Diarrhea after Cholecystectomy

Diagnostic Challenges

• The Canadian Association of Gastroenterology evaluated the diagnostic accuracy of bile acid biomarkers, finding that the sensitivity of C4 is only 40%, with a specificity of 85% for diagnosing bile acid-induced diarrhea 1, 2
• The sensitivity of FGF19 is even lower, at 20%, with a specificity of 75% 1
• The positive predictive value of C4 is only 40%, and FGF19 is 17% 2

Treatment Approaches

• The Canadian Association of Gastroenterology recommends empirical testing with bile acid sequestrants (cholestyramine 2-12 g/day) as often more informative than biochemical testing 4, 3
• A dramatic response to cholestyramine within 1-6 months confirms the diagnosis of bile acid-induced diarrhea 3, 4

Important Considerations

• The American Gastroenterological Association suggests excluding other causes of chronic diarrhea (celiac disease, inflammatory bowel disease, microscopic colitis) before assuming postcholecystectomy diarrhea 4, 3
• Damage or stricture of the bile ducts should be considered if there are alarming symptoms 3
• Bile acid sequestrants should be avoided in patients with extensive ileal resections (>100 cm) due to the risk of steatorrhea 6, 7, 4