While most people who have had gallbladder removal surgery resume normal life quickly, some get stuck with diarrhea.

IF YOU’VE HAD YOUR gallbladder removed, chances are you were looking for relief: Relief from the sharp upper abdominal pain of a gallstone attack that likely sent you to the emergency room desperate to make the pain go away.

But, if in addition to pain relief you also got diarrhea, you’re in good company. While the majority of people who have gallbladder removal surgery resume normal life (and eating patterns) quickly, a non-trivial minority of people experience problematic changes in their digestive functioning – with diarrhea being the most common complaint. The most recent research suggests this affects about 9 percent of people after surgery. Here’s what to know if it’s happened to you or someone you love.

What Is the Gallbladder?

The gallbladder is a small organ that concentrates and stores bile, a digestive fluid produced by the liver that helps fats digest more effectively in the small intestine. When you eat a burger – or anything with some fat, for that matter – the gallbladder contracts and squirts stored bile into the small bowel through a duct it shares with the liver called the common bile duct. The liver can also secrete bile directly into the small intestine without it being diverted to storage.

What’s a Gallstone?

Sometimes the components of stored bile can start to clump together into little crystals called gallstones. When these stones stay put in the gallbladder, you may never even be aware of their presence; in fact, an estimated 10 to 20 percent of Americans will develop them at some point in their lives, and many will never know it.

What’s a Gallstone Attack?

When the gallbladder contracts vigorously, a stone may be projected out into the bile duct. If it gets stuck along the way, it can cause severe pain, as well as nausea. This is commonly known as a gallstone attack, and officially known as “biliary colic.” If these attacks become chronic or a complication occurs (like infection of the bile duct or inflammation of the nearby pancreas), gallbladder removal surgery is typically the treatment.

Why Do I Have Diarrhea After Gallbladder Removal Surgery?

Contrary to many patients’ understanding, post-surgical diarrhea may not be due to the body’s inability to absorb fat effectively. Rather, it seems that without the gallbladder around to mete out squirts of bile only when you eat a meal with fat, the liver sends a steady trickle of bile into the small intestine all the time. This may overwhelm the small intestine’s limited ability to absorb it back into the body for recycling, forcing it to send some of the bile’s building blocks – called bile acids – to the colon. This is called bile acid malabsorption, or BAM, and it may result in bile acid diarrhea. In addition to diarrhea, some people with BAM may experience abdominal pain, bloating and even occasional bowel incontinence.

Who Is at Risk for Bile Acid Diarrhea?

Bile acid diarrhea or BAD – a condition with a very fitting acronym – isn’t unique to people who have had their gallbladders removed. It also often affects people who have had sections of their small intestine (ileum) surgically removed, as may be the case with Crohn’s disease. And interestingly, some new research suggests that a quarter or more of people who have been diagnosed with diarrhea-predominant irritable bowel syndrome (IBS-D) may actually have BAD. A common medication used to treat Type 2 diabetes called metformin has also been shown to cause BAD in a subset of people, and a condition called small intestinal bacterial overgrowth (SIBO) can cause BAD as well.

How Is Bile Acid Diarrhea Diagnosed?

The bad news is that the best test for BAM – called the 75SeHCAT – is not available in the U.S., though a promising new blood test is on the horizon and may soon change the way that BAM is diagnosed. At present, though, most doctors will diagnose you based on your response to a trial of medication called a bile acid sequestrant, which attaches on to these irritating bile acids and allows them to pass through the colon without causing trouble. If the medication improves or eliminates your symptoms, you can be pretty darn sure you have BAD.

How Can You Treat Diarrhea After Gallbladder Removal Surgery?

The good news is that bile acid diarrhea resolves quickly when people with BAM start taking bile acid sequestrants. If you find they work too well and actually constipate you, play around with a lower dose or split doses to find the right balance that delivers the holy grail of regularity. Following a lower-fat diet while also using these medications may provide even greater symptom relief than either intervention does alone. Bile acid sequestrants can interfere with absorption of certain drugs and vitamins, so talk to your doctor about how to space your medications from the bile acid sequestrant to be sure it doesn’t interfere.

Another class of medications called FXR agonists also shows promise in treating BAM by, to put it simply, telling the liver to stop producing so many bile acids. While they don’t have the same side effects as the sequestrants and their delivery method may be more appealing to patients (pill, not powder), many patients find FXR agonists to be somewhat nauseating and unpleasant to get down. Plus, their use is not yet widespread.

The bottom line is that while it’s not unusual to develop diarrhea following gallbladder surgery, this potential side effect isn’t something you will necessarily have to put up with for the rest of your life. Current remedies are quite effective, and there are even more treatment options on the horizon.

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