Last Updated: June 2023 Page 10 of 15 Back to Algorithm
BAM/BAD) can dysregulate this process. Subsequent unabsorbed bile acids stimulate sodium and water
secretion in the colon, increase motility, and stimulate defecation, thereby contributing to chronic diarrhea.
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There are several subtypes:
o Idiopathic: contributing to 25-35% of patients with chronic diarrhea-predominant IBS-D or chronic
functional diarrhea
o Post-cholecystectomy
o Other: secondary to small bowel resection (Crohn’s disease) or radiation therapy affecting the
ileum
Diagnosis and treatment:
Diagnosis may be challenging. Giving an empiric trial of bile acid sequestrants is reasonable, easy, and
inexpensive. See Treatment options - Bile acid sequestrants.
• Small Intestinal Bacterial Overgrowth (SIBO)
Unlike the colon, a significant number of bacteria do not normally reside in the small bowel. Small intestinal
bacterial overgrowth (SIBO) is a condition where dysbiosis or increased bacteria are present proximal to the
ileocecal valve and within the small bowel where there is normally less bacteria. SIBO is a rare cause of
gastrointestinal symptoms.
SIBO should only be considered in patients who have:
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o Severe diabetic neuropathy
o Advanced scleroderma
o Anatomic alterations such as surgery for Crohn’s disease, Crohn’s strictures, and/or radiation
o Immune deficiency (e.g., common variable immunodeficiency)
o Note: The accuracy of the breath test for SIBO is highly variable and may be unreliable. Routine
testing for SIBO is not currently recommended.
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o The use of hydrogen breath testing has been used in the past to make a diagnosis of SIBO.
However, the accuracy is not consistent, therefore; should not be ordered in primary care.
Empiric antibiotic treatment for SIBO should only be considered for symptomatic patients with at least one of
the above considered risk factors. See Second line therapies - Rifaximin.
• Pancreatic exocrine insufficiency (PEI)
The normal functioning pancreas produces enzymes responsible for facilitating macronutrient digestion
(enzymatic cleavage) so absorption can occur. Pancreatic insufficiency is not a common cause of chronic
diarrhea but may be a contributing component in the context of known pancreatic disease (e.g., chronic
pancreatitis, cystic fibrosis, or prior surgical resection of the small bowel or stomach). If you suspect
pancreatic insufficiency in someone with pancreatic disease, consider testing stool for fecal elastase (low
levels suggest pancreatic insufficiency). Routine use of pancreatic enzymes to support digestion are not
supported by evidence and are costly.
8. When to refer for consultation and/or endoscopy
• If alarm features are identified
• If investigation reveals a positive celiac disease screen
• If the fecal calprotectin result is > 120 µg/g
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Sadowski, D. C., Camilleri, M., Chey, W. D., Leontiadis, G. I., Marshall, J. K., Shaffer, E. A., ... & Walters, J. R. (2020). Canadian
association of gastroenterology clinical practice guideline on the management of bile acid diarrhea. Journal of the Canadian
Association of Gastroenterology, 3(1), e10-e27.
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Bull-Henry, K. (2020). Continuing Medical Education Questions: February 2020: ACG Clinical Guideline: Small Intestinal Bacterial
Overgrowth. American Journal of Gastroenterology, 115(2), 164.
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Farmer, A. D., Wood, E., & Ruffle, J. K. (2020). An approach to the care of patients with irritable bowel syndrome. CMAJ, 192(11),
E275-E282.
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Shah, A., Talley, N. J., Jones, M., Kendall, B. J., Koloski, N., Walker, M. M., ... & Holtmann, G. J. (2020). Small intestinal bacterial
overgrowth in irritable bowel syndrome: a systematic review and meta-analysis of case-control studies. American Journal of
Gastroenterology, 115(2), 190-201.