What are the key clinical features that suggest bile acid malabsorption in a patient?

Key clinical features suggesting bile acid malabsorption (BAM) include chronic watery diarrhoea, often without nocturnal symptoms, and urgency or incontinence of stools. Patients may report frequent loose stools that are pale or greasy, sometimes accompanied by abdominal cramping and bloating.

These symptoms commonly overlap with irritable bowel syndrome with diarrhoea (IBS-D), but BAM should be suspected especially when diarrhoea is refractory to standard IBS treatments or when there is a history of ileal disease or resection.

Additional clinical clues include a history of cholecystectomy, Crohn’s disease affecting the terminal ileum, or other conditions impairing bile acid reabsorption.

Laboratory and diagnostic tests such as SeHCAT scanning can confirm BAM, but the initial clinical suspicion arises from the characteristic diarrhoeal pattern and relevant medical history.

Overall, the presence of chronic watery diarrhoea with urgency, particularly in the context of ileal pathology or surgery, strongly suggests bile acid malabsorption as an underlying cause ¹ (Slattery et al., 2015).