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Bile Acid Malabsorption Caused by Ileal Resection

Bile Acid Malabsorption Caused by Ileal Resection Abstract Two syndromes of bile acid malabsorption caused by ileal resection—bile acid diarrhea (cholerheic diarrhea) and fatty acid diarrhea (steatorrheic diarrhea)—have been identified, characterized, and symptomatic therapy has been developed. In patients with small resections, bile acid malabsorption is mild, and compensatory increase in hepatic synthesis of bile acids is sufficient to restore their secretion. The increased passage of bile acids into the colon causes diarrhea. In patients with large resections, bile acid malabsorption is severe, and increase in bile acid synthesis is insufficient to restore their secretion. This results in impaired micellar dispersion of lipolytic products and malabsorption of fat. Diarrhea responds to removal of long-chain triglycerides from the diet, suggesting that unabsorbed fatty acids or their bacterial products cause the diarrhea in these patients. References 1. Hofmann AF, Poley JR: Role of bile acid malabsorption in pathogenesis of diarrhea and steatorrhea in patients with ileal resection. I. Response to cholestyramine or replacement of dietary long chain triglyceride by medium chain triglyceride. Gastroenterology 62:918-934, 1972. 2. Hofmann AF: The syndrome of ileal disease and the broken enterohepatic circulation: Cholerheic enteropathy. Gastroenterology 52:752-757, 1967. 3. Smith LJ, Fromm H, Hofmann AF: Acquired hyperoxaluria, nephrolithiasis and intestinal disease: Description of a new syndrome. New Eng J Med 286:1371-1375, 1972.Crossref 4. Hofmann AF, Tacker MM, Fromm H, et al: Acquired hyperoxaluria, nephrolithiasis, and intestinal disease: Metabolism of cholyl glycine-1-14C and proposed mechanism for syndrome. Mayo Clin Proc , to be published. 5. Dowling RH, Rose GA, Sutor DJ: Hyperoxaluria and renal calculi in ileal disease. Lancet 1:1103-1106, 1971.Crossref 6. Admirand WH, Earnest DL, Williams HE: Hyperoxaluria and bowel disease. Trans Assoc Amer Physicians 84:307-312, 1971. 7. Heaton KW, Read AE: Gallstones in patients with disorders of the terminal ileum and disturbed bile salt metabolism. Brit Med J 3:494-496, 1969.Crossref 8. Hofmann AF, Poley JR: Cholestyramine treatment of diarrhea associated with ileal resection. New Eng J Med 281:397-402, 1969.Crossref 9. Stanley MW, Nemchausky B: Fecal 14C bile acid excretion in normal subjects and patients with steroidwasting syndromes secondary to ileal dysfunction. J Lab Clin Med 70:627-639, 1967. 10. Meihoff WE, Kern F Jr: Bile salt malabsorption in regional ileitis, ileal resection, and mannitol-induced diarrhea. J Clin Invest 47:261-267, 1968.Crossref 11. Heaton KW, Austad WI, Lack L, et al: Enterohepatic circulation of 14C-labeled bile salts in disorders of the small bowel. Gastroenterology 55:5-16, 1968. 12. Woodbury JF, Kern F Jr: Fecal excretion of bile acids: A new technique for studying bile acid kinetics in patients with ileal resection. J Clin Invest 50:2531-2540, 1971.Crossref 13. Mekhjian HS, Phillips SF, Hofmann AF: Colonic secretion of water and electrolytes induced by bile acids: Perfusion studies in man. J Clin Invest 50:1569-1577, 1971.Crossref 14. Galapeaux EA, Templeton RD, Borkon EL: The influence of bile on the motility of the dog's colon. Amer J Physiol 121:130-136, 1938. 15. Grundy SM, Hofmann AF, Davignon J, et al: Human cholesterol synthesis is regulated by bile acids, abstracted. J Clin Invest 45:1018, 1966.Crossref 16. Grundy SM, Ahrens EH Jr, Miettinen TA: Quantitative isolation and gas-liquid chromatographic analysis of total fecal bile acids. J Lipid Res 6:397-410, 1965. 17. Lindstedt S: The turnover of cholic acid in man. Acta Physiol Scand 40:1-9, 1957.Crossref 18. Moore RB, Franz ID, Buchwald H: Changes in cholesterol pool size, turnover rate, and fecal bile acid and sterol excretion after partial ileal bypass in hypercholesteremic patients. Surgery 65:98-108, 1969. 19. Grundy SM, Ahrens EH Jr, Salen G: Interruption of the enterohepatic circulation of bile acids in man: Comparative effects of cholestyramine and ileal exclusion on cholesterol metabolism. J Lab Clin Med 78:94-120, 1971. 20. Moutafis CO, Myant NB, Tabaqchali S: The metabolism of cholesterol after resection or bypass of the lower small intestine. Clin Sci 35:537-545, 1968. 21. Buchwald H, Varco RL: Partial ileal bypass for hypercholesterolemia and atherosclerosis. Surg Gynec Obstet 124:1231-1238, 1967. 22. Go VLW, Hofmann AF, Summerskill WHJ: Simultaneous measurements of total pancreatic, biliary, and gastric outputs in man using a perfusion technique. Gastroenterology 58:321-328, 1970. 23. Grundy SM, Ahrens EH Jr, Salen G: Hourly rates of secretion of biliary lipids in man, abstracted. Clin Res 18:529, 1970. 24. Brunner H, Hofmann AF, Summerskill WHJ: Daily secretion of bile acids and cholesterol measured in health, abstracted. Gastroenterology 62:188, 1972. 25. Hofmann AF: The function of bile in the alimentary canal , in Code CF (ed): Handbook of Physiology , vol 5. Baltimore, Williams & Wilkins Co, 1967, pp 2507-2533. 26. Simmonds WJ, Redgrave TJ, Willix RLS: Absorption of oleic and palmitic acids from emulsions and micellar solutions. J Clin Invest 47:1015-1025, 1968.Crossref 27. Knoebel LK, Ryan JM: Digestion and mucosal absorption of fat in normal and bile-deficient dogs. Amer J Physiol 204:509-514, 1963. 28. Hoffman NE, Simmonds WJ, Morgan RGH: A comparison of absorption of fatty acid and glyceryl monoether in the presence and absence of a micellar phase. Biochim Biophys Acta 231:487, 1971.Crossref 29. Hofmann AF, Borgstrom B: The intraluminal phase of fat digestion in man: The lipid content of the micellar and oil phases of intestinal content obtained during fat digestion and absorption. J Clin Invest 43:247-257, 1964.Crossref 30. Porter HP, Saunders DR: Isolation of the aqueous phase of human intestinal content during the digestion of a fatty meal. Gastroenterology 60:997-1007, 1971. 31. Borgstrom B: Partition of lipids between emulsified oil and micellar phases of glyceride-bile salt dispersions. J Lipid Res 8:598-608, 1967. 32. Borgstrom B, Dahlqvist A, Lundh G, et al: Studies of intestinal digestion and absorption in the lumen. J Clin Invest 36:1521-1536, 1957.Crossref 33. Sjovall J: Bile acids in man under normal and pathological conditions: Bile acids and steroids 73. Clin Chim Acta 5:33-41, 1960.Crossref 34. Nakayama F: Quantitative microanalysis of bile. J Lab Clin Med 69:594-609, 1967. 35. Danielsson HH: Present status of research on catabolism and excretion of cholesterol. Advances Lipid Res 1:335-385, 1963. 36. Hepner GW, Hofmann AF, Thomas PJ: Metabolism of steroid and amino acid moieties of conjugated bio acids in man. II. Glycine-conjugated dihydroxy bio acids. J Clin Invest 51:1898-1905, 1972.Crossref 37. Mcleod GM, Wiggins HS: Bile salts in small intestinal content after ileal resection and in other malabsorption syndromes. Lancet 1:873-876, 1968.Crossref 38. Thaysen EH, Bruusgaard A, Eriksen B: Evaluation of the efficiency of bile salt recirculation in patients with terminal ileopathies by means of deoxycholate determination in duodenal aspirates. Scand J Gastroent 5:39-48, 1970. 39. Mallory A, Smith J, Kern F, et al: Patterns of bile acids and microflora in the human small intestine, abstracted. J Lab Clin Med 78:829-830, 1971. 40. Hofmann AF, Poley JR: Cholestyramine treatment of diarrhea associated with ileal resection: Factors influencing response, abstracted. Gastroenterology 56:1168, 1969. 41. Garbutt JT, Lack L, Tyor MP: The enterohepatic circulation of bile salts in gastrointestinal disorders. Amer J Med 51:627-636, 1971.Crossref 42. Hofmann AF, Small DM: Detergent properties of bile salts: Correlation with physiological function. Ann Rev Med 18:433-476, 1967.Crossref 43. Giller J, Phillips SF: Colonic absorption of electrolytes and water in man: A comparison of 24-hour ileal content and feces, abstracted. Gastroenterology 58:951, 1970. 44. Vlahcevic ZR, Bell CC Jr, Buhac I, et al: Diminished bile acid pool size in gallstones. Gastroenterology 59:165-173, 1970. 45. Danzinger RG, Hofmann AF, Schoenfield LJ, et al: Dissolution of cholesterol gallstones by chenodeoxycholic acid. New Eng J Med 286:1-7, 1972.Crossref 46. Rowe GG: Control of tenesmus and diarrhea by cholestyramine administration. Amer J Med Sci 255:84-88, 1968.Crossref 47. Sickinger K: Die Behandlung der chologene Diarrhoe und Steatorrhoe des enteralen Gallenäureverlustsyndroms mit Cholestyramin und mittelkettigen Triglyceriden. Deutsch Med Wschr 94:1151-1157, 1969.Crossref 48. Johns WH, Bates TS: Quantification of the binding tendencies of cholestyramine. I. Effect of structure and added electrolytes on the binding of unconjugated and conjugated bile acid anions. J Pharm Sci 58:179-183, 1969.Crossref 49. Johns WH, Bates TR: Quantification of the binding tendencies of cholestyramine. II. Mechanisms of interaction with bile salt and fatty acid salt anions. J Pharm Sci 59:329-333, 1970.Crossref 50. Vlahcevic ZR, Miller JR, Farrar JT, et al: Kinetics and pool size of primary bile acids in man. Gastroenterology 61:85-90, 1971. 51. Baker RD, Searle GW: Bile salt absorption at various levels of rat small intestine. Proc Soc Exp Biol Med 105:521-523, 1960.Crossref 52. Tappeiner AJFH: Ueber die Aufsaugung der Gallsauren alkalien im Dunndarme. Wien Akad Sitzber 77:281-304, 1878. 53. Hofmann AF, Grundy SM: Abnormal bile salt metabolism in a patient with extensive lower intestinal resection, abstracted. Clin Res 13:254, 1965. 54. Krone CL, Theodor E, Sleisenger MH, et al: Studies on the pathogenesis of malabsorption: Lipid hydrolysis and micelle formation in the intestinal lumen. Medicine 47:89-106, 1968.Crossref 55. Hardison WGM, Rosenberg IH: Bile salt deficiency in the steatorrhea following resection of the ileum and proximal colon. New Eng J Med 277:337-343, 1967.Crossref 56. Vandeest BW, Fordtran JS, Morawski SG, et al: Bile salt micellar fat concentration in proximal small bowel contents of ileectomy patients. J Clin Invest 47:1314-1324, 1968.Crossref 57. Austad WI, Lack L, Tyor MP: Importance of bile acids and of an intact distal small intestine for fat absorption. Gastroenterology 52:638-646, 1967. 58. Dowling RH, Mack E, Small DM: Effects of controlled interruption of the enterohepatic circulation of bile salts by biliary diversion and by ileal resection on bile salt secretion, synthesis, and pool size in the rhesus monkey. J Clin Invest 49:232-242, 1970.Crossref 59. Abaurre R, Gordon SG, Mann JG, et al: Fasting bile salt pool size and composition after ileal resection. Gastroenterology 57:679-688, 1969. 60. Porter HP, Saunders DR, Tygtat G, et al: Fat absorption in bile fistula in man: A morphological and biochemical study. Gastroenterology 60:1008-1019, 1971. 61. Conner WE, Witiak DT, Stone DB, et al: Cholesterol balance and fecal neutral steroid and bile acid excretion in normal men fed dietary fats of different fatty acid composition. J Clin Invest 48:1363-1375, 1969.Crossref 62. Thomas PJ: Identification of some organisms which convert oleic acid to hydroxy stearic acid. Gastroenterology 62:430-435, 1972. 63. Meyer H: Ueber den Wirksamen Bestandteil des Ricinusoels. Arch Exp Path Pharmak 28:145-152,1890.Crossref 64. James AT, Webb J, Kellock TD: The occurrence of unusual fatty acids in faecel lipids from human beings with normal and abnormal fat absorption. Biochem J 78:333-339, 1961. 65. Chipault JR, Wollaeger EE: Annual Report of the Hormel Institute 1952-1953 , University of Minnesota, pp 21-25. 66. Hofmann AF, Poley JR, Mekhjian HS, et al: Hydroxy fatty acids—an apparent cause of diarrhea in patients with ileal resection. J Clin Invest 49:44A, 1970. 67. Morgan RGH: The effect of bile salts on the lymphatic absorption by the unanaesthetized rat of intraduodenally infused lipids. Quart J Exp Physiol 49:457-465, 1964. 68. Bochenek W, Rodgers JB, Balint JA: Effects of changes in dietary lipids on intestinal fluid loss in the short-bowel syndrome. Ann Intern Med 72:205-213, 1970.Crossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Bile Acid Malabsorption Caused by Ileal Resection

Archives of Internal Medicine , Volume 130 (4) – Oct 1, 1972

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American Medical Association
Copyright
Copyright © 1972 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.1972.03650040121011
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Abstract

Abstract Two syndromes of bile acid malabsorption caused by ileal resection—bile acid diarrhea (cholerheic diarrhea) and fatty acid diarrhea (steatorrheic diarrhea)—have been identified, characterized, and symptomatic therapy has been developed. In patients with small resections, bile acid malabsorption is mild, and compensatory increase in hepatic synthesis of bile acids is sufficient to restore their secretion. The increased passage of bile acids into the colon causes diarrhea. In patients with large resections, bile acid malabsorption is severe, and increase in bile acid synthesis is insufficient to restore their secretion. This results in impaired micellar dispersion of lipolytic products and malabsorption of fat. Diarrhea responds to removal of long-chain triglycerides from the diet, suggesting that unabsorbed fatty acids or their bacterial products cause the diarrhea in these patients. References 1. Hofmann AF, Poley JR: Role of bile acid malabsorption in pathogenesis of diarrhea and steatorrhea in patients with ileal resection. I. Response to cholestyramine or replacement of dietary long chain triglyceride by medium chain triglyceride. Gastroenterology 62:918-934, 1972. 2. Hofmann AF: The syndrome of ileal disease and the broken enterohepatic circulation: Cholerheic enteropathy. Gastroenterology 52:752-757, 1967. 3. Smith LJ, Fromm H, Hofmann AF: Acquired hyperoxaluria, nephrolithiasis and intestinal disease: Description of a new syndrome. New Eng J Med 286:1371-1375, 1972.Crossref 4. Hofmann AF, Tacker MM, Fromm H, et al: Acquired hyperoxaluria, nephrolithiasis, and intestinal disease: Metabolism of cholyl glycine-1-14C and proposed mechanism for syndrome. Mayo Clin Proc , to be published. 5. Dowling RH, Rose GA, Sutor DJ: Hyperoxaluria and renal calculi in ileal disease. Lancet 1:1103-1106, 1971.Crossref 6. Admirand WH, Earnest DL, Williams HE: Hyperoxaluria and bowel disease. Trans Assoc Amer Physicians 84:307-312, 1971. 7. Heaton KW, Read AE: Gallstones in patients with disorders of the terminal ileum and disturbed bile salt metabolism. Brit Med J 3:494-496, 1969.Crossref 8. Hofmann AF, Poley JR: Cholestyramine treatment of diarrhea associated with ileal resection. New Eng J Med 281:397-402, 1969.Crossref 9. Stanley MW, Nemchausky B: Fecal 14C bile acid excretion in normal subjects and patients with steroidwasting syndromes secondary to ileal dysfunction. J Lab Clin Med 70:627-639, 1967. 10. Meihoff WE, Kern F Jr: Bile salt malabsorption in regional ileitis, ileal resection, and mannitol-induced diarrhea. J Clin Invest 47:261-267, 1968.Crossref 11. Heaton KW, Austad WI, Lack L, et al: Enterohepatic circulation of 14C-labeled bile salts in disorders of the small bowel. Gastroenterology 55:5-16, 1968. 12. Woodbury JF, Kern F Jr: Fecal excretion of bile acids: A new technique for studying bile acid kinetics in patients with ileal resection. J Clin Invest 50:2531-2540, 1971.Crossref 13. Mekhjian HS, Phillips SF, Hofmann AF: Colonic secretion of water and electrolytes induced by bile acids: Perfusion studies in man. J Clin Invest 50:1569-1577, 1971.Crossref 14. Galapeaux EA, Templeton RD, Borkon EL: The influence of bile on the motility of the dog's colon. Amer J Physiol 121:130-136, 1938. 15. Grundy SM, Hofmann AF, Davignon J, et al: Human cholesterol synthesis is regulated by bile acids, abstracted. J Clin Invest 45:1018, 1966.Crossref 16. Grundy SM, Ahrens EH Jr, Miettinen TA: Quantitative isolation and gas-liquid chromatographic analysis of total fecal bile acids. J Lipid Res 6:397-410, 1965. 17. Lindstedt S: The turnover of cholic acid in man. Acta Physiol Scand 40:1-9, 1957.Crossref 18. Moore RB, Franz ID, Buchwald H: Changes in cholesterol pool size, turnover rate, and fecal bile acid and sterol excretion after partial ileal bypass in hypercholesteremic patients. Surgery 65:98-108, 1969. 19. Grundy SM, Ahrens EH Jr, Salen G: Interruption of the enterohepatic circulation of bile acids in man: Comparative effects of cholestyramine and ileal exclusion on cholesterol metabolism. J Lab Clin Med 78:94-120, 1971. 20. Moutafis CO, Myant NB, Tabaqchali S: The metabolism of cholesterol after resection or bypass of the lower small intestine. Clin Sci 35:537-545, 1968. 21. Buchwald H, Varco RL: Partial ileal bypass for hypercholesterolemia and atherosclerosis. Surg Gynec Obstet 124:1231-1238, 1967. 22. Go VLW, Hofmann AF, Summerskill WHJ: Simultaneous measurements of total pancreatic, biliary, and gastric outputs in man using a perfusion technique. Gastroenterology 58:321-328, 1970. 23. Grundy SM, Ahrens EH Jr, Salen G: Hourly rates of secretion of biliary lipids in man, abstracted. Clin Res 18:529, 1970. 24. Brunner H, Hofmann AF, Summerskill WHJ: Daily secretion of bile acids and cholesterol measured in health, abstracted. Gastroenterology 62:188, 1972. 25. Hofmann AF: The function of bile in the alimentary canal , in Code CF (ed): Handbook of Physiology , vol 5. Baltimore, Williams & Wilkins Co, 1967, pp 2507-2533. 26. Simmonds WJ, Redgrave TJ, Willix RLS: Absorption of oleic and palmitic acids from emulsions and micellar solutions. J Clin Invest 47:1015-1025, 1968.Crossref 27. Knoebel LK, Ryan JM: Digestion and mucosal absorption of fat in normal and bile-deficient dogs. Amer J Physiol 204:509-514, 1963. 28. Hoffman NE, Simmonds WJ, Morgan RGH: A comparison of absorption of fatty acid and glyceryl monoether in the presence and absence of a micellar phase. Biochim Biophys Acta 231:487, 1971.Crossref 29. Hofmann AF, Borgstrom B: The intraluminal phase of fat digestion in man: The lipid content of the micellar and oil phases of intestinal content obtained during fat digestion and absorption. J Clin Invest 43:247-257, 1964.Crossref 30. Porter HP, Saunders DR: Isolation of the aqueous phase of human intestinal content during the digestion of a fatty meal. Gastroenterology 60:997-1007, 1971. 31. Borgstrom B: Partition of lipids between emulsified oil and micellar phases of glyceride-bile salt dispersions. J Lipid Res 8:598-608, 1967. 32. Borgstrom B, Dahlqvist A, Lundh G, et al: Studies of intestinal digestion and absorption in the lumen. J Clin Invest 36:1521-1536, 1957.Crossref 33. Sjovall J: Bile acids in man under normal and pathological conditions: Bile acids and steroids 73. Clin Chim Acta 5:33-41, 1960.Crossref 34. Nakayama F: Quantitative microanalysis of bile. J Lab Clin Med 69:594-609, 1967. 35. Danielsson HH: Present status of research on catabolism and excretion of cholesterol. Advances Lipid Res 1:335-385, 1963. 36. Hepner GW, Hofmann AF, Thomas PJ: Metabolism of steroid and amino acid moieties of conjugated bio acids in man. II. Glycine-conjugated dihydroxy bio acids. J Clin Invest 51:1898-1905, 1972.Crossref 37. Mcleod GM, Wiggins HS: Bile salts in small intestinal content after ileal resection and in other malabsorption syndromes. Lancet 1:873-876, 1968.Crossref 38. Thaysen EH, Bruusgaard A, Eriksen B: Evaluation of the efficiency of bile salt recirculation in patients with terminal ileopathies by means of deoxycholate determination in duodenal aspirates. Scand J Gastroent 5:39-48, 1970. 39. Mallory A, Smith J, Kern F, et al: Patterns of bile acids and microflora in the human small intestine, abstracted. J Lab Clin Med 78:829-830, 1971. 40. Hofmann AF, Poley JR: Cholestyramine treatment of diarrhea associated with ileal resection: Factors influencing response, abstracted. Gastroenterology 56:1168, 1969. 41. Garbutt JT, Lack L, Tyor MP: The enterohepatic circulation of bile salts in gastrointestinal disorders. Amer J Med 51:627-636, 1971.Crossref 42. Hofmann AF, Small DM: Detergent properties of bile salts: Correlation with physiological function. Ann Rev Med 18:433-476, 1967.Crossref 43. Giller J, Phillips SF: Colonic absorption of electrolytes and water in man: A comparison of 24-hour ileal content and feces, abstracted. Gastroenterology 58:951, 1970. 44. Vlahcevic ZR, Bell CC Jr, Buhac I, et al: Diminished bile acid pool size in gallstones. Gastroenterology 59:165-173, 1970. 45. Danzinger RG, Hofmann AF, Schoenfield LJ, et al: Dissolution of cholesterol gallstones by chenodeoxycholic acid. New Eng J Med 286:1-7, 1972.Crossref 46. Rowe GG: Control of tenesmus and diarrhea by cholestyramine administration. Amer J Med Sci 255:84-88, 1968.Crossref 47. Sickinger K: Die Behandlung der chologene Diarrhoe und Steatorrhoe des enteralen Gallenäureverlustsyndroms mit Cholestyramin und mittelkettigen Triglyceriden. Deutsch Med Wschr 94:1151-1157, 1969.Crossref 48. Johns WH, Bates TS: Quantification of the binding tendencies of cholestyramine. I. Effect of structure and added electrolytes on the binding of unconjugated and conjugated bile acid anions. J Pharm Sci 58:179-183, 1969.Crossref 49. Johns WH, Bates TR: Quantification of the binding tendencies of cholestyramine. II. Mechanisms of interaction with bile salt and fatty acid salt anions. J Pharm Sci 59:329-333, 1970.Crossref 50. Vlahcevic ZR, Miller JR, Farrar JT, et al: Kinetics and pool size of primary bile acids in man. Gastroenterology 61:85-90, 1971. 51. Baker RD, Searle GW: Bile salt absorption at various levels of rat small intestine. Proc Soc Exp Biol Med 105:521-523, 1960.Crossref 52. Tappeiner AJFH: Ueber die Aufsaugung der Gallsauren alkalien im Dunndarme. Wien Akad Sitzber 77:281-304, 1878. 53. Hofmann AF, Grundy SM: Abnormal bile salt metabolism in a patient with extensive lower intestinal resection, abstracted. Clin Res 13:254, 1965. 54. Krone CL, Theodor E, Sleisenger MH, et al: Studies on the pathogenesis of malabsorption: Lipid hydrolysis and micelle formation in the intestinal lumen. Medicine 47:89-106, 1968.Crossref 55. Hardison WGM, Rosenberg IH: Bile salt deficiency in the steatorrhea following resection of the ileum and proximal colon. New Eng J Med 277:337-343, 1967.Crossref 56. Vandeest BW, Fordtran JS, Morawski SG, et al: Bile salt micellar fat concentration in proximal small bowel contents of ileectomy patients. J Clin Invest 47:1314-1324, 1968.Crossref 57. Austad WI, Lack L, Tyor MP: Importance of bile acids and of an intact distal small intestine for fat absorption. Gastroenterology 52:638-646, 1967. 58. Dowling RH, Mack E, Small DM: Effects of controlled interruption of the enterohepatic circulation of bile salts by biliary diversion and by ileal resection on bile salt secretion, synthesis, and pool size in the rhesus monkey. J Clin Invest 49:232-242, 1970.Crossref 59. Abaurre R, Gordon SG, Mann JG, et al: Fasting bile salt pool size and composition after ileal resection. Gastroenterology 57:679-688, 1969. 60. Porter HP, Saunders DR, Tygtat G, et al: Fat absorption in bile fistula in man: A morphological and biochemical study. Gastroenterology 60:1008-1019, 1971. 61. Conner WE, Witiak DT, Stone DB, et al: Cholesterol balance and fecal neutral steroid and bile acid excretion in normal men fed dietary fats of different fatty acid composition. J Clin Invest 48:1363-1375, 1969.Crossref 62. Thomas PJ: Identification of some organisms which convert oleic acid to hydroxy stearic acid. Gastroenterology 62:430-435, 1972. 63. Meyer H: Ueber den Wirksamen Bestandteil des Ricinusoels. Arch Exp Path Pharmak 28:145-152,1890.Crossref 64. James AT, Webb J, Kellock TD: The occurrence of unusual fatty acids in faecel lipids from human beings with normal and abnormal fat absorption. Biochem J 78:333-339, 1961. 65. Chipault JR, Wollaeger EE: Annual Report of the Hormel Institute 1952-1953 , University of Minnesota, pp 21-25. 66. Hofmann AF, Poley JR, Mekhjian HS, et al: Hydroxy fatty acids—an apparent cause of diarrhea in patients with ileal resection. J Clin Invest 49:44A, 1970. 67. Morgan RGH: The effect of bile salts on the lymphatic absorption by the unanaesthetized rat of intraduodenally infused lipids. Quart J Exp Physiol 49:457-465, 1964. 68. Bochenek W, Rodgers JB, Balint JA: Effects of changes in dietary lipids on intestinal fluid loss in the short-bowel syndrome. Ann Intern Med 72:205-213, 1970.Crossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Oct 1, 1972

References