Life without a gallbladder: diarrhoea, fat and symptoms after surgery

Healthy state

The liver makes bile non-stop, with or without a gallbladder. The gallbladder is just a temporary store: it collects bile between meals, concentrates it and releases it in one go when fat reaches the duodenum. How this fits together is explained in the chapter on the digestive chain.

Without a gallbladder, bile flows into the gut continuously in smaller amounts, also at night and between meals. For fat digestion this is enough for the vast majority. In a study of 83 operated patients, quality of life improved after surgery regardless of how much fat they ate.

At the end of the bile duct, where it opens into the duodenum, sits a small ring muscle, the sphincter of Oddi Sphincter of Oddi Ring muscle where the bile duct and pancreatic duct open into the duodenum. It controls the outflow of bile and pancreatic juice. . It controls when bile and pancreatic juice flow into the gut.

Typical biliary colic usually disappears after surgery. However, a review of 38 studies found that upper abdominal pain persists in up to a third and appears newly in up to 14 per cent; new flatulence was the most common new symptom.

Disrupted state: causes and effects

Many people notice changed bowel habits after surgery. In a German study, 2 per cent had loose stools before surgery and 33 per cent three months after, but only 6 per cent had persistent diarrhoea. In an Australian survey, 17 of 100 operated patients reported new, troublesome diarrhoea after 6 to 12 months, more often those under 50, men and people with overweight.

Because bile flows constantly, more bile acids Bile acids Substances made by the liver that make fat digestible. About 95 percent are reabsorbed in the last part of the small intestine; gut bacteria transform the rest. More in the chapter “Bile acids: when bile causes diarrhoea” reach the colon and draw water in there. In people with chronic watery diarrhoea after surgery, a meta-analysis Meta-analysis An analysis that combines the results of several studies. It is only as good as the studies it includes. (361 people) found bile acid loss on the SeHCAT test in about 70 per cent. It is not quite that simple, though: in the German study a blood marker of bile acid loss rose in many, but was not linked to the change in stools. More in the chapter on bile acids.

Post-cholecystectomy syndrome covers all symptoms that persist or appear after surgery; according to a systematic review it affects about one person in ten. The causes are varied: retained stones in the bile duct, reflux, functional dyspepsia, IBS Irritable bowel syndrome Recurring abdominal pain linked to bowel movements, without tests finding another cause. Today it is understood as a disorder of gut–brain interaction. More in the chapter “The gut-brain axis”, bile acid diarrhoea. Often the real cause existed before surgery and the stones were an incidental finding. Early symptoms more often came from the stomach, late ones more often from a stone in the duct.

For a long time, sphincter of Oddi dysfunction was considered a common explanation for pain after surgery, and many people had the muscle cut endoscopically. The EPISOD trial tested this in 214 people with pain but normal blood tests and imaging, against a sham procedure. After one year, more people were doing well after the sham (37 per cent) than after the real cut (23 per cent). Pressure measurement of the muscle predicted nothing, and around one in ten developed pancreatitis from the procedure.

The gut microbiota Microbiome, gut microbiota The community of all microbes in the gut, mainly bacteria, plus viruses, fungi and archaea. Most live in the colon. More in the chapter “Building microbial diversity” changes too. In a population study from Pomerania with almost 2,000 people, those who had been operated on had lower diversity, less Faecalibacterium and more Escherichia/Shigella. People with silent gallstones who still had their gallbladder did not differ from healthy people. Whether these changes cause symptoms is unknown.

The question of colorectal cancer comes up again and again. A 2017 meta-analysis found about a 22 per cent higher relative risk after surgery, mainly in the right colon; however, the journal added a warning to it in 2024 because of doubts about where the data came from. A newer one with 14 studies found no clear association overall. Both rely on observational data: people with gallstones often also have overweight and similar eating habits, which themselves affect colorectal cancer risk. This is no reason to avoid a necessary operation, but a good reason to attend regular colorectal cancer screening.