Question

Your patient is a 39-year old high school guidance counselor who was diagnosed with Chrone’s disease (an inflammatory bowel disease) when he was a teenager. Last year, he had a small bowel obstruction that could not be relieved with nonsurgical procedures, and he underwent emergency surgery that removed 80% of his ileum. Since the surgery, his stool has been oily. Why? (Hint: consider the consequence of reduced enterohepatic circulation).

This patient also suffers from “bile acid diarrhea”. Why would this surgery result in diarrhea? Why doesn’t this occur in a healthy person?

Answer 1

As the patient had undergone the surgery the major part of small intestine is removed due to which the enterohepatic circulation of the patient is reduced. Due to which malabsorption of nutrients is taking place in the patient.

Most of the secreted bile salts are reabsorbed in the small intestine and then are transported into liver back . In the liver they are reused but due to malabsorption the macronutrient such as fats are malabsobed and feces contain fatty residues. This is called as steatorrhoea.

The bile acid diarrhea is seen in the patient because the 80% of his ileum is removed due to which re-absorption of bile acids is not taking place and they are passed directly in the large intestine. In the large intestine such high amount of bile acid irritates the mucosa of large intestine and this stimulates water and salt secretion in the bowel. This is the reason for diarrhea in post-surgical cases of crohn's Disease in which ileum is removed.

Whereas in healthy person ileum is functioning properly bile acids are re-absorbed well and no such condition arises in healthy person.