From the Guidelines
Cholecystectomy can cause long-term diarrhea in some patients, and the most effective treatment is bile acid sequestrants like cholestyramine, as recommended by the Canadian Association of Gastroenterology clinical practice guideline on the management of bile acid diarrhea 1.
Causes of Diarrhea
The diarrhea occurs because without a gallbladder, bile flows continuously into the small intestine rather than being stored and released in response to meals, irritating the intestines and speeding up intestinal transit time, resulting in loose stools.
Treatment Options
Treatment options include:
- Dietary modifications such as reducing fat intake, increasing fiber, and eating smaller, more frequent meals
- Medications that may help include bile acid sequestrants like cholestyramine (2-12 g/d) or colestipol, which bind excess bile acids in the intestine 1
- Antidiarrheal medications such as loperamide can also provide symptomatic relief
Management of Bile Acid Diarrhea
Studies suggested that for some patients, BAD symptoms could remain controlled with on-demand therapy or no therapy at all, and cholestyramine was effective in 23 of 26 patients with postcholecystectomy BAD 1.
Recommendation
The use of cholestyramine as initial therapy is recommended, with alternate bile acid sequestrant therapy when tolerability is an issue, and maintenance therapy should be given at the lowest effective dose, with a trial of intermittent, on-demand administration 1.
From the Research
Long-term Diarrhea after Cholecystectomy
- Cholecystectomy, the surgical removal of the gallbladder, can lead to long-term diarrhea in some patients, as evidenced by studies 2, 3, 4.
- The exact cause of this diarrhea is often attributed to increased amounts of bile acids in the large bowel, resulting in a condition known as "cholerheic enteropathy" 2.
- Research has shown that patients with bile acid malabsorption after cholecystectomy often have daily stool weights greater than 200 g and total fecal bile acids three to ten times greater than normal 2.
- Treatment with cholestyramine resin has been found to be effective in managing this type of diarrhea 2, 3, 4.
Prevalence and Predictors of Postcholecystectomy Diarrhea
- The prevalence of diarrhea after laparoscopic cholecystectomy has been reported to be around 25.2% at 1 week and 5.7% at 3 months after the operation 5.
- Predictors of postlaparoscopic cholecystectomy diarrhea (PLCD) at 1 week include a low-fat diet and a high score on a preoperative diarrhea scale 5.
- However, there were no predictors found for PLCD at 3 months after laparoscopic cholecystectomy 5.
Etiologies of Long-term Postcholecystectomy Symptoms
- A systematic review of the literature found that long-term postcholecystectomy symptoms, including diarrhea, can arise from various etiologies, such as coexistent diseases, physiological changes, and surgical complications 6.
- The review highlighted the importance of considering these different etiologies when diagnosing and treating patients with long-term symptoms after cholecystectomy 6.