Obeticholic acid for severe bile acid diarrhea with intestinal failure: A case report and review of the literature

Table 1 Potential causes of chronic diarrhea and their diagnostic investigations and results in a patient with severe bile acid diarrhea and intestinal failure

Potential cause of diarrhea	Investigations	Results
Excess bile acid production with deficient retention	SeHCAT scintigraphy	0 retention, indicating an excess loss of bile acids
Active Crohn’s disease	Small bowel imaging; colonoscopy; fecal calprotectin	Normal MRI of small bowel and capsule endoscopy; normal colonoscopy with biopsies; fecal calprotectin < 30 mg/kg
Small bowel disease (celiac disease, autoimmune enteropathy)	Duodenal and jejunal biopsies; plasma tissue transglutaminase antibody	Normal biopsies; anti-transglutaminase negative
Clostridium difficile infection	Clostridium difficile toxin test	Positive before fecal transplant; negative repeated tests after fecal transplant
Pathogenic intestinal infection	Salmonella, Shigella, Campylobacter, and Yersinia fecal cultures; PCR for intestinal parasites	Negative
Systemic infection	HIV test; gamma-interferon test for tuberculosis	Negative
Small intestinal bacterial overgrowth (SIBO)	Hydrogen breath test	Negative
Use of antidepressant and antiepileptic medications	Observation during drug holiday; therapeutic drug monitoring	Treatment dose optimized
Laxative use	Urine laxative screen repeated with a patient-blinded sampling time	Negative × 2
Neuroendocrine tumor	Chromogranin A, gastrin, vasoactive intestinal polypeptide, renin, and aldosterone	All within the reference range
Metabolic disease	Thyroid function test and synacthen test	All within the normal range

SeHCAT: Selenium homotaurocholic acid test.