Can cholelithiasis (gallstones) and cholecystitis (inflammation of the gallbladder) cause diarrhea and decreased appetite?

Diarrhea and Decreased Appetite in Cholelithiasis and Cholecystitis

Yes, cholelithiasis (gallstones) and cholecystitis (gallbladder inflammation) can cause diarrhea and decreased appetite, though these are not the most common presenting symptoms.

Clinical Presentation of Gallbladder Disease

Primary Symptoms

• Right upper quadrant pain - The classic and most common symptom 1
• Fever - Particularly in acute cholecystitis 1, 2
• Leukocytosis - Common laboratory finding in acute inflammation 1, 2
• Murphy's sign - Tenderness on palpation of the right upper quadrant during deep inspiration 3
• Nausea and vomiting - Frequently reported symptoms 3, 2

Secondary Symptoms

• Diarrhea - Can occur in gallbladder disease through several mechanisms:

  • Bile acid malabsorption after cholecystectomy (in up to 10% of patients) 1
  • Altered bile flow and composition during acute inflammation
  • Increased entero-hepatic cycling of bile acids 1

• Decreased appetite - Often occurs due to:

  • Nausea associated with gallbladder disease
  • Systemic inflammatory response in acute cholecystitis
  • Pain triggered by eating, leading to food avoidance

Pathophysiological Mechanisms

Diarrhea in Gallbladder Disease

1. Bile acid malabsorption:

   • Altered bile acid pool and cycling during gallbladder disease 1
   • Excess bile acids in the colon stimulate secretion and motility, causing diarrhea

2. Post-cholecystectomy diarrhea:

   • Occurs in approximately 10% of patients after gallbladder removal 1
   • Due to increased gut transit, bile acid malabsorption, and altered entero-hepatic cycling 1

Decreased Appetite

1. Pain-related food avoidance:

   • Eating, especially fatty foods, can trigger or worsen gallbladder pain
   • Patients learn to associate eating with pain and reduce intake

2. Systemic inflammatory response:

   • Acute cholecystitis produces inflammatory mediators that can suppress appetite
   • Fever and systemic illness contribute to anorexia

Diagnostic Approach

Imaging Studies

• Ultrasound - First-line imaging test for suspected gallbladder disease 1, 4

  • Shows gallstones, gallbladder wall thickening, pericholecystic fluid 1
  • Sensitivity of approximately 81% and specificity of 83% for acute cholecystitis 2

• HIDA scan - Gold standard when ultrasound is inconclusive 4, 2

  • Evaluates gallbladder function and confirms biliary colic 4

• MRCP - Excellent for detection of cholelithiasis/choledocholithiasis 1

  • Sensitivity of 85-100%, specificity of 90% 1
  • Superior to CT for biliary evaluation 1

Laboratory Tests

• Complete blood count (elevated WBC in cholecystitis)
• Liver function tests (may be elevated with bile duct obstruction)
• Pancreatic enzymes (to rule out pancreatitis) 4

Management

Indications for Surgery

• Symptomatic gallstones - Laparoscopic cholecystectomy is the treatment of choice 5, 2
• Acute cholecystitis - Early cholecystectomy (within 1-3 days) is preferred 1, 2
  • Results in shorter recovery time and hospitalization compared to delayed approach 1
  • Lower complication rates (11.8% vs 34.4%) 2
  • Shorter hospital stay (5.4 days vs 10.0 days) 2

Conservative Management

• For asymptomatic gallstones or patients with high surgical risk 5
• May include:
  • Dietary modifications
  • Pain management
  • Consideration of gallstone dissolution agents in select cases 3

Clinical Pearls and Pitfalls

Pearls

• Diarrhea after cholecystectomy is common (up to 10% of patients) and should be anticipated 1
• Decreased appetite may be an early warning sign of gallbladder disease before classic pain develops

Pitfalls

• Misattribution of diarrhea to other causes when gallbladder disease is present
• Overlooking gallbladder disease in patients presenting primarily with digestive symptoms rather than pain
• Delaying surgical intervention in symptomatic patients, which can lead to complications 1, 2

Special Considerations

• Elderly patients and those with comorbidities have higher surgical risk but still benefit from definitive treatment 4, 2
• Percutaneous cholecystostomy tube placement may be considered for patients too ill for surgery, but has higher complication rates than cholecystectomy (65% vs 12%) 2