biomarkers of CD diagnosis. We collected serum samples from 316 subjects, including patients with CD and healthy controls (HCs). Serum metabolomics was conducted using liquid chromatography coupled to mass spectrometry. Potential biomarkers were screened and evaluated by univariate and multivariate analyses. A panel of two metabolites (deoxycholic acid and palmitic amide) was identified as a specific biomarker of CD. Receiver operating characteristic analysis (ROC) showed that the panel had a sensitivity of 80.25% with a specificity of 95.54% in discriminating CD patients from healthy controls. The biomarkers identified are increased in CD compared with healthy controls. Our approach successfully identified serum biomarkers associated with CD patients. The potential biomarkers indicated that CD metabolic disturbance might be associated with bile acid biosynthesis, fatty acids and energy metabolism.
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Affiliation(s)
- Huanhuan Liu
- Department of Pharmacy, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
- College of Pharmacy, Jiangsu Collaborative Innovation Center of Chinese Medicinal Resources Industrialization, Nanjing University of Chinese Medicine, Nanjing, China
| | - Minmin Xu
- Department of Pharmacy, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Qiongzi He
- Department of Pharmacy, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Peng Wei
- Department of Pharmacy, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Mengying Ke
- College of Pharmacy, Jiangsu Collaborative Innovation Center of Chinese Medicinal Resources Industrialization, Nanjing University of Chinese Medicine, Nanjing, China
| | - Shijia Liu
- Department of Pharmacy, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
- *Correspondence: Shijia Liu
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7
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Hojo A, Kobayashi T, Matsubayashi M, Morikubo H, Miyatani Y, Fukuda T, Asonuma K, Sagami S, Nakano M, Matsuda T, Hibi T. Usefulness of colestimide for diarrhea in postoperative Crohn's disease. JGH Open 2022; 6:547-553. [PMID: 35928696 PMCID: PMC9344577 DOI: 10.1002/jgh3.12786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 06/22/2022] [Accepted: 06/24/2022] [Indexed: 11/12/2022]
Abstract
Background and Aim Crohn's disease (CD) often causes intractable diarrhea after intestinal resection. Anion exchange resins have been reported to be effective in patients with bile acid diarrhea after distal ileectomy; furthermore, bile acid metabolism has been implicated in the pathogenesis of CD. Therefore, we aimed to examine the effectiveness of colestimide in the management of postoperative CD, and to compare its impact between patients with and those without ileocecal resection. Methods Postoperative CD patients prescribed colestimide for diarrhea between April 2017 and December 2020 were retrospectively evaluated for changes in the total Crohn's disease activity index (CDAI), each CDAI component including diarrhea frequency/week, albumin, and C‐reactive protein (CRP) was evaluated before and after the administration of colestimide. Furthermore, comprehensive patient and physician assessments were reviewed from medical records during the first outpatient visit as a global clinical judgment after the initiation of colestimide therapy. Results A total of 24 patients were included, of whom 17 had a previous history of ileocecal resection. Significant improvement was noted in CDAI and diarrhea frequency only in the ileocecal resection group (CDAI: 114.5 ± 52.7 and 95.4 ± 34.8, P < 0.05; diarrhea frequency/week 23.8 ± 14.1 and 15.4 ± 11.2, P < 0.05, respectively). There was no significant improvement in other CDAI components, albumin level, or CRP level in either group. In the global clinical judgment, 13 and 4 patients in the ileocecal and non‐ileocecal resection groups, respectively, were judged as “effective,” with an overall efficacy rate of 70.8%. Conclusion Colestimide is effective for diarrhea in patients with postoperative CD, especially after ileocecal resection.
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Affiliation(s)
- Aya Hojo
- Center for Advanced IBD Research and Treatment Kitasato University Kitasato Institute Hospital Tokyo Japan
- Department of Gastroenterology and Hepatology Kitasato University Kitasato Institute Hospital Tokyo Japan
- Division of Gastroenterology and Hepatology Toho University Omori Medical Center Tokyo Japan
| | - Taku Kobayashi
- Center for Advanced IBD Research and Treatment Kitasato University Kitasato Institute Hospital Tokyo Japan
- Department of Gastroenterology and Hepatology Kitasato University Kitasato Institute Hospital Tokyo Japan
| | - Mao Matsubayashi
- Center for Advanced IBD Research and Treatment Kitasato University Kitasato Institute Hospital Tokyo Japan
| | - Hiromu Morikubo
- Center for Advanced IBD Research and Treatment Kitasato University Kitasato Institute Hospital Tokyo Japan
- Department of Gastroenterology and Hepatology Kitasato University Kitasato Institute Hospital Tokyo Japan
| | - Yusuke Miyatani
- Center for Advanced IBD Research and Treatment Kitasato University Kitasato Institute Hospital Tokyo Japan
| | - Tomohiro Fukuda
- Center for Advanced IBD Research and Treatment Kitasato University Kitasato Institute Hospital Tokyo Japan
- Department of Gastroenterology and Hepatology Kitasato University Kitasato Institute Hospital Tokyo Japan
| | - Kunio Asonuma
- Center for Advanced IBD Research and Treatment Kitasato University Kitasato Institute Hospital Tokyo Japan
| | - Shintaro Sagami
- Center for Advanced IBD Research and Treatment Kitasato University Kitasato Institute Hospital Tokyo Japan
- Department of Gastroenterology and Hepatology Kitasato University Kitasato Institute Hospital Tokyo Japan
| | - Masaru Nakano
- Center for Advanced IBD Research and Treatment Kitasato University Kitasato Institute Hospital Tokyo Japan
- Department of Gastroenterology and Hepatology Kitasato University Kitasato Institute Hospital Tokyo Japan
| | - Takahisa Matsuda
- Division of Gastroenterology and Hepatology Toho University Omori Medical Center Tokyo Japan
| | - Toshifumi Hibi
- Center for Advanced IBD Research and Treatment Kitasato University Kitasato Institute Hospital Tokyo Japan
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Battat R, Sandborn WJ. Advances in the Comprehensive Management of Postoperative Crohn's Disease. Clin Gastroenterol Hepatol 2022; 20:1436-1449. [PMID: 33819666 DOI: 10.1016/j.cgh.2021.03.048] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 03/21/2021] [Accepted: 03/30/2021] [Indexed: 02/06/2023]
Abstract
Patients with postoperative Crohn's disease are difficult to manage because of their risk of experiencing a more severe course, multiple symptom confounders, and poor sensitivity of symptomatic remission to rule out intestinal inflammation. In this group, data are lacking on biologic therapeutic efficacy, and recommendations are lacking for those with multiple medication failures. Novel noninvasive testing can simultaneously exclude alternate causes of symptoms (serum C4, fecal fat, small intestinal bowel overgrowth breath testing) and assess intestinal inflammation (fecal calprotectin, endoscopic healing index). In addition, endoscopy-based disease activity assessment and management are required. Endoscopy should be performed within 6 months of surgery, and aggressive disease activity monitoring can be considered with colonoscopy every 1-2 years subsequently to ensure late recurrence is detected. Patients with multiple resections should be screened for short bowel syndrome. Predictive biomarkers are needed to guide medication selection in this high-risk population. Postoperative prophylactic biologic therapy is prudent for patients with preoperative biologic failure. However, there are no high-quality data to guide which agent should be selected. Selecting biologics with an alternative mechanism of action in those who had failed a biologic with adequate drug concentrations and selection of different agents in those with previous intolerance are reasonable. Significantly more study is required to assess the efficacy of therapies in this setting.
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Affiliation(s)
- Robert Battat
- Jill Roberts Center for IBD, Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York.
| | - William J Sandborn
- Division of Gastroenterology, University of California San Diego, La Jolla, California
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Di Vincenzo F, Puca P, Lopetuso LR, Petito V, Masi L, Bartocci B, Murgiano M, De Felice M, Petronio L, Gasbarrini A, Scaldaferri F. Bile Acid-Related Regulation of Mucosal Inflammation and Intestinal Motility: From Pathogenesis to Therapeutic Application in IBD and Microscopic Colitis. Nutrients 2022; 14:nu14132664. [PMID: 35807844 PMCID: PMC9268369 DOI: 10.3390/nu14132664] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 06/23/2022] [Accepted: 06/25/2022] [Indexed: 02/06/2023] Open
Abstract
Inflammatory bowel diseases (IBD) and microscopic colitis are chronic immune-mediated inflammatory disorders that affect the gastroenterological tract and arise from a complex interaction between the host’s genetic risk factors, environmental factors, and gut microbiota dysbiosis. The precise mechanistic pathways interlinking the intestinal mucosa homeostasis, the immunological tolerance, and the gut microbiota are still crucial topics for research. We decided to deeply analyze the role of bile acids in these complex interactions and their metabolism in the modulation of gut microbiota, and thus intestinal mucosa inflammation. Recent metabolomics studies revealed a significant defect in bile acid metabolism in IBD patients, with an increase in primary bile acids and a reduction in secondary bile acids. In this review, we explore the evidence linking bile acid metabolites with the immunological pathways involved in IBD pathogenesis, including apoptosis and inflammasome activation. Furthermore, we summarize the principal etiopathogenetic mechanisms of different types of bile acid-induced diarrhea (BAD) and its main novel diagnostic approaches. Finally, we discuss the role of bile acid in current and possible future state-of-the-art therapeutic strategies for both IBD and BAD.
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Affiliation(s)
- Federica Di Vincenzo
- IBD Unit—UOS Malattie Infiammatorie Croniche Intestinali, CEMAD, Digestive Diseases Center, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Università Cattolica del Sacro Cuore, L. Go A. Gemelli 8, 00168 Rome, Italy; (P.P.); (L.R.L.); (V.P.); (L.M.); (A.G.); (F.S.)
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, L. Go F. Vito 1, 00168 Rome, Italy; (B.B.); (M.M.); (M.D.F.); (L.P.)
- Correspondence:
| | - Pierluigi Puca
- IBD Unit—UOS Malattie Infiammatorie Croniche Intestinali, CEMAD, Digestive Diseases Center, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Università Cattolica del Sacro Cuore, L. Go A. Gemelli 8, 00168 Rome, Italy; (P.P.); (L.R.L.); (V.P.); (L.M.); (A.G.); (F.S.)
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, L. Go F. Vito 1, 00168 Rome, Italy; (B.B.); (M.M.); (M.D.F.); (L.P.)
| | - Loris Riccardo Lopetuso
- IBD Unit—UOS Malattie Infiammatorie Croniche Intestinali, CEMAD, Digestive Diseases Center, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Università Cattolica del Sacro Cuore, L. Go A. Gemelli 8, 00168 Rome, Italy; (P.P.); (L.R.L.); (V.P.); (L.M.); (A.G.); (F.S.)
| | - Valentina Petito
- IBD Unit—UOS Malattie Infiammatorie Croniche Intestinali, CEMAD, Digestive Diseases Center, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Università Cattolica del Sacro Cuore, L. Go A. Gemelli 8, 00168 Rome, Italy; (P.P.); (L.R.L.); (V.P.); (L.M.); (A.G.); (F.S.)
| | - Letizia Masi
- IBD Unit—UOS Malattie Infiammatorie Croniche Intestinali, CEMAD, Digestive Diseases Center, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Università Cattolica del Sacro Cuore, L. Go A. Gemelli 8, 00168 Rome, Italy; (P.P.); (L.R.L.); (V.P.); (L.M.); (A.G.); (F.S.)
| | - Bianca Bartocci
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, L. Go F. Vito 1, 00168 Rome, Italy; (B.B.); (M.M.); (M.D.F.); (L.P.)
| | - Marco Murgiano
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, L. Go F. Vito 1, 00168 Rome, Italy; (B.B.); (M.M.); (M.D.F.); (L.P.)
| | - Margherita De Felice
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, L. Go F. Vito 1, 00168 Rome, Italy; (B.B.); (M.M.); (M.D.F.); (L.P.)
| | - Lorenzo Petronio
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, L. Go F. Vito 1, 00168 Rome, Italy; (B.B.); (M.M.); (M.D.F.); (L.P.)
| | - Antonio Gasbarrini
- IBD Unit—UOS Malattie Infiammatorie Croniche Intestinali, CEMAD, Digestive Diseases Center, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Università Cattolica del Sacro Cuore, L. Go A. Gemelli 8, 00168 Rome, Italy; (P.P.); (L.R.L.); (V.P.); (L.M.); (A.G.); (F.S.)
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, L. Go F. Vito 1, 00168 Rome, Italy; (B.B.); (M.M.); (M.D.F.); (L.P.)
| | - Franco Scaldaferri
- IBD Unit—UOS Malattie Infiammatorie Croniche Intestinali, CEMAD, Digestive Diseases Center, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Università Cattolica del Sacro Cuore, L. Go A. Gemelli 8, 00168 Rome, Italy; (P.P.); (L.R.L.); (V.P.); (L.M.); (A.G.); (F.S.)
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, L. Go F. Vito 1, 00168 Rome, Italy; (B.B.); (M.M.); (M.D.F.); (L.P.)
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10
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Marasco G, Cremon C, Barbaro MR, Falangone F, Montanari D, Capuani F, Mastel G, Stanghellini V, Barbara G. Pathophysiology and Clinical Management of Bile Acid Diarrhea. J Clin Med 2022; 11:jcm11113102. [PMID: 35683489 PMCID: PMC9180966 DOI: 10.3390/jcm11113102] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 05/27/2022] [Accepted: 05/28/2022] [Indexed: 11/16/2022] Open
Abstract
Bile acid malabsorption (BAM) represents a common cause of chronic diarrhea whose prevalence is under-investigated. We reviewed the evidence available regarding the pathophysiology and clinical management of bile acid diarrhea (BAD). BAD results from dysregulation of the enterohepatic recirculation of bile acids. It has been estimated that 25–33% of patients with functional diarrhea and irritable bowel syndrome with diarrhea have BAM. Currently, the selenium homotaurocholic acid test is the gold standard for BAD diagnosis and severity assessment. However, it is an expensive method and not widely available. The validation of the utility in the clinical practice of several other serum markers, such as 7α-hydroxy-4-cholesten-3-one (C4) and the fibroblast growth factor 19 (FGF19) is ongoing. The first-line treatment of patients with BAD is bile acid sequestrants. Patients that are refractory to first-line therapy should undergo further diagnostics to confirm the diagnosis and to treat the underlying cause of BAD. An early and correct diagnosis of BAD would improve patient’s quality of life, avoiding additional diagnostic tests that burden health care systems. Considering the limited availability and tolerability of specific medications for BAD treatment, future research is awaited to identify other therapeutic approaches, such as gut microbiota modulating therapies.
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Affiliation(s)
- Giovanni Marasco
- Division of Internal Medicine, IRCCS Azienda Ospedaliero Universitaria di Bologna, 40138 Bologna, Italy; (G.M.); (C.C.); (M.R.B.); (D.M.); (F.C.); (G.M.); (V.S.)
- Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy
| | - Cesare Cremon
- Division of Internal Medicine, IRCCS Azienda Ospedaliero Universitaria di Bologna, 40138 Bologna, Italy; (G.M.); (C.C.); (M.R.B.); (D.M.); (F.C.); (G.M.); (V.S.)
- Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy
| | - Maria Raffaella Barbaro
- Division of Internal Medicine, IRCCS Azienda Ospedaliero Universitaria di Bologna, 40138 Bologna, Italy; (G.M.); (C.C.); (M.R.B.); (D.M.); (F.C.); (G.M.); (V.S.)
| | - Francesca Falangone
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, University Sapienza, 00185 Rome, Italy;
| | - Davide Montanari
- Division of Internal Medicine, IRCCS Azienda Ospedaliero Universitaria di Bologna, 40138 Bologna, Italy; (G.M.); (C.C.); (M.R.B.); (D.M.); (F.C.); (G.M.); (V.S.)
- Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy
| | - Federica Capuani
- Division of Internal Medicine, IRCCS Azienda Ospedaliero Universitaria di Bologna, 40138 Bologna, Italy; (G.M.); (C.C.); (M.R.B.); (D.M.); (F.C.); (G.M.); (V.S.)
- Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy
| | - Giada Mastel
- Division of Internal Medicine, IRCCS Azienda Ospedaliero Universitaria di Bologna, 40138 Bologna, Italy; (G.M.); (C.C.); (M.R.B.); (D.M.); (F.C.); (G.M.); (V.S.)
- Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy
| | - Vincenzo Stanghellini
- Division of Internal Medicine, IRCCS Azienda Ospedaliero Universitaria di Bologna, 40138 Bologna, Italy; (G.M.); (C.C.); (M.R.B.); (D.M.); (F.C.); (G.M.); (V.S.)
- Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy
| | - Giovanni Barbara
- Division of Internal Medicine, IRCCS Azienda Ospedaliero Universitaria di Bologna, 40138 Bologna, Italy; (G.M.); (C.C.); (M.R.B.); (D.M.); (F.C.); (G.M.); (V.S.)
- Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy
- Correspondence: ; Tel.: +39-0512144103
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11
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Camilleri M, Nurko S. Bile Acid Diarrhea in Adults and Adolescents. Neurogastroenterol Motil 2022; 34:e14287. [PMID: 34751982 PMCID: PMC8957499 DOI: 10.1111/nmo.14287] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 09/22/2021] [Accepted: 10/12/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Bile acids are central to enterohepatic signaling pathways activated through natural receptors, farnesoid X receptor [FXR mediates synthesis of fibroblast growth factor-19 (FGF-19)], and G protein-coupled bile acid receptor 1 (GPBAR1, also known as TGR5). Although bile acid diarrhea (BAD) is more commonly encountered in ileal resection or disease, there is evidence documenting "idiopathic" BAD in about 20% of adolescents and 30% of adults presenting with chronic, non-bloody diarrhea often attributed to irritable bowel syndrome. Mechanism(s) leading to increased hepatic synthesis and colonic bile acid levels in "idiopathic" BAD include reduced synthesis of FGF-19 by the ileal mucosa, or genetic variation in hepatocyte proteins klotho β and FGF receptor 4 (FGFR4) that mediate negative feedback of bile acid synthesis. PURPOSE The objective of this review is to summarize the diagnosis of BAD in adults and adolescents. In addition to 75 SeHCAT retention for diagnosis of BAD, studies have validated fasting serum 7αC4 and FGF-19, respectively, by-product and inhibitor of hepatic bile acid synthesis, as well as fecal bile acid measurements. These assays are widely available through reference laboratories, and they are being simplified (eg, measurement of primary fecal bile acids in a random stool sample). BAD has also been identified as a co-factor contributing to persistent diarrhea in other diseases in remission including inflammatory bowel disease, microscopic colitis, celiac disease, and neuroendocrine tumors. In summary, advances in diagnosis of BAD provide opportunities for generalists and pediatric and adult gastroenterologists to provide targeted treatment for BAD presenting as chronic non-bloody diarrhea.
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Affiliation(s)
- Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.) and Division of Gastroenterology and Hepatology Mayo Clinic Rochester MN USA
| | - Samuel Nurko
- Department of Pediatric Gastroenterology Boston Children’s Hospital Boston MA USA
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12
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Chang C, Jiang J, Sun R, Wang S, Chen H. Downregulation of Serum and Distal Ileum Fibroblast Growth Factor19 in Bile Acid Diarrhoea Patients. Dig Dis Sci 2022; 67:872-879. [PMID: 34041651 DOI: 10.1007/s10620-021-07042-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 05/05/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Bile acid diarrhoea or BAD is a common but little recognised cause of chronic diarrhoea. Few of these patients in China have been diagnosed due to a lack of diagnostic options. AIMS To clarify the diagnostic value of serum fibroblast growth factor19 (FGF19) in BAD patients. METHODS We reported on 60 chronic diarrhoea patients and 80 healthy volunteers (HV). Based on the 90th percentile levels of serum 7a-hydroxy-4-cholesten-3-one (C4) of HV, these patients were divided into BAD group (C4 ≥ 90th) and non-bile acid diarrhoea group (NBAD, C4 < 90th). Serum FGF19 in the two clinical groups and HV group were compared, as was distal ileum FGF19 in clinical groups. The diagnostic value of serum FGF19 for BAD was evaluated. RESULTS The 90th percentile of serum C4 in HV group was 65.87 ng/ml. Serum FGF19 concentrations in BAD group (Median 69.28 pg/ml; n = 23) were significantly lower than those in HV (Median 122.18 pg/ml; n = 80) and NBAD (Median 129.57 pg/ml; n = 29) groups. FGF19 mRNA of the distal ileum in BAD group, was lower than that in NBAD group, P = 0.002. The rate of FGF19 protein low expression of distal ileum in BAD and NBAD group were 78.3% and 48.3%, P = 0.027. Using an ROC curve, statistical analysis yielded a threshold FGF19 concentration of 117.3 pg/ml (AUC, 0.906; 91.3% sensitivity, 79.3% specificity) for a clinical diagnosis of BAD. CONCLUSIONS Serum and distal ileum expression of FGF19 significantly decreased in BAD patients. The suggested clinical ranges for serum FGF19 < 117.3 pg/ml has high sensitivity and specificity for BAD patients with a normal structural and histological ileum.
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Affiliation(s)
- Chunxia Chang
- Nanjing Medical University, Nanjing, 211166, Jiangsu, People's Republic of China.,Department of Gastroenterology, Nanjing Tongren Hospital, School of Medicine, Southeast University, Nanjing, 211102, Jiangsu, People's Republic of China
| | - Jingjing Jiang
- School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, People's Republic of China
| | - Rui Sun
- School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, People's Republic of China
| | - Shenggen Wang
- Department of Gastroenterology, Nanjing Tongren Hospital, School of Medicine, Southeast University, Nanjing, 211102, Jiangsu, People's Republic of China
| | - Hong Chen
- Nanjing Medical University, Nanjing, 211166, Jiangsu, People's Republic of China. .,Department of Gastroenterology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, People's Republic of China.
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13
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Serum 7-alfa-hydroxy-4-cholesten-3-one and fibroblast growth factor-19 as biomarkers diagnosing bile acid malabsorption in microscopic colitis and inflammatory bowel disease. Eur J Gastroenterol Hepatol 2021; 33:380-387. [PMID: 33177381 DOI: 10.1097/meg.0000000000001925] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Bile acid malabsorption is common in microscopic colitis, irritable bowel syndrome with diarrhea, and inflammatory bowel disease. We investigated the diagnostic accuracy of 7-alfa-hydroxy-4-cholesten-3-one and compared it with fibroblast growth factor-19 as biomarkers for bile acid malabsorption. METHODS We enrolled consecutively 109 chronic diarrhea patients with standard laboratory tests, fecal calprotectin, and endoscopy separated into six groups: n = 30 with active inflammatory bowel disease, n = 21 with inflammatory bowel disease in remission reporting >3 bowel movements per day, n = 21 with inflammatory bowel disease after surgery, n = 23 with irritable bowel syndrome with diarrhea, n = 14 with microscopic colitis and 11 healthy subjects (controls). We defined bile acid malabsorption as >3 bowel movements and lower fibroblast growth factor-19 (<60 pg/ml). RESULTS Median levels of 7-alfa-hydroxy-4-cholesten-3-one in inflammatory bowel disease active were 53.1 ng/ml, inflammatory bowel disease remission were 52.2 ng/ml, inflammatory bowel disease after surgery were 85.7 ng/ml, irritable bowel syndrome with diarrhea were 7.5 ng/ml, microscopic colitis were 69.3 ng/ml, and healthy controls were 3.7 ng/ml. We estimate a 7-alfa-hydroxy-4-cholesten-3-one cutoff of 48.9 ng/ml with 82.6% sensitivity and 84.3% specificity for detecting bile acid malabsorption. Both 7-alfa-hydroxy-4-cholesten-3-one >48.9 ng/ml and fibroblast growth factor-19 (<60 pg/ml) were found in 52% of the patients, compared with those 8% of patients below this 7-alfa-hydroxy-4-cholesten-3-one cutoff (P < 0.001). Serum 7-alfa-hydroxy-4-cholesten-3-one correlated with the number of bowel movements/day (r = -0.709; P < 0.001) and correlated inversely with fibroblast growth factor-19 (r = -0.741; P < 0.001). CONCLUSIONS Serum 7-alfa-hydroxy-4-cholesten-3-one above 48.9 ng/ml and fibroblast growth factor-19 below 60 pg/ml identify patients with diarrhea likely attributable to bile acid malabsorption with high diagnostic accuracy and they can be used as screening biomarkers for bile acid malabsorption in microscopic colitis and inflammatory bowel disease.
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14
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Biochemical Diagnosis of Bile Acid Diarrhea: Prospective Comparison With the 75Seleno-Taurohomocholic Acid Test. Am J Gastroenterol 2020; 115:2086-2094. [PMID: 32740083 DOI: 10.14309/ajg.0000000000000772] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION The diagnosis of bile acid diarrhea is often missed because the availability of the seleno-taurohomocholic acid (SeHCAT) test is limited. We aimed to compare the biomarkers 7α-hydroxy-4-cholesten-3-one (C4) and fibroblast growth factor 19 (FGF19) with the SeHCAT test. METHODS Patients with chronic diarrhea without intestinal resection referred for SeHCAT were prospectively recruited for this diagnostic accuracy study. Blood was sampled at fasting and after a stimulation meal with chenodeoxycholic acid. SeHCAT retention ≤10% defined bile acid diarrhea and >10% defined miscellaneous diarrhea. Receiver operating characteristics (ROC) were analyzed with SeHCAT as the gold standard. www.clinicaltrials.gov (NCT03059537). RESULTS Patients with bile acid diarrhea (n = 26) had mean C4 of 30 ng/mL (95% confidence interval: 19-46) vs 8 (7-11; P < 0.001) in the miscellaneous diarrhea group (n = 45). Area under the ROC curve (ROCAUC) for C4 was 0.83 (0.72-0.93). C4 < 15 ng/mL had 85% (74%-96%) negative predictive value; C4 > 48 ng/mL had 82% (59%-100%) positive predictive value. Twenty patients had C4 values 15-48 ng/mL, of whom 11/20 had SeHCAT ≤10%. Median fasting FGF19 was 72 pg/mL (interquartile range: 53-146) vs 119 (84-240) (P = 0.004); ROCAUC was 0.71 (0.58-0.83). Stimulated FGF19 responses did not differ (P = 0.54). DISCUSSION We identified C4 thresholds with clinically useful predictive values for the diagnosis of and screening for bile acid diarrhea in patients with chronic watery diarrhea. Further validation of the cutoff values with the placebo-controlled effect of sequestrant therapy is warranted (see Visual Abstract, Supplementary Digital Content 2, http://links.lww.com/AJG/B603).
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Abstract
Bile acid diarrhea is a frequent, treatable cause of functional diarrhea but is difficult to diagnose when the nuclear medicine seleno-taurohomocholic acid test is unavailable. An alternative approach is testing blood for the bile acid precursor, 7α-OH-4-cholesten-3-one, which is raised with increased bile acid synthesis. A recent article has defined measurements that have high negative and positive predictive values, further exploring how they can be improved by incorporating measures such as age, stool number, fibroblast growth factor 19, or plasma sulfated bile acids. Other articles have looked at the percentage of fecal primary bile acids. Together, they promise better use of diagnostic biomarkers for this condition.
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Abstract
Bile acids (BAs) are the central signals in enterohepatic communication, and they also integrate microbiota-derived signals into enterohepatic signaling. The tissue distribution and signaling pathways activated by BAs through natural receptors, farsenoid X receptor and G protein-coupled BA receptor 1 (GPBAR1, also known as Takeda G-coupled receptor 5), have led to a greater understanding of the mechanisms and potential therapeutic agents. BA diarrhea is most commonly encountered in ileal resection or disease, in idiopathic disorders (with presentation similar to functional diarrhea or irritable bowel syndrome with diarrhea), and in association with malabsorption such as chronic pancreatitis or celiac disease. Diagnosis of BA diarrhea is based on Se-homocholic acid taurine retention, 48-hour fecal BA excretion, or serum 7αC4; the latter being a marker of hepatic BA synthesis. BA diarrhea tends to be associated with higher body mass index, increased stool weight and stool fat, and acceleration of colonic transit. Biochemical markers of increased BA synthesis or excretion are available through reference laboratories. Current treatment of BA diarrhea is based on BA sequestrants, and, in the future, it is anticipated that farsenoid X receptor agonists may also be effective. The optimal conditions for an empiric trial with BA sequestrants as a diagnostic test are still unclear. However, such therapeutic trials are widely used in clinical practice. Some national guidelines recommend definitive diagnosis of BA diarrhea over empirical trial.
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Abstract
There are ten good reasons why it is important to think about abnormalities in bile acid control in inflammatory bowel disease. Before reviewing these reasons, it is relevant to review essential elements in the enterohepatic circulation, synthesis and actions of bile acids.
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Affiliation(s)
- Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA,Corresponding author: Michael Camilleri, MD, Mayo Clinic, Charlton 8–110, 200 First St. S.W., Rochester, MN 55905, USA. Tel: 507-266-2305;
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Labarile N, Ghosh S, Ng SC, Walters J, Iacucci M. Tests that now deserve to be more widely adopted in IBD clinical practice. Therap Adv Gastroenterol 2020; 13:1756284820944088. [PMID: 32782481 PMCID: PMC7385848 DOI: 10.1177/1756284820944088] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 06/30/2020] [Indexed: 02/04/2023] Open
Abstract
Inflammatory bowel diseases are chronic relapsing immune-mediated diseases of the intestinal tract with multifaceted manifestations and treatment related morbidity. Faecal and blood tests, radiological, endoscopic and histologic investigations are now widely used for managing both ulcerative colitis and Crohn's disease. Over the years, a number of new investigations have been proposed but not widely adopted yet. Patients with Crohn's disease may have multiple causes of diarrhoea, not always attributable to disease exacerbation, but sometimes linked to bile acid malabsorption; we have a reliable serum test, C4, that allows us to recognize and treat this cause of diarrhoea efficaciously and not empirically, but it is not available or used widely. There is genetic inter-individual variability in drug responses, in terms of both efficacy and toxicity, leading to high rates of therapeutic failure. Patients treated with thiopurine or, more rarely, 5-aminosalicylic acid may suffer from unpredictable and serious adverse events, some of these with pathogenesis related to genetic variants: myelosuppression, acute pancreatitis and nephrotoxicity. The identification of pre-treatment genetic tests can optimize therapeutic choice and avoid adverse events. With regard to biological drugs, patients can experience primary non-response or loss of response due to induction of immune responses to the drugs affecting drug efficacy and determining hypersensitivity reactions. We have specifically reviewed a number of investigations, whose use is currently limited, and highlighted four tests that deserve to be more widely incorporated in clinical practice as these could improve medical decision-making and patient outcomes.
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Affiliation(s)
| | - Subrata Ghosh
- Institute Translational of Medicine, Institute of Immunology and Immunotherapy and NIHR Birmingham Biomedical Research Centre, University Hospitals NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - Siew C Ng
- Department of Medicine and Therapeutics, Institute of Digestive Disease, State Key Laboratory of Digestive Diseases, Li Ka Shing Institute of Health Science, The Chinese University of Hong Kong, Hong Kong, China
| | - Julian Walters
- Division of Digestive Diseases, Imperial College London, Imperial College Healthcare, London, UK
| | - Marietta Iacucci
- Institute Translational of Medicine, Institute of Immunology and Immunotherapy and NIHR Birmingham Biomedical Research Centre, University Hospitals NHS Foundation Trust and University of Birmingham, Birmingham, UK
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Yang E, Panaccione N, Whitmire N, Dulai PS, Vande Casteele N, Singh S, Boland BS, Collins A, Sandborn WJ, Panaccione R, Battat R. Efficacy and safety of simultaneous treatment with two biologic medications in refractory Crohn's disease. Aliment Pharmacol Ther 2020; 51:1031-1038. [PMID: 32329532 PMCID: PMC8032452 DOI: 10.1111/apt.15719] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Revised: 02/09/2020] [Accepted: 03/21/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Biologic therapies in patients with Crohn's disease often yield low clinical and endoscopic remission rates. After multiple failed therapies, combining two biologic therapies is possibly the sole medical alternative to recurrent surgery. However, data on this approach are limited. AIMS To assess the efficacy and safety of concomitant use of two biologic therapies in the largest cohort to date of refractory Crohn's disease patients. METHODS Data were extracted from Crohn's disease patients started on dual biologic therapy at two referral centres. Biologics utilised include infliximab, adalimumab, vedolizumab, ustekinumab, certolizumab and golimumab. The primary outcome was endoscopic improvement (>50% reduction in Simplified Endoscopic Score-Crohn's disease [SES-CD] or explicitly stated). Endoscopic remission (SES-CD < 3 or stated), clinical response (Crohn's disease-patient-reported outcome-2 score [PRO2] reduced by 8), clinical remission (PRO2 < 8), and C-reactive protein (CRP) were also assessed. RESULTS A total of 22 patients with 24 therapeutic trials of dual biologic therapy were identified. The majority of patients had prior surgical resections (91%), stricturing (59%) or penetrating (36%) phenotype, and perianal fistulas (50%). Median number of prior failed biologics was 4. Endoscopic improvement occurred in 43% of trials and 26% achieved endoscopic remission. Fifty per cent had clinical response and 41% achieved clinical remission. There were significant post-treatment reductions in median SES-CD (14.0 [12.0-17.5] to 6.0 [2.5-8.0], P = 0.0005], PRO-2 (24.1 [20.3-27.0] to 13.4 [4.6-21.8], P = 0.002] and CRP (17.0 [11.0-24.0] to 9.0 [4.0-14.0], P = 0.02). Presence of perianal fistulas decreased from 50% to 33%. Adverse events occurred in 13% of trials. CONCLUSION Dual biologic therapy was associated with clinical, biomarker and endoscopic improvements in selected patients with refractory Crohn's disease who failed multiple biologics. Further studies are needed to validate this approach.
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Affiliation(s)
- Edward Yang
- UCSD Inflammatory Bowel Disease Center, Division of Gastroenterology, Department of Medicine, 9500 Gilman Drive, La Jolla, California 92093
| | - Nicola Panaccione
- Faculty of Health Science, Western University, 1151 Richmond Street, London, Ontario, Canada
| | - Natalie Whitmire
- UCSD Inflammatory Bowel Disease Center, Division of Gastroenterology, Department of Medicine, 9500 Gilman Drive, La Jolla, California 92093
| | - Parambir S. Dulai
- UCSD Inflammatory Bowel Disease Center, Division of Gastroenterology, Department of Medicine, 9500 Gilman Drive, La Jolla, California 92093
| | - Niels Vande Casteele
- UCSD Inflammatory Bowel Disease Center, Division of Gastroenterology, Department of Medicine, 9500 Gilman Drive, La Jolla, California 92093
| | - Siddharth Singh
- UCSD Inflammatory Bowel Disease Center, Division of Gastroenterology, Department of Medicine, 9500 Gilman Drive, La Jolla, California 92093
| | - Brigid S. Boland
- UCSD Inflammatory Bowel Disease Center, Division of Gastroenterology, Department of Medicine, 9500 Gilman Drive, La Jolla, California 92093
| | - Angelina Collins
- UCSD Inflammatory Bowel Disease Center, Division of Gastroenterology, Department of Medicine, 9500 Gilman Drive, La Jolla, California 92093
| | - William J. Sandborn
- UCSD Inflammatory Bowel Disease Center, Division of Gastroenterology, Department of Medicine, 9500 Gilman Drive, La Jolla, California 92093
| | - Remo Panaccione
- University of Calgary Inflammatory Bowel Disease Center, Division of Gastroenterology, Department of Medicine, 3280 Hospital Drive NW, Calgary, Alberta
| | - Robert Battat
- UCSD Inflammatory Bowel Disease Center, Division of Gastroenterology, Department of Medicine, 9500 Gilman Drive, La Jolla, California 92093,Weill Cornell Jill Roberts Center for Inflammatory Bowel Disease, Division of Gastroenterology and Hepatology, Department of Medicine, 1283 York Avenue, 9th Floor, New York, New York 10065
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Weaver MJ, McHenry SA, Sayuk GS, Gyawali CP, Davidson NO. Bile Acid Diarrhea and NAFLD: Shared Pathways for Distinct Phenotypes. Hepatol Commun 2020; 4:493-503. [PMID: 32258945 PMCID: PMC7109338 DOI: 10.1002/hep4.1485] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 01/13/2020] [Indexed: 12/16/2022] Open
Abstract
Irritable bowel syndrome with diarrhea (IBS-D) and NAFLD are both common conditions that may be influenced by shared pathways of altered bile acid (BA) signaling and homeostatic regulation. Pathophysiological links between IBS-D and altered BA metabolism include altered signaling through the ileal enterokine and fibroblast growth factor 19 (FGF19) as well as increased circulating levels of 7α-hydroxy-4-cholesten-3-one, a metabolic intermediate that denotes increased hepatic BA production from cholesterol. Defective production or release of FGF19 is associated with increased BA production and BA diarrhea in some IBS-D patients. FGF19 functions as a negative regulator of hepatic cholesterol 7α-hydroxylase; therefore, reduced serum FGF19 effectively de-represses hepatic BA production in a subset of IBS-D patients, causing BA diarrhea. In addition, FGF19 modulates hepatic metabolic homeostatic response signaling by means of the fibroblast growth factor receptor 4/klotho beta receptor to activate cascades involved in hepatic lipogenesis, fatty acid oxidation, and insulin sensitivity. Emerging evidence of low circulating FGF19 levels in subsets of patients with pediatric and adult NAFLD demonstrates altered enterohepatic BA homeostasis in NAFLD. Conclusion: Here we outline how understanding of shared pathways of aberrant BA homeostatic signaling may guide targeted therapies in some patients with IBS-D and subsets of patients with NAFLD.
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Affiliation(s)
- Michael J. Weaver
- Division of GastroenterologyWashington University School of MedicineSt. LouisMO
| | - Scott A. McHenry
- Division of GastroenterologyWashington University School of MedicineSt. LouisMO
| | - Gregory S. Sayuk
- Division of GastroenterologyWashington University School of MedicineSt. LouisMO
- U.S. Department of Veterans AffairsVA St. Louis Health Care SystemJohn Cochran DivisionSt. LouisMO
| | - C. Prakash Gyawali
- Division of GastroenterologyWashington University School of MedicineSt. LouisMO
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Lyutakov I, Ursini F, Penchev P, Caio G, Carroccio A, Volta U, De Giorgio R. Methods for diagnosing bile acid malabsorption: a systematic review. BMC Gastroenterol 2019; 19:185. [PMID: 31726982 PMCID: PMC6854889 DOI: 10.1186/s12876-019-1102-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 10/29/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Bile acid malabsorption (BAM) and bile acid-related diarrhea represent an under-recognized cause of chronic diarrhea mainly because of limited guidance on appropriate diagnostic and laboratory tests. We aimed to perform a systematic review of the literature in order to identify and compare the diagnostic accuracy of different diagnostic methods for patients with BAM, despite a proven gold standard test is still lacking. METHODS A PubMed literature review and a manual search were carried out. Relevant full papers, evaluating the diagnostic accuracy of different methods for BAM, were assessed. Available data were analyzed to estimate the sensitivity and specificity of each published test. RESULTS Overall, more than one test was considered in published papers on BAM. The search strategy retrieved 574 articles; of these, only 16 were full papers (with a total of 2.332 patients) included in the final review. Specifically, n = 8 studies used 75Selenium-homotaurocholic-acid-test (75SeHCAT) with a < 10% retention threshold; n = 8 studies evaluated fasting serum 7-α-hydroxy-4-cholesten-3-one (C4); n = 3 studies involved total fecal bile acid (BA) excretion over 48 h; n = 4 studies assessed fibroblast growth factor 19 (FGF19). 75SeHCAT showed an average sensitivity and specificity of 87.32 and 93.2%, respectively, followed by serum C4 (85.2 and 71.1%) and total fecal BA (66.6 and 79.3%). Fasting serum FGF19 had the lowest sensitivity and specificity (63.8 and 72.3%). All the extracted data were associated with substantial heterogeneity. CONCLUSIONS Our systematic review indicates that 75SeHCAT has the highest diagnostic accuracy for BAM, followed by serum C4 assay. The diagnostic yield of fecal BA and FGF19 assays is still under investigation. Our review reinforces the need for novel biomarkers aimed to an objective detection of BAM and therefore improving the management of this condition.
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Affiliation(s)
- Ivan Lyutakov
- Clinic of Gastroenterology, University Hospital "Tsaritsa Yoanna - ISUL", Sofia, Bulgaria
| | - Francesco Ursini
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Plamen Penchev
- Clinic of Gastroenterology, University Hospital "Tsaritsa Yoanna - ISUL", Sofia, Bulgaria
| | - Giacomo Caio
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Antonio Carroccio
- DiBiMIS University of Palermo, Palermo, Italy.,Internal Medicine, Giovanni Paolo II Hospital, Sciacca (ASP Agrigento), Sciacca, Italy
| | - Umberto Volta
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
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