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Right Upper Abdomen

   
Bile Salt Diarrhea

[Diarrhea after Gallbladder Surgery]

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Sally, a 53 year old secretary, was seen in our office recently complaining of a "nervous stomach." It seems that her bowel habit changed drastically over the past two years. Normally she had a regular routine of one formed bowel movement each morning - right after breakfast. Lately, she had been having four or more watery bowel movements throughout day, often right after meals. When asked she denied any changes in her diet, weight loss, or rectal bleeding. Her gallbladder was removed in the past. She had been on an allergy pill for several months and denied taking any other new medications. While she did experience some cramps right before having a bowel movement, she was not having any severe abdominal pain. Often she would skip breakfast and lunch to prevent diarrhea when shopping or going out with friends. She stated that she knew the location of every public restroom in her county. She had seen her family doctor who suggested she try Imodium to lessen the diarrhea. It was not very helpful and she was asked to see us for a consultation....
 


The above case history is suspicious for post-cholecystectomy, or "bile salt" diarrhea. This is an uncommon, but well-recognized, complication of gallbladder surgery. This short article was written to explain what this condition is and how it is treated.

A shock to your system

All abdominal surgery is a shock to your system. But, in most cases, these changes are temporary and improve within a few weeks of the operation. Some individuals, however, are troubled by persistent diarrhea after their gallbladder is removed. The symptoms may vary, but most patients complain that they often experience urgency and watery diarrhea shortly after eating. The diarrhea may even force them to stop and head for the closest bathroom before they finish the meal. This is especially embarrassing when it occurs at work or when dining out with friends. Many patients with this problem become reluctant to eat away from home.

Bile salts are the culprit

Bile is a thick yellow fluid made by the liver. It helps you digest the fat in your diet. Between meals, liver bile is stored in the gallbladder, a little sac beneath the liver. When you eat, the gallbladder squeezes and releases the stored bile salts into the small intestine to help with digestion. After food is digested and absorbed, the bile salts are reabsorbed at the end of the small intestine and recycled to be used over and over again. When the gallbladder is surgically removed, the liver must make more bile salts, and more are released between meals beca use there is no place to store them. The increased amount of bile salts can sometimes overwhelm the small intestines' capacity to reabsorb them. The excess spills over into the large intestine, or colon, where bile acts somewhat like a laxative, leading to diarrhea.

How can this side effect be prevented?

It can't. Why some patients develop this side effect after gallbladder surgery and others do not is still a mystery. Unfortunately, there is no way to predict before surgery who will develop this problem afterwards. Having this side effect does not reflect on the skill of the surgeon or how the surgery was done. It is really just bad luck. Fortunately, the vast majority of patients do not develop bile salt diarrhea after gallbladder surgery. The exact risk is not well studied but estimated to be about 5% of patients.

How does your doctor know?

Since there is no specific diagnostic test for this condition, your doctor must confirm his suspicion that bile salt diarrhea is the culprit by ruling out other possible causes of diarrhea such as infection, colitis, cancer, and others. To do so the doctor will ask questions about your health history in general and specifically about the change in bowel habits. A physical examination is then performed. Special tests of blood and stool samples may be requested. In most cases, the doctor will need to examine the lining of the colon with a "scope" test such as colonoscopy to be sure that colitis and cancer are not present. Every case is a little different and it is the doctor's job to determine which tests are necessary to confirm the diagnosis.

How is this treated?

There is no cure for this problem, but treatment is available. Once it has been established that bile salt diarrhea is the problem, treatment is usually prescribed to lessen the symptoms of diarrhea and urgency. The mainstay of treatment is a powder called cholestyramine resin (Pronunciation: kole ESS tir a meen). This medication is primarily marketed as a drug for patients with high blood cholesterol. It comes as a powder that is mixed with about 6 ounces of water. Several formulations are available such as Locholest, Locholest Light, Prevalite, Questran, Questran Light. It also comes in a tablet form called Colestid. Much like a chemical "sponge," this medicine lowers blood cholesterol by trapping and inactivating bile salts in the intestine, preventing their reabsorption. By trapping bile salts, cholestyramine also helps patients with bile salt diarrhea. The dose required to treat this condition is usually only once daily.

Precautions

Avoid ingesting or breathing in the dry cholestyramine powder. Do not take cholestyramine if you are constipated, stop it and call your doctor. Take other medications at least 1 hour before or 4 hours after taking a dose of cholestyramine. Cholestyramine can decrease the effectiveness of many other drugs if they are taken too close to one another. Cholestyramine decreases the absorption of certain vitamins. If you are on this medication chronically, simply take a multivitamin capsule every morning. Do not take cholestyramine without first talking to your doctor if you are breast-feeding a baby. If you miss a dose just take the missed dose as soon as you remember, but not with other medications. Do not take a double dose of this medication.

What else can you do?

In addition to using cholestyramine, some patients with bile salt diarrhea seem to do better on a low-fat diet. Others find that they are helped by the use non-prescription medications to lessen diarrhea such as Imodium. Imodium can be safely taken several times a day. The main side effect, of course, would be constipation. Some patients find that the use of fiber supplements may help make the bowel movements more formed. A packet of Citrucel daily is often of benefit.

Will this problem eventually go away? Probably not. While some individuals do get better over time, most patients who have bile salt diarrhea that persists longer than 3 months after gallbladder surgery have it for life. It can usually be controlled with treatment. However, if the cholestyramine is stopped, the diarrhea quickly returns. The whole goal of treatment is to prevent attacks of diarrhea and make your life normal again. Take whatever medications your doctor prescribes to control the urgent bowel movements so that your "bowels don't run your life."

 
...Sally's tests of blood and stool were normal as was her colonoscopy. There was no sign of infection, colitis, or cancer. She was then begun on LoCholest one packet in water before lunch daily. Within a week, her bowel habits went back to normal and she is no longer afraid to dine at her favorite restaurant.
 
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