What causes diarrhea and vomiting in patients after cholecystectomy (surgical removal of the gallbladder)?

From the Guidelines

Diarrhea and vomiting after cholecystectomy are most likely caused by postoperative nausea and vomiting (PONV), which is strongly correlated with hypovolaemia and splanchnic hypoperfusion, as evidenced by a recent study published in the British Journal of Anaesthesia 1. The incidence of PONV is high in patients undergoing cholecystectomy, with rates ranging from 30% to 80%, and is associated with increased costs, patient dissatisfaction, and postoperative complications such as dehydration and electrolyte imbalances.

• Key factors contributing to PONV include:
  • Use of nitrous oxide
  • Opioid administration
  • Hypovolaemia
  • Neuromuscular blocker reversal with neostigmine
• A mildly positive fluid balance is recommended to reduce the incidence of PONV in minor noncardiac surgery, including cholecystectomy, as supported by a retrospective cohort study that found lower amounts of intraoperative intravenous fluids were strongly related to PONV 1.
• Management of PONV typically involves a multimodal approach, including preemptive risk assessment, antiemetics, and fluid management, with the goal of reducing the incidence of PONV and its associated complications.
• In terms of specific management, a retrospective analysis of 38,577 surgeries found that an infusion rate of 2 ml kg-1 h-1 was adequate for reducing PONV, and that patients who experienced PONV received significantly more intravenous fluid than those who did not 1.

From the Research

Causes of Diarrhea and Vomiting after Cholecystectomy

• Diarrhea and vomiting in patients after cholecystectomy can be caused by various factors, including bile duct injury, infection, and other post-operative complications 2, 3, 4, 5.
• Bile duct injury is a significant cause of morbidity and mortality after cholecystectomy, and can lead to symptoms such as diarrhea and vomiting 3, 5.
• Infection and abscess formation are also common complications after cholecystectomy, and can cause symptoms such as diarrhea and vomiting 2, 4.
• Other potential causes of diarrhea and vomiting after cholecystectomy include:
  • Retained gallstones 2
  • Hernias 2
  • Postcholecystectomy syndrome 2
  • Enteric injuries, such as those to the duodenum or colon 4

Management and Prevention

• Early recognition and management of bile duct injury and other post-operative complications are crucial to preventing severe symptoms such as diarrhea and vomiting 3, 5.
• The use of antibiotic agents may be recommended in certain cases, such as in patients undergoing laparoscopic cholecystectomy for acute cholecystitis 6.
• A multidisciplinary approach to treatment, including referral to a tertiary care hospital, may be necessary in cases of severe complications 3, 4.
• Surgical reconstruction, such as Roux-en-Y hepaticojejunostomy, may be required in patients with complete dissection or obstruction of the bile duct 5.