Comparison of Demographics, Colonic Transit, and Quality of Life in Patients With Bile Acid Diarrhea With and Without a History of Cholecystectomy

Introduction: Bile acid diarrhea (BAD) accounts for roughly 30% of patients diagnosed with functional diarrhea or diarrhea-predominant irritable bowel syndrome (IBS-D). Patients with BAD have unique biochemical, microbial, and mucosal findings as well as more rapid colonic transit when compared to IBS-D (PMID: 35580964). One cause of BAD in the absence of ileal resection or disease is cholecystectomy. Our aim was to compare demographics, colonic transit, and quality of life (QOL) in patients with BAD with and without a history of cholecystectomy. Methods: We conducted a retrospective analysis of prospectively obtained data from a prior study (IRB #16-001445). Patients with intestinal resection or underlying gastrointestinal diseases were excluded. As part of the study, patients with biochemically confirmed BAD underwent measurement of colonic transit testing by validated scintigraphic method that utilizes 111In-activated charcoal in a methacrylate-coated delayed release capsule. Patients also completed the IBS-QOL and Hospital Anxiety and Depression Scale (HADS) questionnaires. Baseline demographics and those measurements of patients with post-cholecystectomy BAD and idiopathic BAD were compared using median and interquartile range (IQR). Statistical testing between both groups utilized Chi-square, Fisher’s exact, or the Wilcoxon Rank Sum test as appropriate. Results: Among 44 patients with BAD, 36 (83.7%) were female with a median age of 46 years (IQR 35.5, 57.5) and body mass index (BMI) of 33.7 (IQR 29.9, 38.3). Fifteen (34.9%) patients had undergone cholecystectomy; these patients were older (p=0.024) with numerically higher BMI (p=0.09) compared to those without cholecystectomy. Similarly, those patients with BAD with and without cholecystectomy had similar colonic transit at 24 hours (p=0.696), and ascending colon emptying T1/2 (p=0.261). Cholecystectomy did not appear to be associated with different levels of anxiety and depression based on the HADS (p=0.594) or reduced QOL based on the IBS-QOL (p=0.994). Patients with BAD and history of cholecystectomy were more likely to respond with worry about losing control of bowel function (Question 31 of IBS-QOL) (p=0.0296), but this did not meet statistical significance after adjustment for multiple comparisons. Conclusion: Clinical features, QOL, and colonic transit times appear to be similar in BAD secondary to cholecystectomy or idiopathic BAD. Table 1. - Comparison of patients with bile acid diarrhea (BAD) with and without history of cholecystectomy Characteristics [median (IQR) or N (%)] BAD (N = 44) p-value Prior cholecystectomy (N = 16) No cholecystectomy (N = 28) Number, % female 16 (100%) 28 (75%) 0.029 Age, years 56.5 (41.5, 65.0) 39.5 (33.5, 53.5) 0.024 Body mass index, kg/m2 34.5 (32.4, 39.4) 31.8 (28.4, 36.4) 0.09 Serum FGF-19, pg/mL 59.8 (25.1, 91.7) 59.1 (31.1, 110.6) 0.868 Serum 7αC4, ng/mL 74.3 (61.7, 104.0) 73.2 (60.0, 87.4) 0.508 Total fecal bile acids, µmol/g stool 4.9 (2.9, 6.7) 3.7 (2.4, 4.5) 0.097 Fecal primary bile acids (CDCA + CA), % 6.5 (1.0, 31.8) 20.0 (1.8, 53.8) 0.281 Colonic geometric center at 8 hours 1.4 (1.0, 2.9) 1.2 (0.6, 1.6) 0.238 Colonic geometric center at 24 hours 3.6 (2.2, 4.4) 3.4 (2.6, 3.8) 0.696 Ascending colon emptying T1/2, hours 11.0 (4.4, 16.8) 13.9 (7.6, 18.1) 0.261 HADS score, % > 7 1 (6.3%) 3 (10.7%) 0.537 IBS-QOL, composite score* 32.0 (16.5, 44.9) 29.8 (17.6, 44.1) 0.930 *Calculation: [(participant score – minimum score) / (maximum score – minimum score)] x 100, where higher scores equate to worse quality of life.BAD, bile acid diarrhea; CA, cholic acid; CDCA, chenodeoxycholic acid; FGF, fibroblast growth factor; HADS, Hospital Anxiety and Depression Scale; IBS-QOL, Irritable Bowel Syndrome – Quality of Life; IQR, interquartile range.