Association between dietary intake and postlaparoscopic cholecystectomic symptoms in patients with gallbladder disease

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Abstract

INTRODUCTION

Laparoscopic cholecystectomy is an effective treatment for symptomatic cholelithiasis with minimal risk [1]. However, some patients who undergo cholecystectomy report postcholecystectomic syndromes, defined as the recurrence of symptoms similar to those experienced before the cholecystectomy, such as abdominal symptoms, dyspepsia and diarrhea [2].

The absence of the gallbladder after a cholecystectomy was reported to cause rapid enterohepatic recycling, an increase in the secretion and a decrease in the reabsorption of bile acid, and a shortened colonic transit time [3,4]. Some patients who underwent cholecystectomy experienced diarrhea, which could be associated with the malabsorption of bile acid [5]. After cholecystectomy, patients are at an increased risk for duodenogastric reflux, which causes dyspepsia [6,7]. In addition, abdominal pain and irritable bowel syndrome were reported in patients after cholecystectomy; these symptoms could be associated with sphincter of Oddi dysfunction [8,9].

It has been suggested that postcholecystectomic syndromes are related to diet, due to changes in bile acid metabolism [3] and duodenogastric reflux [7]. Taiwanese patients who did not follow instructions to maintain a low-fat diet experienced more diarrhea, both 1 week and 3 months after cholecystectomy [10]. A high-fat diet has been shown to increase fecal bile acid [11], and diarrhea can be caused by the increased passage of bile acids into the colon [12]. In addition, after laparoscopic cholecystectomy, some patients reported troublesome food intolerance, particularly to fatty foods [13,14]. Intolerance to fatty foods appears frequently in patients with dyspepsia, since fatty foods could delay gastric emptying [15,16].

Previous studies have focused only on the relationship between a high-fat diet and postcholecystectomic syndromes [10,13,14], and no other nutrients or foods. Therefore, the present study investigated the hypothesis that dietary intake of nutrients and foods was significantly associated with postcholecystectomic syndromes.

METHODS

RESULTS

Characteristics of symptomatic and asymptomatic patients

After laparoscopic cholecystectomy, symptomatic patients had a more extensive medical history of digestive disease than did asymptomatic patients (Table 1). Symptomatic patients also exercised less (3 to 4 times per week) than did asymptomatic patients (5 to 6 times per week) 3 months after laparoscopic cholecystectomy. Comparing symptomatic and asymptomatic patients, there were no significant differences in age, sex, BMI, waist circumference, family history of gallstone disease, medications, previous experiences of weight control, smoking, drinking, use of supplements, the presence of fatty liver, or the diameter of the common bile duct (Table 1). At postlaparoscopic cholecystectomy and 3 months after laparoscopic cholecystectomy, blood parameters, such as WBC, Hb, Hct, PLT, TP, ALB, FBS, Cr, BUN, AST, ALP, TG, TC, HDL-C, and LDL-C were not significantly different between symptomatic and asymptomatic patients (data not shown) (Supplementary Table 1).

Table 1.

Characteristics of asymptomatic and symptomatic patients immediately postlaparoscopic cholecystectomy and 3 months after laparoscopic cholecystectomy

Dietary intake of symptomatic and asymptomatic patients

Immediately postlaparoscopic cholecystectomy, there were no significant differences in the consumption of nutrients or foods between symptomatic and asymptomatic patients (data not shown) (Supplementary Tables 2 and 3). However, 3 months after laparoscopic cholecystectomy, symptomatic patients consumed more animal protein, cholesterol, and eggs, and fewer vegetables than did asymptomatic patients (Table 2). There were no significant differences in consumption of vitamins, minerals, or other foods between symptomatic and asymptomatic patients 3 months after laparoscopic cholecystectomy (data not shown) (Supplementary Table 4). In addition, for breakfast, symptomatic patients consumed more bread, while asymptomatic patients consumed more rice (Table 3). Symptomatic patients avoided more foods compared to asymptomatic patients. There were no significant differences in food preferences or avoided foods between symptomatic and asymptomatic patients.

Table 2.

Daily intake of nutrients and foods between asymptomatic and symptomatic patients 3 months after laparoscopic cholecystectomy

Table 3.

Dietary habits between asymptomatic and symptomatic patients 3 months after laparoscopic cholecystectomy

Association between the risk for occurrence of symptoms and dietary intake

There was no significant association between the risk for occurrence of symptoms and dietary intake at postlaparoscopic cholecystectomy (data not shown) (Supplementary Tables 5 and 6). However, at 3 months after laparoscopic cholecystectomy, multivariable-adjusted regression analysis found that the risk for occurrence of symptoms was positively associated with intake of animal protein, cholesterol, and eggs, while it was negatively associated with intake of vegetables, after adjusting for energy intake and exercise frequency (Table 4). There were no significant associations between the risk of symptoms and intake of any other nutrients or foods at 3 months after laparoscopic cholecystectomy (data not shown) (Supplementary Tables 7 and 8).

Table 4.

Association between dietary intake and the risk of symptoms 3 months after laparoscopic cholecystectomy by multivariable logistic regression analysis

DISCUSSION

This study found that the risk of postcholecystectomic syndrome was positively associated with intake of animal protein, cholesterol, and eggs, and negatively associated with intake of vegetables in patients 3 months after laparoscopic cholecystectomy. In addition, 3 months after laparoscopic cholecystectomy, symptomatic patients consumed more bread for breakfast, while asymptomatic patients consumed more rice. However, there was no significant immediately postcholecystectomy association between postcholecystectomic syndrome and dietary intake.

Previous studies indicated that postcholecystectomic diarrhea was reported in patients who did not follow the low-fat diet guidelines [10] and who were intolerant of fatty foods [13]. Bile malabsorption has been shown to be associated with diarrhea in humans [18], and secretion of bile acid was dose dependently associated with fat intake in rats [19]. Thus, previous studies suggested that a high-fat diet could be associated with postcholecystectomic diarrhea, due to the changes in bile acid metabolism. However, the present study did not find a significant association between the intake of fat and the risk for postcholecystectomic syndromes. This inconsistency between the present and previous studies could be because patients in the present study did not consume a high-fat diet, as the average intake of fat was about 25 g/day and only 7% to 8% of the total energy intake.

Postcholecystectomy, patients reported symptoms of flatulent dyspepsia, which could be related to duodenogastric reflux and delayed gastric emptying [7,20]. Previously, food intolerance was observed in patients with postcholecystectomic dyspepsia, particularly, intolerance of eggs [14]. Pelletier et al. [21] also found that breakfast with bread and boiled eggs delayed gastric emptying in healthy volunteers, suggesting that the delayed gastric emptying by consumption of eggs could be positively associated with postcholecystectomic syndromes. Eggs could be a source of animal protein and cholesterol, which were also positively associated with the risk of postcholecystectomic syndromes in the present study. Intake of protein had been reported to slow gastric emptying in healthy volunteers [22], and dietary cholesterol increased fecal excretion of bile acids in rats [23]. Malabsorption of bile acids has been shown to cause postcholecystectomic diarrhea [5,24], since the absence of a gallbladder caused more rapid enterohepatic recycling of bile acids, increased bile acid secretion [3], and shortened colonic transit times [4]. Both the present and previous studies suggested that excretion and malabsorption of bile acids could be exacerbated by cholesterol intake in patients with cholecystectomies.

With the exception of the present study, there are no studies indicating any association between postcholecystectomic syndromes and vegetable intake. However, patients with functional gastrointestinal disorders, such as irritable bowel syndrome, consumed fewer vegetables than did healthy Taiwanese individuals [25]. In addition, dietary fiber has been shown to regulate the enterohepatic circulation of bile acids in patients with ileal resection [26]. In previous in vivo and in vitro studies, dietary fiber bound with bile acids, and reduced free bile acids in feces [27].

Patients with functional dyspepsia consumed more bread than rice [15], and bread had longer gastric emptying times compared with the rice pudding in healthy volunteers [28]. Gluten in meals has been shown to delay gastric emptying and cause gastrointestinal symptoms, such as bloating, abdominal pain and nausea in patients without celiac disease [29,30]. Similar with previous research, the present study found that symptomatic patients consumed more bread than rice, and symptoms could be due to the delayed gastric emptying of bread.

It has been suggested that cholecystectomy increases the risk for nonalcoholic fatty liver disease, due to increased hepatic triglyceride content [31-33]. In animal studies hepatic synthesis of bile acid was inhibited [34] and free fatty acid flux increased from adipose tissue to liver after a cholecystectomy [33,35]. In addition, a high level of fibroblast growth factor 19 was detected in surgically removed gallbladders from patients with gallbladder disease [36]. Fibroblast growth factor 19 has been shown to suppress the ability of insulin to stimulate hepatic fatty acid synthesis [37]. However, in the present study, there was no significant difference in the prevalence of fatty liver between asymptomatic and symptomatic patients at 3 months after a cholecystectomy.

After cholecystectomy, a slight dilatation of the common bile duct diameter commonly occurs [38], and is possibly associated with postcholecystectomic syndromes [39]. However, several previous studies reported inconsistent results regarding the association between dilatation of the common bile duct diameter and postcholecystectomic syndromes [38-40]. In the present study, the diameter of the common bile duct increased by less than 1 mm, and was not significantly different between asymptomatic and symptomatic patients 3 months after cholecystectomy.

This study had several limitations. This study had small sample size, and 3 months of follow-up might have been an insufficient duration. In addition, dietary intake was assessed only once, which could be insufficient to determine the usual intake of patients. However, this was the first study that investigated the association between dietary intake and the risk of postcholecystectomic syndromes.

In conclusion, the present study found that postcholecystectomic syndromes were positively associated with the intake of cholesterol, animal protein, and eggs, and negatively associated with the intake of vegetables, suggesting that diet was plays a role in postcholecystectomic syndromes. However, clinical trials are needed to confirm the cause-effect relationship between dietary intake and postcholecystectomic syndromes.

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Supplementary Materials

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