Biliary and pancreatic illness

Event of cholecystectomy on bowel role: a prospective, controlled study

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  1. S D Hearinga,
  2. L A Thomasa,
  3. K Due west Heatona,
  4. 50 Chaseb
  1. aUniversity Department of Medicine, Bristol Royal Hospital, Bristol, U.k., bUniversity Division of Child Health, Royal Hospital for Sick Children, Bristol, United kingdom of great britain and northern ireland
  1. Dr K W Heaton, Claverham House, Claverham, N Somerset BS49 4QD, UK.

Abstruse

Background Published estimates of the prevalence of postcholecystectomy diarrhoea derive from retrospective or uncontrolled information. They ignore functional bowel syndromes and possible changes in nutrition and drug use.

AIMS To decide prospectively whether and how ofttimes cholecystectomy leads to changes in bowel function and bowel symptoms, especially to liquid stools, over and in a higher place any non-specific effect of laparoscopic surgery.

SUBJECTS Patients: 106 adults undergoing laparoscopic cholecystectomy (85 women, 21 men). Controls: 37 women undergoing laparoscopic sterilisation.

METHODS Before and two–6 months after surgery patients were administered questionnaires virtually bowel frequency, bowel symptoms, diet, and drugs, and kept records of five sequent defecations with cess of stool form or advent on a seven point scale.

RESULTS In cholecystectomised women, stated bowel frequency increased, on average by one motility a week, and fewer subjects felt that they became constipated. However, records showed no consequent modify in bowel frequency, stool form, or defecatory symptoms. Six women reported diarrhoea afterwards the operation but in only one was it clearly new and in her it was balmy. Change in dietary fibre intake did not acquaintance with change in bowel function but stopping constipating drugs did in a minority. In women being sterilised there was no consequent modify in bowel function. In men having cholecystectomy no consistent changes were observed.

CONCLUSIONS In women, cholecystectomy leads to the perception of less constipation and slightly more frequent defecations just brusk term recordings show no consistent change in bowel role. Clinical diarrhoea develops rarely and is not astringent.

  • cholecystectomy
  • bowel habit
  • stools
  • diarrhoea
  • constipation
  • irritable bowel syndrome

  • Abbreviations used in this paper

    IBS
    irritable bowel syndrome

    • Statistics from Altmetric.com

    • cholecystectomy
    • bowel habit
    • stools
    • diarrhoea
    • constipation
    • irritable bowel syndrome

    The issue of cholecystectomy on bowel function is controversial. In three series of operated patients, 5%, 9%, and 12%, respectively, reported having issues with diarrhoea.1-3 These figures are of uncertain significance because the term diarrhoea means different things to different people4-6 and reported bowel habit is often not confirmed by objective records.seven ,eight In a study of recorded defecations, there was no difference in bowel frequency or stool characteristics between cholecystectomised women and women with unoperated (indeed undiagnosed) gallstones, except that the one-time perceived defecation every bit more than urgent.9

    All these studies are difficult to evaluate considering in none was bowel function assessed earlier the operation likewise as after it. Just one such study has been reported.three Of 24 patients, eight reported more frequent or "looser" stools after the performance (but not, apparently, frank diarrhoea). Overall, colonic transit time barbarous from 51 to 38 hours. This study strongly suggests that there is a real effect of cholecystectomy. However, the specificity of the effect can exist questioned because there were no controls undergoing a similar functioning and no account was taken of possible changes in dietary intake and drug usage equally a result of the operation. Also, a possible role for irritable bowel syndrome was not considered.

    Until recently in that location has been no standard definition of diarrhoea but in 1992 an international, consensus working group proposed fluidity of the stools as the key feature.ten In 1999, this was endorsed and information technology is at present recommended that a validated stool form scale be used to assess faecal characteristics.11

    We have undertaken a prospective study of bowel habit including stool class, and of bowel symptoms in patients undergoing laparoscopic cholecystectomy. In order to find and, if necessary, right for non-specific effects of surgery, we as well studied women undergoing laparoscopic sterilisation. In addition to looking for the truthful prevalence of mail service-cholecystectomy diarrhoea, we also aimed to notice out whether some patients experience relief of constipation (as already suggested3), and whether the bowel changes might exist explained by increased dietary fibre intake or reduced use of constipating drugs.

    Subjects and methods

    Betwixt Apr 1993 and June 1996 we wrote to all patients with ultrasonographically diagnosed gallstones who were scheduled for non-urgent laparoscopic cholecystectomy at the Bristol Royal Infirmary. Patients who were attainable on the telephone and gave informed consent were administered a questionnaire (see ) about how often they defecated (per mean solar day and per week), how often they experienced "diarrhoea" and "constipation", and how ofttimes they experienced individual symptoms of constipation, diarrhoea, and irritable bowel syndrome (IBS)—that is, lumpy stools, runny/mushy stools, urgency of defecation, feelings of incomplete evacuation, intestinal pain which lessened with defecation, abdominal bloating or distension, and rectal passage of fungus.

    During the interview, all medications were recorded and particular note fabricated of those known for their constipating properties, for instance, analgesics and antidepressants.

    Subjects were and so mailed a printed bowel record form on which to record each of five consecutive defecations including the engagement and time of each stool and also its form or appearance on the vii betoken Bristol stool form scale, which is sensitive to intestinal transit time, and the type of faeces, ranging from lumpy stools or scybala to watery diarrhoea.12 ,thirteen On the record form the subject also rated the strength of each phone call to stool on the following scale: weak and vague; definite but non strong; stiff, hard to resist; or violent, had to blitz (scored one, 2, 3, and 4 respectively). The sum of the five scores was the urge score for that subject (maximum twenty). With each defecation the subject field also stated whether or not they had a sense of incomplete evacuation or rectal dissatisfaction (scored 1), yielding a dissatisfaction score (maximum 5).

    Between 2 and six months later the performance the interviews and recordings were repeated. While the study was in progress information technology occurred to us that surgery might induce a modify in eating habits and so in bowel part. Accordingly, the concluding 44 cholecystectomy subjects to exist recruited were asked in the postoperative interview whether they had altered the frequency of eating the 4 major classes of fibre rich foods: bran containing products, dark-brown bread, fruit, and vegetables.

    Patients were classified preoperatively by their gall float function, in well-nigh cases past oral cholecystography, function beingness equated with opacification of the gall bladder 12 hours after assistants of 3 m Biloptin orally. In patients who could not or would not accept cholecystography (24%), a thickened gall float wall on ultrasonography was taken to imply loss of part, as was a calculus in the cervix of the gall bladder.

    Women scheduled for laparoscopic sterilisation were recruited and studied contemporaneously but over a slightly shorter time menstruum. The only exclusion criteria were known gastrointestinal illness and prior cholecystectomy; these were never met. The data collected earlier and ii to 3 months after the functioning, were the same as in the cholecystectomy subjects.

    The study was canonical by the local Research Ethics Committee.

    CALCULATIONS

    Men and women were considered separately because they are known to differ in near aspects of bowel office.viii ,14-16 For the questionnaire data, proportions of responders were compared using McNemar's test for change (preoperative versus postoperative), and the χ2 exam and Fisher'due south exact test for grouping comparisons. The number of defecations per week was compared using non-parametric methods: the Wilcoxon matched pairs signed rank examination for preoperative versus postoperative information, and Isle of mann-Whitney U tests for group comparisons. From the bowel record forms we computed for each field of study a hateful value for stool form every bit a semiquantitative alphabetize of intestinal transit time12 and hateful interdefecatory interval as an alphabetize of bowel frequency. These were compared, preoperatively versus postoperatively and between groups, using paired or unpaired Student'st tests. Within subject standard deviations of these parameters were calculated as measures of bowel irregularity, which is a feature of IBS.17 Urge scores and dissatisfaction scores were compared using non-parametric methods as above.

    Results

    LAPAROSCOPIC CHOLECYSTECTOMY

    During the recruitment menstruum 213 patients were scheduled for non-urgent surgery, of whom 200 (94%) could be traced and were invited to accept office. Of these, 140 were willing and able to do so (66% of all those available). Reasons for not taking role were: unwilling (22), not on the telephone (19), changed listen nigh operation (5), already had performance (5), comprehension problems (4), and miscellaneous (5). Of the 140 who entered the report, 34 failed to provide postoperative information because their operations were delayed or they moved house. Thus 106 subjects form the footing of this report, consisting of 85 women (aged 22–80 years, median 56), and 21 men (aged 35–82 years, median 66). All 106 subjects provided questionnaire data. Completed bowel tape forms were received preoperatively and postoperatively from 97 subjects (92%) (79 women and xviii men).

    Preoperatively the gall float was assessed as "operation" in 53 of the women and nine of the men. There was no consequent departure in the results between subjects with and without functioning gall bladders; the data were therefore pooled.

    LAPAROSCOPIC STERILISATION

    Of 65 patients scheduled for operation, 52 were invited to take function in the study and 37 agreed to do so. All 37 women responded to both questionnaires (median age 37 years, range 30–43) and 28 provided both bowel record forms.

    QUESTIONNAIRE Information IN WOMEN

    After laparoscopic cholecystectomy the stated frequency of defecation rose past a median of one bowel motion per calendar week (95% conviction interval 0.5 to 2.0; p<0.001). A substantial increase in stated defecation frequency, defined equally one of 3 movements per week or more than, occurred in 24 of the 85 women having this performance (28%) but in only iv of the 37 women having laparoscopic sterilisation (11%; p=0.062).

    The number of women with perceived constipation at to the lowest degree occasionally cruel by half after cholecystectomy (p<0.001) and did non change significantly after sterilisation.

    Frequent straining to start defecating was reported preoperatively past more than gallstone women than controls (p=0.026) just the difference became non-significant postoperatively, owing to 7 fewer of the gallstone women reporting it. Similarly, lumpy stools were more prevalent in the women with gallstones than in the controls preoperatively (p=0.032), but not significantly and then postoperatively.

    Perceived diarrhoea tended to be more than prevalent later on cholecystectomy but not significantly so (table one). Postoperatively, diarrhoea "usually or always" was reported past one of the 37 sterilised women and by six of the 85 cholecystectomised women (p=0.444). These six were examined in detail, case by case (table ii). Among them, iii had denied diarrhoea preoperatively, ane had said she had information technology occasionally, one ofttimes, and 1 commonly or always. Therefore, past self report, three or perchance four patients tin be said to have had postcholecystectomy diarrhoea. However, ane of them (patient 2) had wrongly denied diarrhoea preoperatively as at that time she admitted to 28 stools a week, ordinarily runny. Another (patient 6) is hard to evaluate because she clearly had irritable bowel syndrome, with frequent abdominal pain relieved past defecation and frequent bloating, both before and afterward the performance (furthermore, she failed to reply the question almost runny stools).

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    Table 1

    Preoperative and postoperative findings from the questionnaires in subjects undergoing laparoscopic sterilisation (controls) or cholecystectomy (gallstones)

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    Table 2

    Findings from the questionnaires preoperatively and postoperatively in the 6 women who, later cholecystectomy, claimed to accept diarrhoea ordinarily or always

    In neither group was there whatsoever significant change in the prevalence of abdominal pain (whether or not relieved by defecation), intestinal bloating, feelings of incomplete evacuation, or passage of mucus—that is, the Manning criteria for irritable bowel syndrome.eighteen

    BOWEL RECORD Class DATA

    The mean interdefecatory interval and the mean stool grade score did not change significantly with either functioning (tabular array 3). There was also no alter in within subject standard deviations. Urge scores and rectal dissatisfaction scores did not change significantly with either performance.

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    Table 3

    Preoperative and postoperative findings from the bowel record forms in subjects undergoing laparoscopic sterilisation (controls) or cholecystectomy (gallstones)

    Of the two cholecystectomised women who, by self written report, may have developed diarrhoea (patients 1 and 4), i (patient 1) must be discounted because her bowel record grade revealed that she was passing liquid stools preoperatively (mean stool form 6.6, see table four). Therefore, simply one patient can exist stated with whatsoever conviction to accept diarrhoea as a sequel to cholecystectomy. Of note, she had admitted to occasional diarrhoea before the operation, and had besides recorded frequent urgency and had admitted frequent bloating, suggesting a tendency to irritable bowel syndrome. Her postoperative diarrhoea was mild and possibly intermittent; she reported 17 stools a week but her mean interdefecatory interval was 17.vii hours.

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    Table iv

    Data from the bowel record forms preoperatively and postoperatively in the vi women who, after cholecystectomy, claimed to have diarrhoea usually or always

    LAPAROSCOPIC CHOLECYSTECTOMY IN MEN

    No alter was noted in stated or recorded bowel frequency, nor in stool course. Self assessed constipation was rare before and after surgery. Diarrhoea usually or ever was denied by all. Symptoms of IBS did not appear; the rectal dissatisfaction score even fell.

    CHANGE IN FIBRE INTAKE AND DRUG USAGE IN RELATION TO CHANGE IN CONSTIPATION

    Amongst the 44 gallstone women with dietary information were 12 who reported a lower frequency of being constipated after cholecystectomy and 32 who reported either no change (due north=30) or more frequent constipation (n=2). These 2 groups did not differ significantly with respect to the proportion who increased their intake of fibre rich foods (50% and 44%). Similar dietary change was reported past 35% of the sterilised women with dietary information (north=23), none of whom experienced less constipation.

    Full drug information was provided by 63 gallstone women (74%) of whom 18 reported a lower frequency of constipation postoperatively. Among these were five (28%) who were taking a drug likely to cause constipation before simply not after cholecystectomy (analgesics or antidepressants).

    Discussion

    The main positive finding of this study is that—in women but non men—cholecystectomy was followed by a subjective change in bowel function, consisting of a slight increase in defecation frequency and a perceived reduction in the incidence of constipation. The data agree with and greatly extend those of an earlier report.3 The changes seem to be specific to this operation as they were not seen after another laparoscopic procedure. They seem to be independent of dietary alter and in merely a small minority were they associated with—and, therefore, conceivably due to—the stopping of constipating drugs.

    The orthodox explanation for the alter in bowel function is that loss of the gall bladder'south reservoir function alters bile acid metabolism. In particular, information technology raises the faecal concentration of deoxycholic acrid,xix this bile acid beingness an agent that sensitises the rectum and tin can crusade an urge to defecate.twenty Yet, we plant no departure between patients with functioning and non-functioning gall bladders, so other mechanisms—so far unknown—may be operating.

    There was no clear increase in perceived diarrhoea subsequently laparoscopic cholecystectomy and, on close examination of the women who claimed to take postoperative diarrhoea, this had already been present in most of them before the operation. Moreover, some had irritable bowel syndrome. Only 1 patient had articulate testify of newly adult diarrhoea and she too had features of IBS before the operation. Moreover, her diarrhoea was very mild. The findings of this study advise, therefore, that diarrhoea is a rare sequel to cholecystectomy whereas relief of constipation is common. This may relate to the fact that the bile acid malabsorption caused past cholecystectomy is relatively mild.21

    The bowel tape forms disagreed with the questionnaires in that they revealed no consistent alter in bowel function, which mirrors the findings of our cross sectional population study.9Discrepancy between recorded and reported bowel information is not unusual.vii ,8 Hither, a possible explanation is that the modify in bowel function which follows cholecystectomy is intermittent, in which case information technology might be missed past a five stool "snapshot".

    There was no evidence of increased urgency of defecation after cholecystectomy, in dissimilarity to what nosotros establish in the population report,nine but in that written report, the strength of the urge had been assessed crudely. In that location was besides no indication that cholecystectomy precipitates the symptoms of IBS or irregularity of bowel addiction.

    As stool form reflects colonic transit time,12 ,22 the lack of change in the bowel record form data contrasts with the findings of the but other prospective study, in which hateful colonic transit time fell from 51 to 38 hours.3 All the same, the latter value is even so within normal limits then the discrepancy may be more than apparent than real.

    In published series, the vast majority of patients reporting postcholecystectomy diarrhoea are women3 and—consequent with this—the men in this study registered no change in bowel function. Nevertheless, the number of men was small and a larger study is necessary to exist sure that there is a real gender departure in this respect.

    An incidental finding of this study is that the women awaiting cholecystectomy were reportedly more prone to lumpy stools and straining than those pending sterilisation, few of whom, at their historic period, volition accept had gallstones.23 This is not explained by the age departure between the two groups considering, although older women are somewhat more prone to strain than younger ones,24 they practice not pass lumpy stools more frequently.8 Therefore, the finding may be seen equally supporting the hypothesis that cholesterol gallstone germination is favoured by boring colonic transit.25 ,26

    This report has limitations: lack of truly objective measures, relatively small number of controls and their low response rate, and a bowel recording period too short to detect occasional diarrhoea. Ideally, we would have started with a rigorous definition of postcholecystectomy diarrhoea and designed the study to expect for it. However, such a definition has still to be fabricated and our approach was in line with international endorsements of stool form scales for the characterisation of diarrhoea and constipation.11 ,27 The data support the conclusion that, while cholecystectomy causes a perceptible change in bowel role in some women (perhaps 20–25%), this is much more often the relief of constipation than the development of diarrhoea. Indeed, equally there was only one clear case of de novo diarrhoea among 106 subjects (0.9%) and the annual incidence of chronic or recurrent diarrhoea in the population is 0.7%,28 the question arises whether cholecystectomised patients feel diarrhoea any more than the general population. In the latter, chronic or recurrent diarrhoea affects 4–eighteen%,15 ,16 ,29 while in cholecystectomised subjects its prevalence is reported every bit 5–12%.1-3 Conversely, amid patients with obscure chronic diarrhoea only 5–8% have undergone cholecystectomy,21 ,xxx a effigy probably no more than expected.23 We advise, therefore, that postcholecystectomy diarrhoea is an unproved entity and will remain so until a prospective written report shows that diarrhoea develops more ofttimes in patients having this performance than in advisable controls.

    Acknowledgments

    This work was supported past a grant from the Special Trustees of the United Bristol Hospitals NHS Trust. Nosotros thank the surgeons who immune us access to their patients.

    SAMPLE QUESTIONS AND Respond OPTIONS

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    Abbreviations used in this paper

    IBS
    irritable bowel syndrome

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      Gut 1999; 45 796-797 Published Online First: 01 Dec 1999. doi: 10.1136/gut.45.vi.796