Many patients facing an operation to remove the gallbladder wonder if their digestive system will be able to manage without it, often saying to me, “But surely we have one for a good reason?” They are quite right – the gallbladder is indeed important in the digestive process, but will they miss it once it has been removed? The short answer to that question is that many people who lose their gallbladder will not miss it at all, but some do notice differences in their digestive function and very few regret their decision to go ahead with surgery. Your surgeon has a duty of care to you to carefully explain both the benefits AND the risks – and “risks” include not just a list of surgical complications but consequences to your health. Life without a gallbladder can have digestive consequences for some people, so let’s try to understand them.
Before we do so, it pays to remember that in the general population most people have no persisting digestive problems, but a surprising number of people out there who still have their gallbladders inside them DO experience digestive upset day-to-day. This can be indigestion, heartburn, reflux, loose stool, bloating, constipation, flatulence etc. This presence of digestive bother “out there” is called the PREVALENT (think “prevailing”) digestive upset in the general population.
So for example, if we use the definition of Chronic Diarrhoea as loose or watery stools occurring at least three times per day for four weeks or longer, such diarrhoea is actually prevalent in 3-5% of the general population in the USA (a study by Wald et al in 2000) and non-infectious functional diarrhoea prevails in 4-5% of the wider world population (Rome IV classification). In other words, some patients who go on to have their gallbladder out ALREADY have diarrhoea troubles. You might counter that by saying that surely some of these people could have had their gallbladders out, which is why diarrhoea prevails in the general population, but a 2008 Swedish population-based study by Halldestam et al. looked at this issue. It compared gallbladder surgery patients with matched “controls” (similar but healthy members of the public who retained their gallbladders). It found that the prevalence of chronic diarrhoea was 5% even in the control group.
Another common prevailing digestive problem is Irritable Bowel Syndrome (IBS). IBS is a gastrointestinal disorder characterised by abdominal pain or discomfort associated with changes in bowel habit (diarrhoea, constipation, or both) but no identifiable disease process causing this. If we use the older Rome III criteria to confirm that someone has IBS, approximately 10-15% of the general population would be noted to have IBS. The newer Rome IV criteria have revised this down to 3.8% This comes down to definitions – the real point I’m making is that IBS is fairly prevalent already in patients who come to me with a gallbladder problem.
An even more common condition is Indigestion or “Functional Dyspepsia”. This is defined as persistent or recurrent pain or discomfort centred in the upper abdomen, often related to eating, with no disease process identified behind it. According to the Rome IV criteria, the prevalence of functional dyspepsia is estimated to be around 7% to 10% in most Western countries and a 2021 review by Ford et al reported an average global prevalence of 10%–12%.
Thus, if we hear in this article about digestive upset after a gallbladder has been removed, we must subtract the general population’s prevalence of these troubles from the observed incidence occurring in patients who have their gallbladder removed. Then one can give context to the data and understand the TRUE incidence, or magnitude, of the “problem” occasionally of having one’s gallbladder removed.
So, what does the data say about this?
- Bowel Habit Changes
Approximately 5-10% of patients who have their gallbladder removed will report an alteration to the pattern of their bowel movements or alteration to the texture of their stools. Very occasionally it is an alteration towards constipation but the vast majority who do report an alteration say that their change is towards looser stools or more frequent visits. Note that over time this tends to reduce spontaneously in some people, but in the interests of transparency I will only mention hard data. It is also important to note that the definitions of diarrhoea vary in different studies, and in some cases we are referring in the study to untreated diarrhoea. In other words, don’t presume that diarrhoea remains an ongoing miserable problem for these patients.
The systematic review of the subject by Nachnani et al. (2020), which analysed 18 studies involving over 9,000 patients, found that 5–12% of individuals developed persistent diarrhoea postoperatively. In a population-based study of over 12,000 patients published in the Scandinavian Journal of Gastroenterology (Andersson et al., 2013), 18% of the patients reported chronic diarrhoea after laparoscopic cholecystectomy.
- Diet Modification
Changes in diet are another common post-operative outcome. In my estimation, about 1:10 patients needs to modify their diet. Some do so with minor changes towards healthier meals and eating habits. They don’t always say that this was because of a need to do so – sometimes it’s because they’ve had a wake-up call about their global health vulnerability, their excess weight or the fatty state of their livers found when they had an ultrasound scan. But certainly, there are about 10% of such patients amongst the 10% who experienced looser or more frequent stools who will need to make some substantial adjustments to their diet.
A meta-analysis by Ukleja et al. (2017) highlighted that while most patients resume a normal diet, a significant minority continue to experience food intolerances, particularly to fatty or fried foods, which may aggravate symptoms. A prospective study by Kwon et al. (2016) followed 1,204 patients for five years and found that more than 40% of respondents reported avoiding high-fat foods due to post-meal discomfort, bloating, or diarrhoea. These changes were self-initiated rather than medically prescribed.
If you are unlucky enough to be affected by the absence of your gallbladder, you might need to consider a few things like:
- Low-Fat Diet:
Diarrhoea after gallbladder removal is often triggered by fat-rich meals. Without the gallbladder to store and regulate bile release, bile flows continuously into the intestine, which can stimulate colonic motility and irritate the mucosa. A low-fat diet (generally <30% of daily caloric intake from fat) is recommended to minimize this effect. Patients are advised to avoid fried and greasy foods, choose lean protein sources and low-fat dairy and consume smaller, more frequent meals. - Soluble Fibre:
Soluble fibre, such as psyllium husk, can absorb excess bile acids in the colon and improve stool consistency. Fibre should be introduced gradually to reduce bloating or cramping. A typical dose is 5–10 grams of soluble fibre daily. - Bile Acid Sequestration:
Although dietary options alone cannot fully sequester bile acids, some anecdotal reports suggest that oat bran, bananas, and other binding foods may modestly reduce diarrhoea severity in mild cases. - Use of Medications and Supplements
Many patients rely on gastrointestinal medications following surgery. A study by Halldestam et al. (2008) with 4,300 patients found that 15% of individuals required regular use of medications like antidiarrheals, bile acid binders, or proton pump inhibitors more than one year after gallbladder removal. It was difficult to know how many of these patients already used such medication prior to their gallbladder surgery. As discussed earlier, such problems – and presumably medication used for them – is widely prevalent in the general population.
Increased use of over-the-counter digestive enzyme supplements and fibre products has also been reported anecdotally and in smaller patient surveys, though these findings are less consistently validated in randomised trials. Some patients will need pharmacological drugs or products to manage their symptoms, which include:
- Bile Acid Sequestrants:
Bile acid diarrhoea (BAD), also called cholerheic enteropathy, is a known cause of diarrhoea in patients without a gallbladder. In these cases, bile salts enter the colon in excessive quantities and stimulate secretion of fluids and electrolytes into the digestive tract and stimulate intestinal motility. First-line treatment is with Cholestyramine (a bile acid sequestrant) at a dose of 4 g orally once or twice daily, typically taken before meals. Alternatives are Colesevelam or Colestipol, newer agents with fewer gastrointestinal side effects.
- Anti-diarrhoeal Agents:
These may be used symptomatically, especially for milder cases not related to bile acid increasing, up to a total of 8–16 mg/day if necessary in divided doses. This drug is Loperamide (Immodium) and it helps to slow intestinal transit.
- Drugs to suppress acid production:
Proton pump inhibitors (Omeprazole, Pantoprazole etc,) and H2 Receptor antagonists (Famotidine) can reduce the amount of bile secreted into the digestive tract by reducing the acidity of gastric juice that arrives in the duodenum to stimulate bile secretion.
Other supportive measures include the short-term use of probiotics, especially for patients with Irritable Bowel Syndrome-type symptoms, replacement of electrolytes and correction of dehydration.
- Functional Gastrointestinal Disorders like IBS
Evidence from large studies and meta-analyses points to a heightened risk of functional gastrointestinal disorders, especially Irritable Bowel Syndrome (IBS) and functional dyspepsia, following removal of the gallbladder. A meta-analysis by Mahid et al. (2015) reported a relative risk of 1.7 for developing IBS symptoms in cholecystectomy patients compared to matched controls. In layman’s terms, matched healthy controls have an incidence of IBS that we could call x, but patients without a gallbladder have an IBS incidence of 1.7 times x.
- Quality of Life and Patient Satisfaction
Patients are often questioned after surgery to help the medical profession understand the consequences of their decisions or actions. If this process is done well, such as by an independent third party, with detailed questionnaires or at different time-points in the recovery, the results are reliable. It also is highly dependent on what degree of trouble the patient experienced from their gallbladder before it was removed. For example, if it was removed because it was cancerous or if they had suffered repeatedly or severely from a gallstone-related complication like pancreatitis, they are more likely to give positive feedback. Conversely, if they had no symptoms but were bullied into an operation with scaremongering about impending disasters from their gallbladder, or if their digestive trouble was never the gallbladder at fault in the first place, they are more likely to give negative feedback. Good patient selection, good communication, good surgical skill and quick intervention for digestive upset after surgery go a long way towards avoiding dissatisfaction. Hopefully in a private setting in New Zealand this happens 99% of the time.
Despite gastrointestinal complaints, most patients report relief from preoperative symptoms like biliary colic. However, long-term follow-ups reveal that about 20% of patients remain dissatisfied, often due to the emergence of new digestive symptoms or the persistence of altered bowel habits. For example, Thirlby et al. (2011) tracked 1,100 patients for 10 years and found a significant minority reporting diminished satisfaction, mainly due to ongoing gastrointestinal discomfort.
….. never forget:
Gallbladder diseases and gallstones passing into the bile system can cause some VERY serious complications and they can permanently damage your digestive health. They can even lead to your death. Conditions like gallbladder cancer, bile sepsis, gallbladder gangrene, pancreatitis and pancreatic necrosis are beyond the scope of this document. The risks of living WITH a gallbladder that has problems in it, and risks of living WITHOUT one, must always be weighed up. A good surgeon will discuss these issues with you very carefully, listen to your concerns and reach a joint decision with you on what is the best course of action in your circumstances.
In conclusion
Whilst removal of the gallbladder typically has little to no effect on your digestive health, long-term consequences to digestion are not negligible for some unfortunate patients. A small proportion of them experience persistent changes in digestion, including altered bowel habits, dietary restrictions, and increased use of medications. Recognising these outcomes is important and must be considered before committing yourself to the surgery.
References
- Wald A., et al. (2000). “Prevalence of functional gastrointestinal disorders and bowel habits in the United States.” Gastroenterology, 118(4), 799–806.
- Halldestam I., et al. (2008). “Long-term effects of cholecystectomy on gastrointestinal symptoms.” British Journal of Surgery, 95(2), 198–203.
- Ford, A. C., et al. (2021). “Epidemiology of functional dyspepsia and subtypes: A systematic review and meta-analysis.“ Gut, 70(2), 234–244.
- Nachnani, J., et al. (2020). “Post-cholecystectomy syndrome: A systematic review.” International Journal of Surgery, 82, 219–226. (Includes >9,000 patients across 18 studies)
- Andersson, R., et al. (2013). “Long-term gastrointestinal symptoms after laparoscopic cholecystectomy.” Scandinavian Journal of Gastroenterology, 48(8), 956–962.
- Ukleja, A., et al. (2017). “Nutritional aspects of cholecystectomy: a review.” Surgical Endoscopy, 31(6), 2477–2485.
- Kwon, A. H., et al. (2016). “Long-term dietary behavior after laparoscopic cholecystectomy.” Digestive Diseases and Sciences, 61(5), 1364–1372.
- Mahid, S. S., et al. (2015). “Risk of functional gastrointestinal disorders after cholecystectomy: a meta-analysis.” World Journal of Gastroenterology, 21(7), 2385–2391.
- Thirlby, R. C., et al. (2011). “Ten-year follow-up of patients after laparoscopic cholecystectomy.” Annals of Surgery, 253(1), 25–31.