Does cholecystectomy cause an increase in Hemoglobin A1c (HgA1C) levels?

Effect of Cholecystectomy on HbA1c Levels

Cholecystectomy may lead to an increase in HbA1c levels due to altered bile acid metabolism and increased insulin resistance, particularly in patients with pre-existing dysglycemia or risk factors for diabetes. 1

Pathophysiological Mechanisms

Cholecystectomy can affect glucose metabolism through several mechanisms:

1. Altered Bile Acid Metabolism:

   • Removal of the gallbladder disrupts the normal enterohepatic circulation of bile acids
   • Bile acids act as signaling molecules that modulate glucose, insulin, and energy metabolism 2
   • Without gallbladder rhythmic function, there is continuous bile flow to the intestine

2. Insulin Resistance:

   • Surgical stress induces insulin resistance regardless of surgical technique 3
   • Marked insulin resistance occurs after abdominal surgery, with studies showing significant increases in fasting blood glucose and decreases in insulin sensitivity postoperatively 3

3. Metabolic Signaling Changes:

   • Altered bile acid flow affects the bile acid/farnesoid X receptor (FXR) and bile acid/G protein-coupled receptor 1 (GPBAR-1) axes 2
   • These changes impact glucose metabolism in the liver, intestine, and other tissues

Evidence for HbA1c Changes After Cholecystectomy

Recent research demonstrates a clear relationship between cholecystectomy and dysglycemia:

• A 2022 cross-sectional and prospective study found that cholecystectomy was associated with:

  • Increased risk of both prediabetes and diabetes
  • Greater risk of deterioration in glycemic control with significant increases in HbA1c (≥10%) during follow-up 1

• Another 2022 study specifically in patients with type 2 diabetes found that after laparoscopic cholecystectomy:

  • Total bile acid levels increased significantly
  • Resting energy expenditure increased
  • Hemoglobin A1c levels decreased significantly 4

Risk Factors for Post-Cholecystectomy Dysglycemia

Patients at higher risk for HbA1c elevation after cholecystectomy include:

• Those with pre-existing dysglycemia or diabetes 1
• Patients with metabolic syndrome components 2
• Individuals with elevated preoperative blood glucose levels 5

Clinical Implications and Management

Preoperative Assessment

• Measure baseline HbA1c: Preoperative measurement of HbA1c is recommended to assist with risk stratification (class IIa, level C-LD) 6
• Screen for undiagnosed diabetes: Approximately 10% of patients may have undiagnosed diabetes 6
• Assess preoperative glucose levels: Higher preoperative blood glucose levels are associated with prolonged hospital stays after cholecystectomy 5

Perioperative Management

• Target glucose control: Maintain blood glucose levels between 100-180 mg/dL (5.6-10.0 mmol/L) within 4 hours of surgery 6
• Monitor for stress hyperglycemia: Surgical stress can cause hyperglycemia in 56-86% of individuals with and without preexisting diabetes 6
• Early oral intake: Encourage early oral intake postoperatively to minimize insulin resistance from prolonged fasting 6

Postoperative Monitoring

• Monitor HbA1c: Consider checking HbA1c 3-6 months postoperatively, especially in at-risk patients 1
• Be aware of HbA1c limitations: In patients with comorbidities like renal disease, HbA1c may be affected by factors such as reduced red blood cell lifespan 7
• Consider alternative glycemic markers: In certain situations, glycated albumin or fructosamine may provide additional information 7

Conclusion

Cholecystectomy appears to be associated with changes in glucose metabolism that may lead to increased HbA1c levels, particularly in at-risk individuals. Clinicians should be aware of this relationship and consider appropriate preoperative screening and postoperative monitoring of glycemic status in patients undergoing cholecystectomy.