CHOLELITHIASIS WITH ACUTE CHOLECYSTITIS

VIDHI SHAH R. D INTERN

INTRODUCTION

CHOLELITHIASIS

▸The formation of gallstones (calculi) in the absence of infection of the

gallbladder is called cholelithiasis.

▸ Acute cholecystitis is inflammation of the gallbladder that develops

over hours, usually because a gallstone obstructs the cystic duct.

▸Acute cholecystitis develops in 1-3% of patients with symptomatic gall

stones.

ACUTE CHOLECYSTITIS

▸Obstruction of the cystic duct causes an

inflammatory process to start. This results

in acute cholecystitis.

▸If the inflammation persists it may cause

perforation or gangrene of the gall

bladder.

▸90% of cases of acute cholecystitis

result from obstruction of the cystic duct

by gall stones.

▸Obstruction of the cystic duct causes the

intraluminal pressure within the gall

bladder to increase and, together with

cholesterol supersaturated bile, triggers

an acute inflammatory response.

SYMPTOMS

• Severe pain in upper right abdomen

• Pain that radiates from the right shoulder or back

• Tenderness over the abdomen when touched

• Nausea

• Vomiting

• Fever

RISK FACTORS

Dietary factors: high caloric diets, high refined carbohydrate diets, low-fibre

diets

Dyslipidemia: hypertriglyceridemia

Hormonal factors: pregnancy, contraceptive pills, oestrogen

replacement therapy

Life style factors: sedentary life style, rapid weight loss

MANAGEMENT

Laparoscopic cholecystectomy – a

type of keyhole surgery where the

gallbladder is removed using special

surgical instruments inserted through

a number of small cuts (incisions) in

your abdomen

Open cholecystectomy – where the

gallbladder is removed through a

single larger incision in the abdomen

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.

▸ Symptoms may include upset stomach, nausea, vomiting, gas, bloating,

diarrhea, or persistent pain in the upper right abdomen.

▸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

postcholecystectomy syndrome.

▸In a recent article by yueh and colleagues, other issues noted were

indigestion, fatty food intolerance, and heartburn.

PATIENT PROFILE

▸Name: abc

▸Age: 47 Years

▸Gender: Female

▸Community: Hindu / Gujarati

▸Economic Status: Higher Socio Economic Group

▸Food Preference: Vegetarian

▸No of family members : 6

▸Date of admission: 14.12.2016

▸Date of discharge: 18.12.2016

▸Length of hospital stay: 5 days

▸SGA Score : A

ANTHROPOMETRIC MEASUREMENTS

MEASUREMENTS VALUES

Height 156cms

Weight 56kgs

5 kgs overweight

Body mass index (BMI) 23kg/m2

Ideal Body Weight (IBW) 51 kgs

BIOCHEMICAL PARAMETERS

TESTS RESULTS REFERENCE RANGE

14.12.2016 15.12.2016 16.12.2016

Hemoglobin 12.1g/dL 12g/dL 12g/dL 12.5-16g/dL

Sodium 138.00mmol/L 139mmol/L 138mmol/L 137-145 mmol/L

Potassium 4.30 mmol/L 4.3mmol/L 4mmol/L 3.5-5.1 mmol/L

Chloride 100.00 mmol/L 103mmol/L 101mmol/L 98-107 mmol/L

Serum Creatinine 0.70 mg/dl 0.7mg/dl 0.7mg/dl 0.7-1.2 mg/dl

Blood Sugar Random 143mg/dL - - 65-165 mg/dl

AST/SGOT 23.00 U/L 24U/L 22U/L 15-46 U/L

ALT/SGPT 36.00U/L 37U/L 35U/L 13-69 U/L

Bilirubin Total 0.79 mg/dl 0.80mg/dl 0.77mg/dl 0.2-1.3 mg/dl

Bilirubin Unconjugated 0.65mg/dl 0.66mg/dl 0.62mg/dl 0-1 mg/dl

Bilirubin Conjugated 0.00mg/dl 0.00mg/dl 0.00mg/dl 0-0.3 mg/dl

Bilirubin Delta 0.14mg/dl 0.14mg/dl 0.15mg/dl 0-0.2 mg/dl

Alkaline Phosphate 76.00U/L 78U/L 75U/L 38-126U/L

Total Proteins 7.18gm/dl 7.17gm/dl 7.19gm/dl 6.3-8.2 gm/dl

Albumin 3.98g/dl 3.99g/dl 3.98g/dl 3.5-5 g/dl

Globulin 3.20g/dl 3.18g/dl 3.21g/dl 2.4-3.5 g/dl

Albumin Globulin Ratio 1.25 1.25 1.23 1.1-2.2

Amylase 64.00 - - 30-110

Lipase 54.00 - - 23-300

Medication

Dosage

Mechanism of action

Side effects

Inj paracip 1g Treatment of headache, toothache, ear pain, joint

pain, periods pain, fever and other conditions.

Feeling of sickness

Skin reddening

Allergic reactions

Shortness of

Ing fortwin 30mg Works in the brain and nervous system to decrease pain. Feel of faint

Skin rash or itchy skin

Fainting

Ing amikacin 750 mg Is an antibiotic used for A number of bacterial infections. Agitation

Black, tarry stools

Bloody or cloudy urine

Inj. Magnex forte 1.5gm Treatment of urinary tract infection, bacterial infections,

surgical infections, bacterial infection of the respiratory

tract, peritonitis

Diarrhea

Rash

Decrease in white blood cells

Decrease in

Inj. Emset 4 mg Treatment of nausea and vomiting Uneven heartbeats, headache,

low blood pressure leading to

fainting or dizziness,

Inj. Dynapar 75 Mg Treatment Of Joint Pain, Lower Back

Pain, Sprains, Bone Fractures, Inflammation

Of Joints, Pain Due To Skeletal Muscle And

Other Conditions.

Fluid Retention

Abnormal Liver Function Tests

Stomach Ulcers Or Bleeding

Spinning Sensation

Inj Pan 40 Mg Pan 40 Mg Injection Is Used In The

Treatment Of Acidity, Heartburn, Intestinal

Ulcers And Stomach Ulcers

Nausea, Headache, Abdominal

Pain, Constipation, Diarrhoea,

Flatulence

Inj Perfalgan 100 ml Sos For Pain Perfalgan Is Indicated For The Short-term

Treatment Of Moderate Pain, Especially

Following Surgery And For The Short-term

Treatment Of Fever

Pain And Burning Sensation At

Injection Site.

General Feeling Of Being

Unwell (Malaise).

CLINICAL PRESENTATION

Present Complaints:

•Pain in the right hypochrondrium radiating to back since 1 month which

increased from past few days

•Mild tenderness on right hypochondriam

•2-3 episodes of vomiting since afternoon

CT Scan - Mild Fatty Liver

Calculi In Gall Bladder Of 1.6 Cm And 1.7 Cm

Another Calculus Of 1.1 Cm

Gall Bladder Thickness 4.4 Cm

Gall Bladder Edematous

Thin Rim Of Pericholecystic Fluid Noted

Stone Obstructing The Hartmann’s Pouch

Final Medical Diagnosis: Acute Cholecystisis

Surgery performed:Laproscopic Cholecystectomy

24 HOUR HOME RECALL

Meal Ingredient Amounts

energy

(kcals) CHO (g) Protein(g) Fat (g) Na (mgs) K(mgs) Fe (mg) TDFf(g) IDFg) SDFg)

BREAKFAST

Cornflakes Cornflakes 30 gms 99 22.6 1.7 0.3 4.6 0.7

Milk Milk 100 ml 66 4 3.3 4 73 160 0.2

Sugar 10gms 40 10

MID MORNING

Thepla

Wheat

Flour 30gms 100 21 2.5 0.5 6 94.5 1.47 3.75 2.85 0.87

Oil 10 ml 90 10

Tea Milk 50 ml 33 2 1.62 2 36.5 80 0.1

Sugar 5 gms 20 5

LUNCH

Rotli

Wheat

Flour 45gms 150 31.5 3.75 0.75 9 141.75 2.2 5.6 4.2 1.3

Paneer Nu

Sakh Paneer 40 gms 100 2 7 8

Tomato 50 gms 12.5 3 0.5 6.45 73 0.32 0.85 0.6 0.25

Onion 100 gms 40 10 1 4 127 0.6

Rice Rice 30 gms 100 21 2.5 0.5 0.21 1.23 0.96 0.27

Dal Tur Dal 15 gms 50 8.5 3.5 0.25 8.55 331.2 0.81 2.73 2.04 0.69

Fat Oil 15 ml 135 15

Papad 1 no 50 8.5 3.5 0.25 195 0.69 0.18

Pickle 1 tsp 9 5.6 0.68

Meal Ingredient Amounts

energy

(kcals) CHO (g)

Protein(g

) Fat (g) Na (mgs) K(mgs) Fe (mg) TDFf(g) IDFg) SDFg)

MID EVENING

Pudla Besan 30gms 100 17 7 0.5 21.96 216 1.59 4.59 7.56 0.93

Peas 25gms 10 2.5 0.25 2.15 1.8 0.35

Tomato 25gms 6.25 1.5 0.25 3.15 36.5 0.16 0.42 4.8 0.12

Oil 5 ml 45 5

Tea Milk 50 ml 3 2 1.6 2 36.5 80 0.1

Sugar 5 gms 20 5

Fruit Apple 1 ex 50 10 28 75 0.66 3.2 2.3 0.9

DINNER

Dal Dhokli

Wheat

Flour 30 gms 100 21 2.5 0.5 6 94.5 1.47 3.75 2.85 0.87

Dal 15 gms 50 8.5 3.5 0.25 8.55 331.2 0.81 2.73 2.04 0.69

Sugar 5 gms 20 5

Oil 10 ml 90 10

Peanuts 5 gms 33.3 1.1 0.5 2.6

Total 1622.05 228.3 46.47 63.08 442.66 1840.65 15.99 31.88 32 7.24

INTERPRETATION

▸High calorie consumption

▸Fat consumption – 35 % of total calories

▸Cooking oil used at home – groundnut oil

▸Protein consumption- 0.8g/ kg body weight

▸Processed food consumption

▸Refined sugar consumption

MEDICAL NUTRITION THERAPY

ENERGY:

25-30 calories / kg body weight

PROTEIN

Adequacy of protein through the diet is essential to maintain positive nitrogen balance.

0.8g to 1g of protein is recommended.

More than 50% of the protein provided to the patient should be HBV

CARBOHYDRATES

Dietary fiber intake decreased the prevalence of gastroesophageal reflux disease

(GERD), peptic ulcer disease, gallbladder disease, diverticular disease, colorectal cancer,

and hemorrhoids.

High intake of dietary fiber reduced acute intestinal infections and significantly slowed

diarrhea

(Ötles S., Ozgoz S., 2014. Health eff ects of dietary fi ber. Acta Sci. Pol., Technol.

Aliment. 13(2), 191-202)

FAT 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 diagnosisrelated care. 7th ed. Baltimore, MD: lippincott williams &

wilkins; 2012:516-518.)

Patients who have undergone laparoscopic cholecystectomy to follow a

low-fat diet for at least 1 week to reduce the possibility of diarrhea (Diarrhea after laparoscopic cholecystectomy: associated factors and predictors.Yueh TP, chen FY, lin

TE, chuang MT. Asian J surg. 2014 oct;37(4):171-7. Doi: 10.1016/j.Asjsur.2014.01.008. Epub 2014 mar)

Trans-fats and saturated fats have been correlated with the development of

gallstones. A diet high in saturated fat increases the risk for gallstones and

cholecystectomy

VITAMIN C

Vitamin C supplementation is associated with reduced incidence of

gallstones and appears to be protective against the development of

gallstones.

Vitamin C deficiency is associated among the risk factors for gallstones. Walcher, T.et al. (2009). Vitamin C Supplement Use May Protect Against Gallstones: an Observational

Study on Randomly Selected Population. BMC Gastroenterology, 2009, Vol 9., p 74-82

CURCUMIN

An interesting study researched the effects of the spices capsaicin (from

red pepper) and curcumin (from turmeric), and their combination on mice

Both spices are known for their hypolipidemic properties, including

improving lipid profile and had been studied previously for their

antilithogenic potential in mice. The study showed the combination to be

beneficial in both the prevention and regression of cholesterol gallstones. Applied Physiology, Nutrition, and Metabolism, 2011, 36(2): 201-209, 10.1139/h10-102 Malenahalli C.

Shubha, Raghunatha R.L. Reddy, Krishnapura SrinivasanDepartment of Biochemistry and Nutrition,

Central Food Technological Research Institute, CSIR, Mysore 570 020, India.

▸Turmeric (curcumin) improves postoperative pain- and fatigue-related

PROs(patient related outcome )following LC. Agarwal, K.A., Tripathi, C.D., Agarwal, B.B. et al. Surg Endosc (2011) 25: 3805. doi:10.1007/s00464-

011-1793-z

CASE PROGRESSION

Day 1 NBM For Surgery, Post Surgery Clear Liquids Were

Started

Day 2 Full Liquids + Soft Diet

Day 3 Soft Diet

Day 4 Soft Diet

Day 5 Full Diet – Discharge

GOALS FOR MEDICAL NUTRITION THERAPY

▸To provide early recovery from the surgery

▸To prevent and reduce the symptoms of post cholecystectomy syndrome

(PCS)

▸To decrease the incidence of gastroesophageal reflux seen

after cholecystectomy.

▸To further reduce the risk of gall stone formation

▸To treat and prevent nutritional deficiency

▸To improve and maintain quality of life

HOSPITAL DIET

NUTRITIONAL CALCULATION

Full liquids + soft diet and Soft Diet

▸Energy -1400 kcals (25 calories / kg present body wt)

▸Proteins -56 gms (1 g /kg present body wt)

▸Fat -31 gms (20% of total calories)

▸Carbohydrate- 896 gms (64% of total calories)

▸MCT

▸Dietary fiber

Menu Amounts

Energy

(Kcals) CHO(g) Protein (g) Fat (g) Na (mg) K (mg) Fe (mg) TDF(g) IDF(g) SDF (g)

BREAKFAST

Milk Milk 100 ml 29 4.6 2.5 0.1 73 160 0.2

Sugar 5g 20 5

SMP 15g 50 7.65 5.7 0.21

Upma Rawa 30gms 100 21 2.5 0.5 6.3 24.9 0.48

Peas 25gms 10 2.5 0.25 2.15 1.8 0.35

Onion 25gms 10 2.5 0.25 4 127 0.6

Oil 5 gms 45 5

MID MORNING

St apple puree Apple 1 no 50 10 28 75 0.66 3.2 2.3 0.7

Porridge Milk 100ml 29 4.6 2.5 0.1 73 160 0.2

Oats 30gms 100 21 2.5 0.5

Sugar 5 gms 20 5

SMP 15gms 50 7.65 5.7 0.21

LUNCH

Fat free soup

Tomato

soup 50 gms

Rice Rice 30 100 21 2.5 0.5 0.21 1.23 0.96 0.27

Saute french

beans

Boil french

beans 30gms 7.5 1.5 1.29 36

Butter 5 gms 35 5

Boil dal

Dal

(moong) 30gms 100 17 7 0.5 8.16 345 1.17 2.46 1.95 0.51

Butttermilk Curd 50gms 14.75 2.3 1.25 0.25 36.5 80 0.1

Menu Amounts

Energy

(Kcals) CHO(g) Protein (g) Fat (g) Na (mg) K (mg) Fe (mg) TDF(g) IDF(g) SDF (g)

TEA TIME

Banana Milk

Shake Banana

1/2ex/ 25

gms 25 5 18.3 44 1.6 0.55 0.35

Milk 100 ml 29 4.6 2.5 0.1 73 160 0.2

Sugar 5gms 20 5

Smp 15gms 50 7.65 5.7 0.21

Evening

Bread Bread 40gms 100 21 2.5 0.5 8 216 0.88 5 3.84 1.16

Butter Butter 10gms 70 10

DINNER

Fat Free

Khichdi Rice 15gms 50 10.5 2.5 0.5 0.1 0.61 0.48 0.13

Dal (Moong) 15gms 50 8.5 3.5 0.5 4.08 172.5 0.58 1.23 0.97 0.25

Curd Curd 100gms 29 4.6 2.5 0.1 73 160 0.2

Fat Free Mash

Potato Potatoes 50gms 50 12 0.5 8.25 185.2 0.36 1.27 0.51 0.24

Dudhi Bhaji Dudhi 50gms 12.5 1.5 1.2 38.1 0.18 0.75 0.51 0.24

Tomato 50 gms 12.5 1.5 3.87 43.8 0.19 0.5 0.36 0.15

Oil 5gms 45 5

Plain Custard Milk 100ml 29 4.6 2.5 0.1 73 140 0.2

Sugar 5 gms 20 5

BEDTIME

Fruit Watermelon ½ ex 50 10 13.65 80 3.95 0.3 0.15 5.5

Total 1424kcal 237.7g 55g 29g 513mg 2320mg 11.4mg 21.16g 15.29g 10.3g

SOFT DIET

Menu Ingredients Amounts

Energy(kc

al) CHO (g) Protein (g) fFat(g) Na [mgs] K [mgs] Fe [mgs] TDF [gms] IDF[gms] SDF[gms]

Calcium

[mgs]

BREAKFAST

Milk Milk 150ml 43.5 6.9 3.75 0.15 109.5 210 0.3 180

Smp 15gms 50 7.65 5.7 0.21 205.5

Sugar 5gms 20 5

Poha

Rice

Flakes 30gms 100 21 2.5 0.5 3.27 46.2 6 6

Tomato 30gms 12 2.5 0.3 3.87 43.8 0.192 0.51 0.36 0.15 14.4

Onion 30gms 12 2.5 0.3 1.2 38.1 0.18 0.75 0.51 0.24 14.07

Oil 5 gms 45 5

Fruit Banana 1 ex 50 10 18.3 44 0.18 0.9 0.55 0.35 8.5

MID MORNING

Porridge Milk 100ml 29 4.6 2.5 0.1 73 140 0.2 120

Oats 30gms 100 22 5 3 1.2 1.3 1.28 1.88

Sugar 5 gms 20 5

Smp 15 gms 50 7.65 5.7 0.21 205.5

LUNCH

Fat Free

Soup

Tomato

Soup 50 gms 12.5 1.5 1.935 21.9 0.096 0.255 0.18 0.075 7.2

Soft Rice Rice 30 gms 100 21 2.5 0.5 0.21 1.23 0.96 0.27

Curd Curd 100 gms 29 4.6 2.5 0.5 32 130 0.2 149

Dal Dal 30 gms 100 17 7 0.5 8.55 331.2 0.81 2.73 2.04 0.69 21.9

Saute Mix

Veg Chop

Boiled

Cauliflowe

r 30 gms 7.5 1.5 0.3 15.9 41.4 0.369 1.11 0.78 0.33 9.9

Boiled

Carrot 30 gms 12 2.5 0.3 10.68 32.4 0.309 1.32 0.9 0.42 24

Boiled

Beans 30 gms 12 2.5 0.3 1.29 36 0.183 15

Butter 10 gms 70 10

Menu Ingredients Amounts

Energy(kc

al) CHO (g) Protein (g) fFat(g) Na [mgs] K [mgs] Fe [mgs] TDF [gms] IDF[gms] SDF[gms]

Calcium

[mgs]

TEA TIME

Fruit

Muskmelo

n 1 ex 50 10 104.6 341 1.4 0.8 0.5 0.3 32

Evening

Threptin

Biscuits Biscuits 2 no 44 48 3 1.4

Milk Milk 100 ml 29 4.6 2.5 0.1 73 140 0.2 120

DINNER

Fat Free

Khichdi Rice 15 gms 50 10.5 1.25 0.25 0.1 0.61 0.48 0.13

Dal 15gms 50 8.5 3.5 0.25 4.275 165.6 0.405 1.365 1.02 0.345 10.95

Curd Curd 100 gms 29 4.6 2.5 0.1 32 130 0.2 149

Aloo Bhaji Potato 75 gms 75 18 0.75 8.25 185.25 0.36 1.275 0.825 0.45 7.5

Onion 30gms 10 12 2.5 0.3

Oil 5 gms 45 5

Saute

Doodhi

Saute

Doodhi 30gms 7.5 1.8 0.3 1.2 38.1 0.18 0.75 0.51 0.24 14.07

Butter 5 gms 35 5 0.54 26.1 0.138 0.6 0.51 0.09 6

Plain

Custard Milk 100 ml 29 4.6 2.5 0.1 73 140 0.2 120

Sugar 5 gms 20 5

BED TIME

Fruit

Watermelo

n 100 gms 50 10 0 0 27.3 160 7.9 0.6 0.3 0.3 11

TOTAL 1398 283 54.95 30.25 603.66 2441.05 21.932 16.105 11.705 6.26 1451.49

COMPLIANCE

Case progression Compliance

Day 1 NBM For Surgery, Post Surgery Clear Liquids

Were Started

Day 2 Full Liquids + Soft Diet Energy 86 %

Protein 96%

Day 3 Soft Diet Energy 88%

Protein 97%

Day 4 Soft Diet Energy 90%

Protein 98%

Day 5 Full Diet – Discharge

DISCHARGE DIET

NUTRITIONAL CALCULATION

Full Diet

▸Energy -1400 kcals (25 calories / kg present body wt)

▸Proteins -56 gms (1 g /kg present body wt)

▸Fat -31 gms (20% of total calories)

▸Carbohydrate- 896 gms (64% of total calories)

▸Dietary fiber

▸Iron

▸Calcium

EXCHANGE LIST

Food group No of

exchanges

Amounts

[gms/ml]

Calories

[Kcals]

CHO

[gms]

Proteins[gms] Fats [gms]

Cereal 4 120 gms 400 84 10 2

Pulse 1 ½ 45 gms 150 42.5 10.5 0.75

Milk

[skimmed]

2 ½ 350 ml 116.6 14 11.6 -

Skim Milk

Powder

1 30 gms 100 15.3 11.4 -

Oats 1 30 gms 100 22 5 3

Veg A 1 ½ 100 gms 50 9 1.5 -

Veg B 1 ½ 150 gms 60 15 1.5 -

Veg C 1 100 gms 100 24 1 -

Fruits 2 2 ex 100 20 - -

Sugar 10 gms 10 gms 40 9.6 - -

Oil 2 ½ 25 ml 225 25

Total 1441kcals 255.4gms 53gms 31gms

65% 15% 20%

Menu Ingredients Amounts

Energy(

kcals) CHO(g)

Protein

(g) Fat (g)

Calcium

[mgs] Fe[mgs] Na [mgs] K [mgs]

TDF

[gms] IDF [gms] SDF[gms]

BREAKFAST

Oats

Porridge Oats 30 gms 100 22 5 3 1.2 1.3 3.11 1.28 1.88

Milk 100 ml 33.3 4 3.33 120 0.2 73 140

Sugar 5 gms 20 4.8

Smp 15 gms 50 7.65 5.7 205.5 0.21

Fruit Banana 50 gms 50 10 8.5 0.18 18.3 44 0.9 0.55 0.35

MID MORNING

Yogurt Curd 100 gms 33.3 4 3.33 149 0.2 32 130

Pomogranat

e 25 gms 16.2 3.62 2.5 0.4475 0.225 33.25 0.7 0.575 0.125

Lunch

Rotli Wheat Flour 45 gms 150 31.5 3.75 0.75 4.5 0.21 0.27 0.96

Dudhi Nu

Sakh

100 gms 25 6 1 4.5 6 1.8 87 2 0.28

Oil 5 ml 45 5

Salad

Sweet

Potato Salad 100gms 100 24

46 0.21 9 393 3.9 2.6 1.3

Oil 5 ml 45 5

TEA TIME

Pudla Moong Dal 15 gms 50 8.5 3.5 0.25 11.25 0.585 4.08 172.5 1.23 0.975 0.255

Mint

Chutney Rice 30 gms 100 21 2.5 0.5 3 0.2 1.22 0.96 0.26

Oil 5 ml 45 5

Menu Ingredients Amounts Energy Cho Protein Fat

Calcium

[mgs] Fe[mgs] Na [mgs] K [mgs]

TDF

[gms] IDF [gms] SDF[gms]

EVENING

Soup

Pumpkin And

Carrot Soup Pumpkin 50 gms 12.5 3 0.5

5 0.22 2.8 69.5

Carrot 50 gms 20 5 0.5 40 0.515 17.8 54 2.2 1.5 0.7

Oil 5 ml 45 5

DINNER

Vegetable

Khichdi Rice 45 gms 150 31.5 3.75 0.75 4.5 0.31 1.84 1.44 0.4

Dal 30 gms 100 17 7 0.5 21.9 0.81 8.55 331.2 2.73 2.04 0.69

Onion 50 gms 20 5 0.5 20 0.6

Peas 25gms 10 2.5 0.5 5 0.375 1.95 19.75 2.15 1.8 0.35

Carrot 25 gms 10 2.5 0.5 20 0.2575 8.9 27 1.1 0.75 0.35

Oil 5 ml 45 5

Raita Curd 100 gms 33.3 4 3.33

149 0.2 32 130

Dill Leaves

BED TIME

Fruit Custard Milk 50 ml 16.65 2 1.66

60 0.1 36.5 70

Apple 50 gms 29.5 6.7 5 0.33 14 37.5 1.6 1.15 0.45

SMP 15 gms 20 4.8

Sugar 5 gms 50 7.65 5.7 0 0 0 0 0 0 0 0

TOTAL 1424.75 238.72 53 30.75 928.65 8.1 273.305 1797.7 26.22 18.26 8.01

MENU ALTERNATIVES PHYTONUTRIENTS

Oats porridge

Fruit

Oats milkshake

Cinnamon powder

Yoghurt Buttermilk

Rotli

Dudhi nu sakh

Sweet potato salad

Bhakri , rice chilla

Methi nu sakh , tamatanu sakh

Yam salad

Turmeric

Pudla

Mint chutney

Dhokla , handva

Coriander chutney

Turmeric

Ginger

Pumpkin and carrot soup Celery soup Garlic

Veg khichdi

Raita

Dal khichdi , dal dhokli

Curd, buttermilk

Turmeric

Pepper

Garlic

Fruit custard Pudding Cinnamon powder

FAT CALCULATION

Amounts SFA MUFA PUFA Omega 6 Omega 3

Rice 75 gms 0.33 0.3 0.38 0.37 0.0075

Wheat 45 gms 0.225 0.13 0.57 0.49 0.07

Potato 100 gms 0.152 0.15 0.14 0.08 0.06

Green Gram 15 gms 0.06 0.0075 0.12 0.09 0.03

Red Gram 30 gms 0.14 0.03 0.33 0.3 0.03

Total 0.907 0.6175 1.54 1.33 0.1975

Coconut Oil 5 ml 4.48 0.39 0.1 0.1

Flaxseed Oil 5 ml 0.25 0.25 2 0.4 1.6

Rice Bran Oil 10 ml 2.21 4.1 3.57 3.43 0.14

Olive Oil 5 ml 0.72 3.72 0.5 0.5

Total 7.66 8.46 6.17 4.43 1.74

Grand Total 8.567 9.0775 7.71 5.76 1.9375

SUPPLEMENTATION

SR. NO NUTRIENT SOURCE NAME COMPOSITION COST PER USE

1. Fiber Fenu G

6g soluble fiber per

sachet

Rs 6.50/- Per use

2. Omega 3 SanofiTriomega (Capsule)

Omega3- 300mg

EPA -180mg

DHA-120mg 4/-

3. Symbiotic INLIFE Prebiotics And

Probiotic Capsules

Lactobacillus

rhamnosus , Bifobact

erium bifidum,

Lactobacillus

acidophillis,

Bifidobacterium

longum,

Sacchromyces

Boulardi,Fructo

Oligosaccharides

(150g)

Rs 8/-

4. Celiin Vitamin C 500mg Vit C

1.5Rs

RECOMMENDATIONS

▸Add foods back into your diet gradually

▸low-fat and smaller portions- avoid high fat foods for the discomfort

which includes :

▸Fried foods , such as farsans

High-fat dairy, such as cheese, ice cream and whole milk

Creamy soups and sauces and gravies

Chocolates

Slowly reintroduce high fiber foods

▸Maintain a journal or a dairy – to record any side effects

OPD FOLLOW UP

▸Patient was tolerating the low fat diet well

▸There were no GI related symptoms which were noted

▸Patient was advised to continue on a low fat diet

▸ No changes in the weight was observed

▸High fiber food list was given to the patient – to gradually increase

and incorporate in the diet

▸Hemoglobin levels were normal