OC29 Improving the diagnosis and management of bile salt malabsorption in Paediatrics

Introduction Chronic diarrhoea, malnutrition, and deficits in fat-soluble vitamins are signs of bile salt malabsorption (BSM), which is characterised by the inadequate reabsorption of bile acids from the ileum. This condition is well-recognised amongst adult patients and can be diagnosed in up to a third of patients presenting with features of irritable bowel syndrome. BSM is less commonly considered in children. The aetiology of BSM in children can be multifactorial. Secondary causes of BSM (such as ileal resection, ileal Crohn’s disease, coeliac disease, and specific infections like giardiasis) are more prevalent in children, while primary BSM is frequently idiopathic. Aims This study aims to audit the outcome of 23-seleno-25-homotaurocholic acid, selenium homocholic acid taurine or tauroselcholic acid test (SeHCAT scan) requests to gain an understanding of how to improve the diagnosis and management of children with symptoms consistent with BSM. Methods This was a retrospective single-centre study of all children aged 5 to 17 years with chronic diarrhoea (defined as passing 3 or more loose stools for > 1 month) with no clear diagnosis found on initial/standard screening investigations who had SeHCAT scans completed at a tertiary centre between 2018 and 2023 (5 years). Results 20 out of the 43 (47%) children who had SeCHAT scans were diagnosed with BSM. Of these, 7 (35%) had mild BSM (retention values of SeHCAT between 10–15%), 4 (20%) had moderate BSM (retention values of SeHCAT between 5–10%), and 9 (45%) had severe BSM (retention values of SeHCAT <5%). Of the 13 cases with moderate-severe BSM, secondary causes were found in 8. 3 children had an ileo-caecal resection for Crohn’s disease, 2 children had radiotherapy for neuroblastoma, and there was 1 child each with coeliac disease, AIRE gene defect, and post-cholecystectomy. In the 5 remaining cases with moderate-severe BSM and all of the 7 cases with mild BSM no secondary causes were identified and were therefore considered as primary/idiopathic. All patients were given dietary advice. 18/20 (90%) patients were given a trial of bile salt sequesters, Cholestyramine or Colesevelam. 10/18 (55%) had significant symptom improvement with resolution of diarrhoea and of these, 7/10 (70%) experienced notable improvements in their growth trajectory. Conclusion This audit suggests the importance of considering a diagnosis of BSM in those with chronic diarrhoea especially if the initial/standard screening investigations are negative. It highlights the improvements in symptoms and growth that can result from timely diagnosis and effective management. Reference National Institute of health. Riemsma R, Al M, Corro Ramos I, et al. SeHCAT [tauroselcholic (selenium-75) acid] for the investigation of bile acid malabsorption and measurement of bile acid pool loss: a systematic review and cost-effectiveness analysis. Health Technology Assessment 2013 Dec;No. 17.61. Southampton (UK): NIHR Journals Library. Systematic review: The prevalence of idiopathic bile acid malabsorption as diagnosed by SeHCAT scanning in patients with diarrhoea-predominant irritable bowel syndrome. Alimentary Pharmacology & Therapeutics 2009 July;30(7):707–17. DOI:10.1111/j.1365-2036.2009.04081.x Daniel C. Canadian association of gastroenterology clinical practice guideline on the management of bile acid diarrhea. September 14, 2019. DOI:https://doi.org/10.1016/j.cgh.2019.08.062 Marwa Al-Azzawi, Sally Darnborough, Lynsey Devlin, Sai Han, Alison Bolster, Gary Nicholson. SeHCAT scan as an investigation for chronic diarrhoea; a single trust experience. British Journal of Surgery October 2021;108(Supplement_7):znab362. https://doi.org/10.1093/bjs/znab362

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