Skip to main content
Log in

Absence of significant role of bile acids in diarrhea of a heterogeneous group of postcholecystectomy patients

  • Original Articles
  • Published:
Digestive Diseases and Sciences Aims and scope Submit manuscript

Abstract

Twenty-five postcholecystectomy (PC) patients who underwent a diagnostic work-up for persistent diarrhea and six control subjects were studied. Fourteen of the 25 patients were also characterized by conditions other than PC which could play a role in the pathogenesis of the diarrhea. However, none of the patients had evidence of ileal disease or resection. The average follow-up of the patients after the study was approximately 4.4 years. Excretion, composition, and aqueous-phase concentrations of fecal bile acids were analyzed using gas-liquid chromatography. Eleven of the 25 PC patients showed an increased fecal bile acid excretion. In three of the 11 patients, the magnitude of the bile acid loss, which ranged from 2.26 to 3.34 mmol/24 hr, indicated the presence of severe bile acid malabsorption. The fecal bile acid composition showed a significant shift from secondary to primary bile acids. In spite of the presence of marked bile acid malabsorption, the aqueous-phase concentrations of the dihydroxy bile acids, chenodeoxycholic and deoxycholic acids, did not, with one exception, reach the secretory level of 1.5 mM. The relatively low aqueous concentrations were the result of low bile acid solubility, due to an acidic fecal pH. Only two of nine patients, one with severe, and the other with equivocal bile acid malabsorption, who were treated with cholestyramine, showed an improvement of the diarrhea. The findings of subsecretory bile acid concentrations in the fecal aqueous phase and of inconsistent therapeutic responses to cholestyramine indicate that, in spite of the presence of bile acid malabsorption, the diarrhea was, with few exceptions, not bile acid-induced. The results of the study also suggest that the diarrhea in many PC patients is multifactorial in origin.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others

References

  1. Krejs GJ, Fordtran JS: Diarrhea.In Gastrointestinal Disease: Pathophysiology, Diagnosis, Management. MH Sleisenger, JS Fordtran (eds). Philadelphia, WB Saunders, 1983, pp 273

    Google Scholar 

  2. Hutcheon DF, Bayless TM, Gadacz TR: Postcholecystectomy diarrhea. JAMA 241:823–824, 1979

    Google Scholar 

  3. Hepner GW, Hofmann AF, Malagelada JR, Szczepanik PA, Klein P: Increased bacterial degradation of bile acids in cholecystectomized patients. Gastroenterology 66:556–564, 1974

    Google Scholar 

  4. Mekhjian HS, Phillips SF, Hofmann AF: Colonic secretion of water and electrolytes induced by bile acids: Perfusion studies in man. J Clin Invest 50:1569–1577, 1971

    Google Scholar 

  5. Hofmann AF, Poley JR: Role of bile acid malabsorption in the pathogenesis of diarrhea and steatorrhea in patients with ileal resection. I. Response to cholestyramine or replacement of dietary long chain triglyceride by medium chain triglyceride. Gastroenterology 62:918–934, 1972

    Google Scholar 

  6. McJunkin B, Fromm H, Sarva RP, Amin P: Factors in the mechanism of diarrhea in bile acid malabsorption: Fecal pH—a key determinant. Gastroenterology 80:1454–1464, 1981

    Google Scholar 

  7. Fromm H, Thomas PJ, Hofmann AF: Sensitivity and specificity in tests of distal ileal function: Prospective comparison of bile acid and vitamin B12 absorption in ileal resection of patients. Gastroenterology 64:1077–1090, 1973

    Google Scholar 

  8. Fromm H, Sarva RP, Ravitch MM, McJunkin B, Farivar S, Amin P: Effects of jejunoileal bypass on the enterohepatic circulation of bile acids, bacterial flora in the upper small intestine and absorption of vitamin B12. Metabolism 12:1133–1141, 1983

    Google Scholar 

  9. Grundy SM, Ahrens EH, Miettinen TA: Quantitative isolation and gas-liquid chromatographic analysis of total fecal bile acids. J Lipid Res 6:397–410, 1965

    Google Scholar 

  10. Bailey NTJ: Statistical Methods in Biology. London, The English Universities Press, 1968

    Google Scholar 

  11. Pomare EW, Heaton KW: The effect of cholecystectomy on bile salt metabolism. Gut 14:753–762, 1973

    Google Scholar 

  12. Almond HR, Vlahcevic ZR, Bell PCC, Gregory DH, Swell L: Bile acid pools, kinetics and biliary lipid composition before and after cholecystectomy. N Engl J Med 289:1213–1216, 1973

    Google Scholar 

  13. Samuel P, Saypol GM, Meilman E, Mosbach EH, Chafizadeh M: Absorption of bile acids from the large bowel in man. J Clin Invest 47:2070–2078, 1968

    Google Scholar 

  14. Mekhjian HS, Phillips SF, Hofmann AF: Colonic absorption of unconjugated bile acids. Perfusion studies in man. Dig Dis Sci 24:545–550, 1979

    Google Scholar 

  15. Hofmann AF: The syndrome of ileal disease and the broken enterohepatic circulation: Cholerheic enteropathy. Gastroenterology 52:752–757, 1967

    Google Scholar 

  16. Meihoff WE, Kern F Jr: Bile salt malabsorption in regional ileitis, ileal resection and mannitol-induced diarrhea. J Clin Invest 47:261–267, 1968

    Google Scholar 

  17. Farivar S, Fromm H, Schindler D, et al: Tests of bile acid and vitamin B12 metabolism in ileal Crohn's disease. Am J Clin Pathol 73:69–74, 1980

    Google Scholar 

  18. Hofmann AF: Bile acid malabsorption caused by ileal resection. Arch Intern Med 130:597–604, 1972

    Google Scholar 

  19. Mitchell WD, Eastwood MA: Fecal bile acids and neutral steroids in patients with ileal dysfunction. Scand J Gastroenterol 7:29–32, 1972

    Google Scholar 

  20. Small DM: The physical chemistry of cholanic acids.In PP Nair, D Kritchevsky (eds). The Bile Acids. Chemistry, Physiology, and Metabolism, Vol 1. New York, Plenum Press, 1971, pp 249–356

    Google Scholar 

  21. Igimi H, Carey MC: pH-solubility relations of chenodeoxycholic and ursodeoxycholic acids: Physical-chemical basis for dissimilar solution and membrane phenomena. J Lipid Res 21:72–90, 1980

    Google Scholar 

  22. Hofmann AF: Bile acids, diarrhea, and antibiotics: Data, speculation, and a unifying hypothesis. J Infect Dis 135:S126-S132, 1977

    Google Scholar 

  23. Oddsson E, Rask-Madsen J, Krag EA: Secretory epithelium of the small intestine with increased sensitivity to bile acids in irritable bowel syndrome associated with diarrhea. Scand J Gastroenterol 13:409–416, 1978

    Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Rights and permissions

Reprints and permissions

About this article

Cite this article

Fromm, H., Tunuguntla, A.K., Malavolti, M. et al. Absence of significant role of bile acids in diarrhea of a heterogeneous group of postcholecystectomy patients. Digest Dis Sci 32, 33–44 (1987). https://doi.org/10.1007/BF01296685

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Issue Date:

  • DOI: https://doi.org/10.1007/BF01296685

Keywords

Navigation