Bile acid diarrhoea — ESEGH MCQ

Instant feedback + full explanation. One question, done properly.

ModerateLuminal GIBile acid diarrhoeaESEGH

A 51-year-old woman has persistent watery, postprandial diarrhoea after a 30 cm terminal ileal resection for Crohn's disease. Her symptoms improve when fasting. Ileocolonoscopy shows no active inflammation, and CRP and faecal calprotectin are normal. SeHCAT retention is 3% at 7 days. What is the most appropriate initial targeted management?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: C — Start a bile acid sequestrant

The correct answer is **B: start a bile acid sequestrant**, such as colesevelam or colestyramine. Terminal ileal resection impairs enterohepatic bile acid reabsorption, allowing excess bile acids to enter the colon and cause secretory, often postprandial diarrhoea. A 7-day SeHCAT retention of 3% denotes severe bile acid diarrhoea. A low-fat diet may be useful as an adjunct but is not adequate alone for severe disease. Normal inflammatory markers, faecal calprotectin and ileocolonoscopy argue against recurrent inflammatory Crohn's disease, so corticosteroids are inappropriate. Pancreatic enzymes are indicated for pancreatic exocrine insufficiency, which is not suggested here. Loperamide may provide additional symptomatic benefit but does not address the underlying bile acid-mediated mechanism and should not be the sole targeted treatment.

Reference: British Society of Gastroenterology, Practice guidance on the management of acute and chronic gastrointestinal symptoms and complications as a result of treatment for cancer, section 'Bile acid diarrhoea/malabsorption', 2025. https://www.bsg.org.uk/getmedia/a1740ab6-2987-4fd5-ba3b-96612d6e66c5/gutjnl-2024-333812.pdf