I.Introduction
A. Concepts in nutrition, medical nutrition therapy, and organ systems concerned
Nutrition is the study of food in relation to health. The Food and Nutrition Council of the American Medical Association defined nutrition as the “science of food, the nutrients and other substances therein, their action, interaction and balance in relation to health and disease, and the processes by which the organism ingests, digests, absorbs, transports, utilizes and excrete food substances.”
Nutrition is also concerned with the physiologic needs of the body in terms of specific nutrients, the means of supplying these nutrients through adequate diets, and the effects of failure to meet nutrient needs. In this similar viewpoint, nutrition is also concerned with the social, economic, cultural, and psychological implications of food and eating. Nutrition follows the four basics concepts, namely: 1.) Adequate nutrition is essential for health. 2.) Food items are classified according to content in terms of majority of nutrients, broadly classified as carbohydrates, proteins, fats, minerals, vitamins and water and are needed daily in the diet of humans. 3.) An adequate diet is the foundation of good nutrition, and it should consist of a wide variety of natural foods. 4.) Nutrients should be provided preformed in food, whereas a few may be synthesized within the body. 5.) Nutrients are interrelated and there should be metabolic balance in the body. 6.)
The body constituents are in a dynamic state of equilibrium. 7.) Human requirements for certain nutrients are known quantitatively within certain limits. 8.) The effects of nutritional inadequacy are more than physical; behavioral patterns and mental performance are also compromised, and; 10.) Proper education, technical expertise in addition to the use of all resources available in the practice of nutrition will help upgrade the nutritional status of people. (Lagua, Claudio and Ruiz, 2004) Race has been a predisposing factor in developing gallstones. Westerners usually develop cholesterol stones, while Asians tend to have pigment or mixed stones. There has been an increasing prevalence of calculous cholecystitis in the Philippines. Whatever the type, size or origin of these stones, they can present with a variety of signs and symptoms.
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Stones develop in a sluggish, diseased gallbladder. Formation of stones may be due to infection, stagnation of the bile or changes in the chemical composition of the bile, overeating or poor eating habits. Obesity is highly associated with prevalence of gallstones. Prevalence increases with age, history of diabetes mellitus and elevated serum triglycerides ( Lagua, Claudio, 2011)
The gallbladder may contain one large stone or many small ones. Infection accompanied by formation of gallstones is referred as calculous cholecystitis.
Often times, people with gallstones must have their gallbladder removed through a process called cholecystectomy. Transition diets are given accordingly after surgery and if the patient advances to an oral diet post-surgery, intake of fat is allowed as tolerated. As an accessory organ, the gallbladder is fairly easy to live without. Once it is removed, bile travels from the liver directly into the small intestine.
B. IMPORTANCE/ SIGNIFICANCE OF THE STUDY
Disorder of the accessory organs present a significant impact on the absorption and nutritional status of an individual. Failure to give immediate treatment could bring about complications which are more difficult to manage. These complications may or may not possibly lead to death of an individual.
This study was conducted to enable the students to practice his/ her skills on Diet Therapy I. It may help the students to understand better the disease condition, the actions and interactions of food and medications to the body and the rationale for the diet prescription for the case patient. Moreover, it would help the students, as well as the readers to draft a nutritional care plan for patients with calculous cholecystitis upon acquiring information about the disease through data collection. C. Objectives (General and Specific)
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The study generally aims to analyze, assess and give proper recommendations to a patient diagnosed with calculous cholecystitis. This study was also conducted to allow students to apply the knowledge gained in the lecture and laboratory class of Diet Therapy I.
The study specifically aims to:
1) Gather all the necessary information from the patient’s medical records and the interview 2) Assess the patient’s nutritional status and disease condition base from the information obtained 3) Know the causes, signs and symptoms of the disease condition and its complications 4) Determine and relate the factors and causality for the formation of the patient’s disease 5) Interpret and relate the findings to the patient’s disease condition 6) Formulate a nutritional care plan for the patient
7) Provide a diet prescription appropriate for the condition of the patient 8) Provide short and long term intervention for the patient and other recommendation that could help the prevent disease condition of the patient.
D. Limitations of the Study
The case study is only limited to the disease condition of the patient with calculous cholecystitis and its possible complications if not given immediate intervention. Due to time constraints, the attending physician and nurse were not interviewed for further understanding of the disease. There was also no diet prescription written on the patient’s medical chart, thus, the hospital’s cycle menu was used as a basis for some computations and analysis.
II. Methodology
Students of Diet Therapy I were grouped into pairs and were asked to get a patient for the case study. Approved letters provided by instructors of Diet Therapy II, requesting for a case patient with infections, burns, surgery, allergies and diseases of the gastro-intestinal tract were personally submitted to different hospitals in Laguna. Laguna Provincial Hospital in Sta. Cruz Laguna accommodated the request, with the approval of the medical director and assistance of the attending physician, nurse and head nutritionist-dietitian. In the nurses’ station, the necessary information was gathered on the selected case patient and the medical records were copied as data for the study. An interview with the case patient followed afterwards. The patient, together with her aunt, was interviewed to collect necessary data such as personal information, nutritional and dietary history and the 24hr. food recall.
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Before the said interview, a questionnaire was formulated to systematically and completely obtain all the essential information for a better further analysis. Questions include the 24-hour food recall of the patient food intake (prior to admission and during confinement), personal data, signs and symptoms experienced, patient’s tolerance and acceptance to the food given in the hospital, and some other information that would be beneficial to the study. After data gathering, the case was analyzed and a case study was then formulated. This was done through evaluation of the disease condition of the patient and correlating the symptoms experienced by the patient with the clinical manifestation of the disease.
The dietary and the medical intervention given to the patient were also analyzed. This included correlating the principle and rationale of the diet with the patients’ actual illness. The possible nutrient-drug interaction that can happen due to the prescribed medication to the patient was also analyzed. The result of the laboratory and biochemical findings of the patient was also interpreted. After this, the diet of the patient PTA and DC were analyzed quantitatively and qualitatively. The diet was evaluated quantitatively by computing the CPF of the patient’s food intake and computing the adequacy of that diet. Qualitative evaluation, on the other hand, was used using RDA. After analyzing the recommendations given to the patient, short-term and long-term diet plan was prepared for the patient.
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In computing the desirable body weight (DBW), the Tanhausser’s Method. The WHO standards for body mass index served as the basis in determining whether the client’s nutritional status. Method I was used to determine the patient’s total energy requirement (TER) for long term intervention and the carbohydrates-protein-fat distribution was distributed using the non-protein calorie method.
III. Theoretical Considerations
A. Disease Condition
Calculous cholecystitis or cholecystolithiasis, is caused by the precipitation of the substances contained in the bile, mainly cholesterol and bilirubin with accompanying inflammation. The bile is consisted of bile salts, cholesterol, bilirubin, lecithin, fatty acids, electrolytes and water usually found in the plasma. The cholesterol formed in the bile has no function; it is only a by-product of bile salt formation and the presence is only linked in the excretion of bile. Cholesterol is normally insoluble in water and this is where lecithin and bile salts combine with it to form micelles. Inside the gallbladder, water and electrolytes are absorbed in the liver bile, causing it to be more concentrated. Lecithin and bile salts are not absorbed in the gallbladder, their concentrations increases alongside cholesterol’s. This is the mechanism of maintaining the solubility of cholesterol.
B. Definitions and Classifications
Cholecystitis – inflammation of the gallbladder. There has been an association of cholecystitis with cholelithiasis. There is almost always a close association with complete or partial obstruction of the stones formed inside the gallbladder.
Cholelithiasis – gallstones that precipitated from bile, cholesterol or bilirubin due to impaired gallbladder function or excessive production of by-products from fat digestion.
C. Etiology
Gallstone formation is due to bile salt, pigments and cholesterol salt accumulation. The stones rub off on the walls of the gallbladder, causing pain and inflammation in the subsequent internal structures. There is also a link between elevated or abnormal estrogen levels with gallstone formation.
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D. Incidence/ Prevalence
There is a 10% incidence of adults getting gallstones. Approximately, there are twice as many women who develop this disease and it increases with age: after 60 years old, there is a 10-15% prevalence in men while a 20-40% prevalence in women was noted.
E. Pathology
Gallstones obstruct bile flow and causes reflux and subsequent inflammation in the gallbladder. The inflammation is caused by chemical irritation from the concentrated bile, along with the swelling of the mucosal area and ischemia from venous congestion and stasis. Bacterial infections may be a complication and this could account for the infection and could reach the adjacent gallbladder through the circulation. Staphylococci and enterococci are the most common pathogens. Perforation of the gallbladder could lead to gangrene.
F. Clinical Manifestations and Underlying Mechanisms
Pain is evident in early cholecystolithiasis. There is similarity in the pain experienced with biliary colic and is usually felt after a fatty meal. Pain is experienced in the right upper quadrant and there is spasm in the right, subcostal region. There is elevation in total serum bilirubin, amino transferase and alkaline phosphatase.
G. Prognosis
After cholecystectomy, patients can return to work in a span of 1-6 weeks.
IV. The Patient
A. Personal Data
The patient is Chastine Salazar, 28 years old, female admitted on January 3, 2013 at Laguna Provincial Hospital in Sta Cruz, Laguna. Her physician is Dr. Flores.
B. Socio-Economic History
The patient works as a registrar in the Head Office of AMA in Quezon City, Philippines. Due to her sedentary lifestyle, she and her husband jogs for 2 hours every weekend. Her middle-class income allows her to select food items of higher market value, thus chocolate is always present after every meal. The patient does not smoke nor drink but based on the interview, it was found out that she uses laxatives due to constipation problems.
C. Present illness and chief complaint
Patient has cholecystolithiasis with cholecystectomy as the surgical procedure of which 8 marble-sized gallstones were removed. Pain and vomiting was experienced by the patient and was immediately rushed to the hospital on January 3, 2013.
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D. Past Illnesses and surgery, allergies, hospitalization
There were no family history of predisposing risk factors to cholecystolithiasis but it was found out from the interview that the patient has allergic reaction to sea foods and patient has allergic rhinitis of which she has treated before with steroids.
E. Physical State of Health
Patient has allergy to sea foods and has allergic rhinitis. Patient also has constipation of which she self-medicates with laxatives.
G. Nutritional and Dietary History
It was observed from the 24-hr food recall that the patient has frequent consumption of chocolates and carbonated beverages. There was also a high intake of fatty and fried food and dishes every day. Snacking patterns are also noted as the patient tends to overeat every 3 hours.
