What could be causing episodic left upper quadrant pain that worsens at night, triggered by extreme exercise, anger, fatty foods, and fried foods, in a patient with a history of cholecystectomy and presenting with sticky stool?

Pancreatic Exocrine Insufficiency with Possible Bile Acid Malabsorption

Your presentation of episodic left upper quadrant pain triggered by fatty/fried foods, extreme exercise, and anger, combined with sticky stool (steatorrhea) after cholecystectomy, most likely represents pancreatic exocrine insufficiency, potentially complicated by bile acid malabsorption—both of which are well-documented post-cholecystectomy complications.

Primary Diagnostic Considerations

Post-Cholecystectomy Syndrome with Steatorrhea

• Chronic diarrhea occurs in up to 10% of patients after cholecystectomy through mechanisms including bile acid malabsorption, increased enterohepatic cycling of bile acids, and altered gut transit 1
• The sticky stool adhering to the toilet bowl is pathognomonic for steatorrhea (fat malabsorption), which indicates either pancreatic exocrine insufficiency or bile acid-related malabsorption 1
• Cholestyramine should be considered for bile acid malabsorption in post-cholecystectomy patients, as it binds excess bile acids in the colon 1

Pancreatic Pathology

• Episodic left upper quadrant pain that worsens at night and is triggered by fatty foods strongly suggests chronic pancreatitis or recurrent acute pancreatitis 1, 2
• The pain pattern wrapping around the left rib cage to the back is classic for pancreatic pain radiation 1
• Triggers including extreme exercise, anger (stress), and fatty foods align with pancreatic inflammation exacerbation 1
• Pancreatic exocrine insufficiency causes steatorrhea and requires pancreatic enzyme replacement therapy (PERT) 1

Essential Diagnostic Workup

Laboratory Studies (First Priority)

• Serum lipase and amylase should be obtained during an acute episode; lipase >2× upper limit or amylase >4× normal confirms acute pancreatitis 2
• Fecal elastase measurement to assess pancreatic exocrine function, though starting PERT empirically is appropriate when steatorrhea follows specific triggers without waiting for results 1
• Complete metabolic panel including liver function tests (AST, ALT, alkaline phosphatase, GGT, bilirubin) to exclude biliary obstruction or hepatobiliary pathology 3
• Complete blood count to assess for anemia from malabsorption or inflammatory processes 3

Imaging Strategy

• CT abdomen and pelvis with IV contrast is the preferred initial imaging for left upper quadrant pain, providing comprehensive evaluation of pancreatic pathology, splenic abnormalities, and other causes with 95% diagnostic accuracy 2, 4
• CT can identify chronic pancreatitis findings (calcifications, ductal dilatation, atrophy) and exclude complications like pseudocysts 2
• MRI with MRCP provides superior visualization of the pancreatic duct and can detect subtle chronic pancreatitis changes not visible on CT 1
• Ultrasound has limited utility for pancreatic evaluation due to overlying bowel gas 2

Management Algorithm

Immediate Interventions

1. Start pancreatic enzyme replacement therapy (PERT) empirically given clear steatorrhea symptoms—waiting for fecal elastase is unnecessary when clinical presentation is diagnostic 1
2. Trial of cholestyramine (4g with meals) for potential bile acid malabsorption post-cholecystectomy 1
3. Dietary modification: low-fat diet (25g/day) to reduce pancreatic stimulation and steatorrhea 1
4. Avoid alcohol completely if any history of alcohol use, as it exacerbates pancreatic inflammation 1

If Symptoms Persist Despite Initial Management

• Consider functional dyspepsia if structural workup is negative; trial of proton pump inhibitor therapy for 4-8 weeks 2
• Tricyclic antidepressants (TCAs) can modulate visceral pain perception and are effective for chronic abdominal pain when standard treatments fail 1, 2
• Gastroenterology referral for consideration of endoscopic ultrasound to evaluate for early chronic pancreatitis or sphincter of Oddi dysfunction 1

Critical Pitfalls to Avoid

• Do not assume post-cholecystectomy symptoms are benign "dyspepsia"—steatorrhea indicates organic pathology requiring specific treatment 1, 5
• Do not miss chronic pancreatitis by relying only on serum enzymes during asymptomatic periods; lipase/amylase are often normal between attacks 1
• Do not delay PERT initiation waiting for fecal elastase results when steatorrhea is clinically evident after fatty food triggers 1
• Do not overlook bile acid malabsorption—it is specifically associated with cholecystectomy and responds to cholestyramine 1
• Do not attribute all symptoms to stress/anger without excluding organic pancreatic disease, though stress can genuinely trigger pancreatic pain exacerbations 1

Specific Symptom Correlation

Nocturnal Pain Worsening

• Pancreatic pain characteristically awakens patients from sleep and is steady rather than colicky 6
• This distinguishes pancreatic etiology from biliary colic, which is episodic but not specifically nocturnal 6

Exercise and Anger Triggers

• Extreme exercise increases intra-abdominal pressure and can exacerbate pancreatic inflammation 1
• Stress and anger trigger autonomic responses that affect pancreatic secretion and gut motility 1

Fatty Food Intolerance with Steatorrhea

• This combination definitively indicates fat malabsorption requiring either PERT or bile acid sequestrants 1
• Post-cholecystectomy patients have altered bile acid delivery to the intestine, impairing fat digestion 1

Expected Outcomes with Treatment

• PERT should improve steatorrhea within 2-4 weeks if pancreatic insufficiency is the primary cause 1
• Cholestyramine improves bile acid diarrhea in 70-80% of post-cholecystectomy patients within days to weeks 1
• If both treatments fail, reconsider the diagnosis and pursue advanced imaging (MRCP, endoscopic ultrasound) 1, 2