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Gallbladder

Why do I have diarrhoea after gallbladder surgery?

It happens to about one patient in eight. The mechanism is bile reaching the colon, and the published evidence on who it happens to is weaker than the rate itself.

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Answer

Diarrhoea after gallbladder removal affected 13.3 percent of 3,476 patients pooled across 21 studies in a systematic review, and is attributed to bile draining continuously into the intestine rather than being released after meals, so that bile acids reach the colon and draw water into it.

Key takeaways

  • A systematic review published in BMJ Open pooled 21 studies covering 3,476 patients and found 462 of them (13.3 percent) developed postcholecystectomy diarrhoea.
  • Without a gallbladder to store it, bile drains into the small intestine continuously rather than in pulses after meals, and bile acids that reach the colon draw water into it.
  • The review found no agreement across its included studies on who is likely to develop it: sex, age and weight were each proposed as predictors by some studies and not confirmed by others.
  • The review's authors note that the rate, predictive factors and mechanism of postcholecystectomy diarrhoea have not been well determined despite the symptom being well recognised.
  • The pooled studies recorded whether diarrhoea occurred, not how severe or how lasting it was.

Bile is a detergent. Its job is to break fat into droplets small enough for enzymes to work on, and the gallbladder's job is to hold a concentrated supply of it and release it when a meal arrives. Take the gallbladder away and the release stops being timed: bile trickles into the small intestine continuously, meal or no meal.

Bile acids that are not reabsorbed in the small intestine reach the colon, where they draw water into the bowel. That is the accepted explanation for the loose stool some people have after this operation.

How common it is

A systematic review published in BMJ Open in February 2022 searched Medline, Embase, PubMed, Cochrane and Google Scholar, screened 1,204 papers, and found 21 that reported postcholecystectomy diarrhoea as a distinct outcome.

462 of 3,476

pooled patients developed diarrhoea after cholecystectomy — 13.3 percent — across 21 studiesFarrugia A et al., BMJ Open, 2022

About one patient in eight, in other words: common enough that it should be mentioned before an operation, and uncommon enough that it is not the expected outcome.

Who it happens to is not settled

The same review looked for factors that predict which patients develop it, and did not find a consistent answer. Sex, age and patient weight were each proposed as predictive in some of the included studies and not confirmed in others. The authors state plainly that the rate, the predictive factors and the mechanism have not been well determined, despite the symptom being well reported.

What to do about it

This is a question for the surgical team that performed the operation or a gastroenterologist, and not one this publication will answer. What the evidence supports is the narrower point that new persistent diarrhoea after cholecystectomy is a recognised outcome with a plausible mechanism, common enough to be worth raising with a clinician rather than tolerating silently.

Sources

  1. 1

    Farrugia A, Attard JA, Khan S, Williams N, Arasaradnam R

    Postcholecystectomy diarrhoea rate and predictive factors: a systematic review of the literature

    BMJ Open 2022;12(2):e046172

    doi:10.1136/bmjopen-2020-046172 · PMID:35177439

    https://doi.org/10.1136/bmjopen-2020-046172