From the Guidelines
Chronic diarrhea and vomiting after cholecystectomy are most likely caused by bile acid malabsorption, and treatment with bile acid sequestrants such as cholestyramine is recommended as the initial therapy. The Canadian Association of Gastroenterology clinical practice guideline on the management of bile acid diarrhea suggests that consideration of risk factors, including cholecystectomy, is crucial for identifying patients with possible bile acid diarrhea (BAD) 1.
Causes of Chronic Diarrhea and Vomiting
- Bile acid malabsorption: The most common cause, where bile acids continuously flow into the small intestine, irritating the intestinal lining and causing diarrhea.
- Sphincter of Oddi dysfunction: The sphincter controlling bile flow spasms or narrows, leading to abnormal bile flow.
- Small intestinal bacterial overgrowth (SIBO): An overgrowth of bacteria in the small intestine, which can contribute to diarrhea and vomiting.
- Functional gastrointestinal disorders: Triggered by the surgery, these disorders can cause chronic diarrhea and vomiting.
Treatment Options
- Dietary modifications: Reducing fat intake and eating smaller, more frequent meals can help alleviate symptoms.
- Medications: + Bile acid sequestrants like cholestyramine (2-12 g/d) or colesevelam, which can bind excess bile acids and reduce diarrhea. + Antispasmodics such as dicyclomine (10-20mg three times daily) may help with cramping. + For SIBO, a course of rifaximin 550mg three times daily for 14 days may be beneficial.
- Maintenance therapy: Cholestyramine should be given at the lowest effective dose, with a trial of intermittent, on-demand administration, concurrent medication review, and reinvestigation for patients whose symptoms persist despite therapy 2.
Further Evaluation
If symptoms persist beyond 3 months despite these interventions, further evaluation with specialized tests like SeHCAT scan or endoscopy may be necessary to rule out other conditions. Patients should avoid trigger foods, particularly fatty, spicy, or high-fiber items, and maintain adequate hydration.
From the Research
Causes of Chronic Diarrhea and Vomiting after Cholecystectomy
- Chronic diarrhea and vomiting in patients after cholecystectomy can be caused by bile acid malabsorption, also known as "cholerheic enteropathy" 3, 4, 5, 6
- This condition occurs when increased amounts of bile acids are presented to the large bowel, leading to an imbalance in the absorption of water and electrolytes 3, 6
- Studies have shown that patients with bile acid malabsorption have daily stool weights greater than 200 g and total fecal bile acids three to ten times greater than normal 3
- Other factors that may contribute to chronic diarrhea after cholecystectomy include a high-fat diet, preoperative excretion pattern, gastrointestinal disorders, personality disorders, and the effect of drugs 7
Treatment and Management
- Treatment with cholestyramine resin has been shown to be effective in managing bile acid diarrhea in patients with chronic diarrhea after cholecystectomy 3, 4, 5
- A low-fat diet has also been recommended to reduce the possibility of diarrhea in patients after laparoscopic cholecystectomy, especially in those who are ≤45 years of age, of male sex, and had a high preoperative tendency for diarrhea 7
- Diagnosis of bile acid diarrhea requires a comprehensive medical history and physical examination in combination with laboratory evaluation, including the 23-seleno-25-homotaurocholic acid (SeHCAT) test 5, 6