慢性腹泻影响约5%的总体人口。胆汁酸代谢改变是常见但经常未诊断的原因。
我们对出版物数据库进行了系统搜索,以研究胆汁酸性腹泻(BAD)的评估和管理。证据的确定性(质量)和建议的强度根据建议评估的等级进行评级,开发和评估方法。患者群体,干预,比较器,和结果问题是通过迭代过程制定的,并由一组专家进行了投票。
证据的确定性通常被评为非常低。因此,17项建议中有16项是有条件的。在慢性腹泻患者中,考虑危险因素(回肠末端切除术,胆囊切除术,或腹部放疗),但不是额外的症状,建议用于识别可能患有BAD的患者。该小组建议使用75硒高胆酸牛磺酸(如果可用)或7α-羟基-4-胆甾烯-3-酮进行测试,包括腹泻的肠易激综合征患者,功能性腹泻,和克罗恩病没有炎症。建议进行经验性胆汁酸螯合剂治疗(BAST)。一旦可补救的原因得到管理,该小组建议将消胆胺作为初始治疗,当耐受性是一个问题时,使用备用的BAST。该小组建议对患有广泛回肠克罗恩病或切除的患者不使用BAST,如果BAST不能耐受,则建议使用其他止泻药。应以最低有效剂量给予维持BAST,随着间歇性的试验,按需管理,同时进行药物审查,和重新调查的患者的症状仍然存在,尽管采取了。
在系统回顾的基础上,慢性腹泻患者应考虑BAD。对于BAD检测结果阳性的患者,对BAST的审判,最初是用消胆胺,是建议的。
Chronic diarrhea affects about 5% of the population overall. Altered bile acid metabolism is a common but frequently undiagnosed cause.
We performed a systematic search of publication databases for studies of assessment and management of bile acid diarrhea (BAD). The certainty (quality) of evidence and strength of recommendations were rated according to the Grading of Recommendation Assessment, Development and Evaluation approach. Patient population, intervention, comparator, and outcome questions were developed through an iterative process and were voted on by a group of specialists.
The certainty of evidence was generally rated as very low. Therefore, 16 of 17 recommendations are conditional. In patients with chronic diarrhea, consideration of risk factors (terminal ileal resection, cholecystectomy, or abdominal radiotherapy), but not additional symptoms, was recommended for identification of patients with possible BAD. The group suggested testing using 75selenium homocholic acid taurine (where available) or 7α-hydroxy-4-cholesten-3-one, including patients with irritable bowel syndrome with diarrhea, functional diarrhea, and Crohn\'s disease without inflammation. Testing was suggested over empiric bile acid sequestrant therapy (BAST). Once remediable causes are managed, the group suggested cholestyramine as initial therapy, with alternate BAST when tolerability is an issue. The group suggested against BAST for patients with extensive ileal Crohn\'s disease or resection and suggested alternative antidiarrheal agents if BAST is not tolerated. Maintenance BAST should be given at the lowest effective dose, with a trial of intermittent, on-demand administration, concurrent medication review, and reinvestigation for patients whose symptoms persist despite BAST.
Based on a systematic review, BAD should be considered for patients with chronic diarrhea. For patients with positive results from tests for BAD, a trial of BAST, initially with cholestyramine, is suggested.