A 58-year-old obese woman comes to the physician with a 6-month history of intermittent, postprandial, colicky right-upper quadrant abdominal pain. Each bout of pain lasts about 15 minutes. The patient has a 10-pack-year smoking history (she quit 20 years ago) and drinks alcohol socially. Both her parents died of heart attacks. Her older brother is in good health. The patient's temperature is 36.7 C (98 F), blood pressure is 130/90 mm Hg, pulse is 62/min, and respirations are 14/min. Palpation of the abdomen shows tenderness in the right upper quadrant. Murphy's sign is present. Abdominal ultrasound reveals several gallstones and biliary sludge. The patient undergoes an uncomplicated laparoscopic cholecystectomy and is discharged the following day. On a follow-up visit 2 months later, she complains of daily diarrhea (4-5 watery bowel movements per day). She has tried dietary changes with no improvement. What is the most appropriate next step in management of this patient?

Question

A 58-year-old obese woman comes to the physician with a 6-month history of intermittent, postprandial, colicky right-upper quadrant abdominal pain.  Each bout of pain lasts about 15 minutes.  The patient has a 10-pack-year smoking history (she quit 20 years ago) and drinks alcohol socially.  Both her parents died of heart attacks.  Her older brother is in good health.  The patient's temperature is 36.7 C (98 F), blood pressure is 130/90 mm Hg, pulse is 62/min, and respirations are 14/min.  Palpation of the abdomen shows tenderness in the right upper quadrant.  Murphy's sign is present.  Abdominal ultrasound reveals several gallstones and biliary sludge.  The patient undergoes an uncomplicated laparoscopic cholecystectomy and is discharged the following day.  On a follow-up visit 2 months later, she complains of daily diarrhea (4-5 watery bowel movements per day).  She has tried dietary changes with no improvement.  What is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: Postcholecystectomy diarrhea is a form of bile salt-induced diarrhea that occurs in 5%-10% of patients following cholecystectomy. Bile salts are conjugated bile acids. Primary bile acids produced in liver cells are secreted into the intestinal lumen, where they are converted into secondary bile acids by bacteria. These secondary bile acids can cause colonic stimulation if present in excess amounts. Gallbladder surgery alters gut dynamics and leads to increased bile acid flux to the colon, resulting in an increased proportion of secondary bile acids and causing diarrhea. Bile salt-induced diarrhea is also seen with ileal resection or short bowel syndrome. Cholestyramine is a bile salt-binding resin that sequesters excess bile salts and is often effective against this form of diarrhea. (Choice B) A colonoscopy can be useful in the evaluation of chronic diarrhea when other tests are inconclusive or when a biopsy is needed (eg, inflammatory bowel disease). However, there is a more obvious cause of diarrhea in this patient. (Choice C) The antibiotic rifaximin is used to treat small intestine bacterial overgrowth. This is a malabsorption syndrome due to anatomic (eg, surgically created blind loops) or motility (eg, diabetes, systemic sclerosis) disorders that typically present with abdominal bloating, flatulence, and diarrhea. It has also been used to avoid recurrence of hepatic encephalopathy and treat Clostridium difficile-associated disease. (Choice D) The somatostatin analogue octreotide is useful in some forms of AIDS-related diarrhea and in diarrhea due to neuroendocrine tumors (eg, VIPomas). (Choice E) Pancreatic enzyme supplements are useful in steatorrhea due to exocrine pancreatic insufficiency (eg, chronic pancreatitis). Educational objective: Bile salt-induced diarrhea occurs in 5%-10% of patients following cholecystectomy and in patients with short bowel syndrome. The treatment of choice is bile salt-binding resins such as cholestyramine. References: Managing bile acid diarrhoea. (http://www.ncbi.nlm.nih.gov/pubmed/21180614)

A 58-Year-Old Obese Woman Comes to the Physician with a 6-Month