Guideline sources The following summarized guidelines for the evaluation and management of bile acid diarrhea (BAD) are prepared by our editorial team based on guidelines from the Canadian Association of Gastroenterologists (CAG 2020). 1 Guidelines 1. Diagnostic investigations Clinical evaluation: Ask about risk factors (history of terminal ileal resection, cholecystectomy, or abdominal radiotherapy) in the initial assessment of patients presenting with chronic non-bloody diarrhea to identify possible BAD. B Do not use presenting symptoms in the initial assessment in patients presenting with chronic non-bloody diarrhea to identify possible BAD. D Laboratory testing: obtain SeHCAT and serum C4 assay for the diagnosis of BAD in patients with chronic diarrhea, including IBS-D and functional diarrhea. B Show 2 more 2. Medical management https://web.pathway.md/diseases/recCYlHcNlojwbo8r 1/2 6/29/23, 3:17 AM Bile acid diarrhea Pathway Bile acid sequestrants (choice of agent): consider administering cholestyramine for induction of clinical response in patients with BAD. C Show 2 more Bile acid sequestrants (dosing): titrate the daily dose of empiric bile acid sequestrants gradually to minimize side effects in patients with BAD. E Show 2 more Bile acid sequestrants (monitoring): Review concurrent medications to minimize the potential for drug interactions in patients with BAD considered for bile acid sequestrant therapy. E Insufficient evidence to recommend for or against measuring fat-soluble vitamin levels at baseline and annually thereafter in patients with BAD receiving long-term maintenance therapy with bile acid sequestrants. I Anti-diarrheal agents: consider offering alternative anti-diarrheal agents for long-term symptomatic therapy in patients with BAD unable to tolerate bile acid sequestrant therapy. C Management of secondary causes: Treat secondary causes, such as Crohn's disease, microscopic colitis, SIBO, for induction of clinical response in patients with type 1 or 3 BAD. B Consider avoiding the use of bile acid sequestrants in patients with BAD and Crohn's disease with extensive ileal involvement or resection. D 3. Follow-up and surveillance Follow-up: obtain diagnostic reevaluation in patients with BAD and recurrent or worsening symptoms despite stable bile acid sequestrant therapy. E References 1. Daniel C Sadowski, Michael Camilleri, William D Chey et al. Canadian Association of Gastroenterology Clinical Practice Guideline on the Management of Bile Acid Diarrhea. Clin Gastroenterol Hepatol. 2020 Jan;18 1 24 41.e1. Open https://web.pathway.md/diseases/recCYlHcNlojwbo8r 2/2