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What Medical Nutrition Therapy Guideline Is Recommended Post-Cholecystectomy?

      The gallbladder is a pear-shaped organ that functions as the reservoir for bile, which is produced by the liver, until it is needed for digestion of fats in the small bowel. The liver produces about 3 to 5 cups of bile every day. Bile is a green-brown fluid that is composed of bile salts, fatty compounds, cholesterol, and other substances. Bile salts act as emulsifiers/surfactants to reduce the size of the fat droplets.
      Risk factors for gallbladder disease or stones include the following: female, especially if pregnant, on hormone therapy or using birth control pills, or over the age of 60 years; people with a history of rapid or significant weight loss using very-low-kilocalorie diets; increased fat and sugar intake in the food history; and a sedentary lifestyle.

      Academy of Nutrition and Dietetics. Nutrition Care Manual. Gallbladder. http://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=5522&lv2=145224&ncm_toc_id=18679&ncm_heading=Nutrition%20Care. Accessed April 25, 2014.

      Being either Hispanic or Native American also predisposes an individual to gallbladder disease. In addition, the prevalence of gallstones is associated with a number of diseases: type 2 diabetes, dyslipidemia, and hyperinsulinemia.
      • Poetincasa P.
      • DiCiaula A.
      • Bonfrate L.
      • Wang D.Q.H.
      Therapy of gallstone disease.
      The majority of stones appear to remain “silent” and do not require medical or surgical treatment. When mild symptoms are present, a low-fat nutrition prescription (<30% energy from fat) with a modest protein content, small, frequent feedings, and the avoidance of alcohol may assist in controlling symptoms. In an acute gallbladder attack, all food is held until an evaluation can be completed and treatment options considered.

      Academy of Nutrition and Dietetics. Nutrition Care Manual. Gallbladder. http://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=5522&lv2=145224&ncm_toc_id=18679&ncm_heading=Nutrition%20Care. Accessed April 25, 2014.

      The prevalence of gallbladder disease ranges from 10% to 15% in adults and is one of the most common digestive diseases requiring hospital admission and financial resources.
      • Poetincasa P.
      • DiCiaula A.
      • Bonfrate L.
      • Wang D.Q.H.
      Therapy of gallstone disease.
      Surgical removal of the gallbladder either as an open operation or as laparoscopic cholecystectomy is standard treatment for gallbladder disease. Laparoscopic cholecystectomy is considered the gold standard for treating patients with symptomatic gallstones.
      • Poetincasa P.
      • DiCiaula A.
      • Bonfrate L.
      • Wang D.Q.H.
      Therapy of gallstone disease.
      A number of post-surgical complications following cholecystectomy have been cited in the scientific literature. The Nutrition Care Manual states diarrhea may occur in some people, probably as a result of an increased amount of bile in the large bowel. In most cases, the diarrhea lasts no more than a week to a few months, with increased duration of diarrhea with higher intake of fatty food.
      Post-cholecystectomy syndrome (PCS) may occur when abdominal symptoms develop after surgery. Prevalence of PCS has been reported from 5% to 40% of people following cholecystectomy.

      Glasgow RE, Mulvihill SJ. Treatment of gallstone disease. In Feldman M, Friedman LS, Brandt LJ, eds. Sleisenger and Fordtran's Gastrointestional and Liver Disease, 9th ed, vol. 1. Philadelphia, PA: Saunders; 2010:1121-1138.

      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. In addition, patients may experience symptoms of gastritis secondary to duodenogastric reflux of bile acids. The reflux may also be responsible for symptoms in the post-cholecystectomy syndrome.
      • Mahan L.K.
      • Escott-Stump S.
      • Raymond J.L.
      Krause's Food and the Nutrition Care Process.
      In a recent article by Yueh and colleagues, other issues noted were indigestion, fatty food intolerance, and heartburn.

      Yueh T-P, Chen F-Y, Lin T-E, Chuang M-T. Diarrhea after laparoscopic cholecstectomy: Associated factors and predictors. Asian J Surgery. 2014. http://dx.doi.org/10.1016/j.asjsur.2014.01.008.

      There is not a standard guideline for medical nutrition therapy (MNT) post-cholecystectomy. MNT should be individualized based on the patient's issues and a number of diet modifications may be indicated. Fat intake should be limited for several months to allow the liver to compensate for the gallbladder's absence, should be introduced gradually, and excessive amounts at any one meal should be avoided.
      • Escott-Stump S.
      Nutrition and Diagnosis-Related Care.
      Increased fiber intake will help normalize bowel movements. Be sure to increase the amount of fiber slowly over several weeks. 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.
      • Mahan L.K.
      • Escott-Stump S.
      • Raymond J.L.
      Krause's Food and the Nutrition Care Process.
      If reflux is an issue, avoid alcohol, caffeinated and carbonated drinks, chocolate, citrus foods and juices, coffee, vinegar-based dressing, onions, tomato-based foods, spicy foods, and mint, and eat smaller meals.

      Academy of Nutrition and Dietetics. Nutrition Care Manual. Gallbladder. http://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=5522&lv2=145224&ncm_toc_id=18679&ncm_heading=Nutrition%20Care. Accessed April 25, 2014.

      Conflicting research regarding post-cholecystectomy complications continues to be cited in the literature. As a registered dietitian nutritionist, it is imperative to use critical-thinking skills to assess and interpret data to provide appropriate MNT for each patient.

      References

      1. Academy of Nutrition and Dietetics. Nutrition Care Manual. Gallbladder. http://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=5522&lv2=145224&ncm_toc_id=18679&ncm_heading=Nutrition%20Care. Accessed April 25, 2014.

        • Poetincasa P.
        • DiCiaula A.
        • Bonfrate L.
        • Wang D.Q.H.
        Therapy of gallstone disease.
        World J Gastrointest Pharmacol Ther. 2012; 3: 7-20
      2. Glasgow RE, Mulvihill SJ. Treatment of gallstone disease. In Feldman M, Friedman LS, Brandt LJ, eds. Sleisenger and Fordtran's Gastrointestional and Liver Disease, 9th ed, vol. 1. Philadelphia, PA: Saunders; 2010:1121-1138.

        • Mahan L.K.
        • Escott-Stump S.
        • Raymond J.L.
        Krause's Food and the Nutrition Care Process.
        13th ed. Saunders, St Louis, MO2012: 667
      3. Yueh T-P, Chen F-Y, Lin T-E, Chuang M-T. Diarrhea after laparoscopic cholecstectomy: Associated factors and predictors. Asian J Surgery. 2014. http://dx.doi.org/10.1016/j.asjsur.2014.01.008.

        • Escott-Stump S.
        Nutrition and Diagnosis-Related Care.
        7th ed. Lippincott Williams & Wilkins, Baltimore, MD2012: 516-518