Medical Nutrition Therapy (MNT) Recommended Post-Cholecystectomy

The gallbladder is a pear-shaped organ that functions as the reservoir for bile, which is produced by the liver. The liver produces about 3 to 5 cups of bile every day. Bile is a green-brown fluid composed of bile salts and other substances which aid in digestion. The bile salts, specifically, act as emulsifiers and surfactants to reduce the size of fat droplets. Gallstones form when the bile salts become concentrated, and if obstruction occurs within the bile ducts this can result in symptoms and infection. Many gallstones appear to remain "silent" and do not require a medical or surgical intervention.

Hispanic and Indigenous Americans are predisposed to gallbladder disease at higher rates, as are individuals over age 65. Increased risk is also prevalent with obesity, especially abdominal fat, pregnancy, certain medications, having a history of diabetes or following a Western diet (one high in calories, fat and refined carbohydrates). Rapid weight loss and periods of starvation and fasting may additionally trigger gallbladder attacks.

With acute gallbladder disease, all food and fluids may be restricted for a short period of time. With chronic gallbladder disease, a low fat diet of less than 30 percent of calories from fat is often recommended. The intake of magnesium-rich foods is thought to be a preventive measure against symptomatic gallstones, and some studies have indicated that a Mediterranean diet is associated with a reduced risk for cholecystectomy.

Surgical removal of the gallbladder, either as an open operation or as laparoscopic cholecystectomy, is standard treatment for gallbladder disease when symptoms persist. However, a number of side-effects following cholecystectomy have been cited in the scientific literature. The Nutrition Care Manual states diarrhea may occur in some people, citing an increased amount of bile in the large bowel as a probable cause. However, in most cases, diarrhea lasts no more than a week to a few months. An increased duration has been noted with higher intake of fatty food.

Prevalence of postcholecystectomy syndrome (PCS) has been reported from 5 to 40% of people following cholecystectomy. PCS is described as abdominal pain and symptoms similar to that of a gallbladder attack, only they occur after surgery has been performed. Symptoms may include upset stomach, nausea, vomiting, gas, bloating, diarrhea or persistent pain in the upper right abdomen. It is thought that the symptoms are not caused by, but are exacerbated by, the cholecystectomy – resulting from residual gallstones that may remain in the bile duct or muscle malfunction at the sphincter of Oddi. In addition, patients may experience these symptoms due to concurrent conditions, such as irritable bowel syndrome or peptic ulcer disease.

Medical nutrition therapy should be individualized based on the issues the patient is experiencing. There is not a universal standard diet post-cholecystectomy and several diet modifications may be indicated. For example, to allow time for the liver to compensate for the gallbladder's absence, fats should be introduced gradually and throughout the day to avoid excessive amounts at any one meal.

Increasing dietary fiber slowly over several weeks may help normalize bowel movements. It has been suggested that adding soluble fiber to the diet will act as a sequestering agent and bind the bile in the stomach between meals to avoid gastritis. If reflux is an issue, additional assessment may be needed to identify foods that exacerbate it. A trial of limiting alcohol, caffeinated drinks, chocolate and any fruits, vegetables or beverages that cause discomfort – may be recommended.

As a registered dietitian nutritionist, it is imperative to monitor the patient's tolerance to the post-surgical diet and to modify nutrition recommendations based on their individual recovery.

References:

• Academy of Nutrition and Dietetics. Nutrition Care Manual®. Gallbladder. Accessed December 21, 2021.
• Escott-Stump S. Nutrition and Diagnosis-Related Care. 9th ed. Baltimore, MD: Wolters Kluner; 2022:680-682.
• Lindenmeyer CC. (2020). Postcholecystectomy Syndrome. In Merk Manual: Professional Version. Accessed December 21, 2021.
• Mahan LK, Escott-Stump S, Raymond JL. Krause's Food and the Nutrition Care Process, 13th ed. St. Louis, MO; Saunders: 2012:667