Sign in →

Test ID: 7AC4 7AC4, Bile Acid Synthesis, Serum

Specimen Required

Patient Preparation:

1. Patient must be fasting for at least 12 hours; fasting morning specimen is preferred.

2. Patient should not be taking bile acid sequestrants or statins.

Collection Container/Tube:

Preferred: Serum gel

Acceptable: Red top

Submission Container/Tube: Plastic vial

Specimen Volume: 1 mL

Collection Instructions:

1. Centrifuge and aliquot 1 mL of serum into plastic vial.

2. Send specimen frozen.

Useful For

Screening for bile acid malabsorption in patients with irritable bowel syndrome-diarrhea (IBS-D)

Method Name

Liquid Chromatography-Tandem Mass Spectrometry (LC-MS/MS)

Reporting Name

7AC4, Bile Acid Synthesis, S

Specimen Type


Specimen Minimum Volume

0.5 mL

Specimen Stability Information

Specimen Type Temperature Time Special Container
Serum Frozen (preferred) 90 days
  Refrigerated  72 hours
  Ambient  24 hours

Clinical Information

Bile acids are synthesized from cholesterol in the liver and released into the digestive tract where they function to emulsify dietary fats and facilitate lipid absorption in the small intestine. More than 95% of bile acids are then reabsorbed primarily by active uptake in the distal ileum, while less than 5% are excreted in stool. The synthesis of bile acids in the liver is regulated by a negative feedback mechanism from the bile acids reabsorbed from the intestine. 7 Alpha-hydroxy-4-cholesten-3-one (7aC4) is an intermediate in the biosynthesis pathway of cholesterol to bile acids. The concentration of 7aC4 in serum is a surrogate for the amount of bile acid synthesis in the liver. There is some diurnal variation in 7aC4 serum concentrations, so measurement should be performed on a fasting morning sample.


Patients with increased bile acid in their stool suffer from chronic diarrhea termed bile acid diarrhea (BAD). Approximately 10% to 33% of patients with irritable bowel syndrome with primarily diarrhea (IBS-D) have BAD. Identifying patients with BAD can be done by measuring total and fractionated bile acids in stool. The increased bile acids in feces can be caused by an inability to reabsorb bile acids in the terminal ileum (bile acid malabsorption: BAM). The loss of intestinal reabsorption leads to increase synthesis of bile acids in the liver. Recent studies have shown that serum concentrations of 7aC4 are elevated in patients with BAD and can be used as a surrogate to the timed fecal collection. Several intestinal diseases or functional abnormalities can lead to BAD. Identification of these patients can influence treatment decisions that could include the use of bile acid sequestrants.


Conversely, patients with IBS with predominately constipation (IBS-C) may have lower circulating 7aC4 as compared to healthy individuals.

Reference Values

≥18 years: 2.5-63.2 ng/mL

Reference values have not been established for patients who are <18 years of age.


In patients with irritable bowel syndrome-diarrhea (IBS-D), elevated 7alpha-hydroxy-4-cholesten-3-one (7aC4) is consistent with bile acid diarrhea (BAD). A result of 17.6 ng/mL or greater is 83% sensitive and 53% specific for BAD. In these cases, a confirmatory 48-hour fecal bile acid test could be considered. A result above 52.5 ng/mL is 40% sensitive and 85% specific for BAD.


Interpretation in patients with chronic diarrhea (bile acid malabsorption: BAM):



   BAM unlikely                                 Indeterminate                                   BAM likely

   (consider other                       (consider confirmatory                          (consider bile acid

    conditions)                            fecal bile acids test or trial                    sequestrant therapy)

                                                  of bile acid sequestrant)

Clinical Reference

1. Vijayvargiya P, Camilleri M, Carlson P, et al: Performance characteristics of serum C4 and FGF19 measurements to exclude the diagnosis of bile acid diarrhoea in IBS-diarrhoea and functional diarrhoea. Aliment Pharmacol Ther. 2017;46(6):581-588. doi: 10.1111/apt.14214

2. Vijayvargiya P, Camilleri M, Shin A, et al: Methods for diagnosis of bile acid malabsorption in clinical practice. Clin Gastroenterol Hepatol. 2013;11(10):1232-1239

3. Camilleri M, Nadeau A, Tremaine WJ, et al: Measurement of serum 7 alpha-hydroxy-4-cholesten-3-one (or 7AC4), a surrogate test for bile acid malabsorption in health, ileal disease and irritable bowel syndrome using liquid chromatography-tandem mass spectrometry. Neurogastroenterol Motil. 2009;21(7):734-743

4. Wong BS, Camilleri M, Carlson P, et al: Increased bile acid biosynthesis is associated with irritable bowel syndrome with diarrhea. Clin Gastroenterol Hepatol. 2012 Sep;10(9):1009-1015.e3

Day(s) Performed


Report Available

2 to 9 days

Test Classification

This test was developed, and its performance characteristics determined by Mayo Clinic in a manner consistent with CLIA requirements. This test has not been cleared or approved by the US Food and Drug Administration.

CPT Code Information


LOINC Code Information

Test ID Test Order Name Order LOINC Value
7AC4 7AC4, Bile Acid Synthesis, S 94866-1


Result ID Test Result Name Result LOINC Value
65504 7AC4, Bile Acid Synthesis, S 94866-1


If not ordering electronically, complete, print, and send Gastroenterology and Hepatology Client Test Request (T728) with the specimen

Mayo Clinic Laboratories | Gastroenterology Catalog Additional Information: