1

GALLBLADDER ADENOCARCINOMA STAGE IVA SECONDARY

TO LYMPH NODE AND LIVER METASTASIS WITH

HYPERTENSIVE CARDIOVASCULAR DISEASE

_____________________________________

A Case Study Presented

To the

Dietary Department

Cebu Doctors University Hospital

_____________________________________

In Partial Fulfillment of the

Requirements for the Degree of

Bachelor of Science in Nutrition and Dietetics

_____________________________________

By

Sosing, Marem C.

Pausanos, Hannah Mae R.

April 5, 2017
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Table of Contents

Contents Page

I. General Information
A. Social History
B. Medical History
C. Diagnosis
D. Diet History
a. Usual Food Intake
E. Clinical and Biochemical Tests Results
II. Information About the Disease
Anatomy and Physiology of the Gallbladder
A. Definition of the Gallbladder Adenocarcinoma Stage IVA
Prevalence
Etiological Factors
Clinical manifestations
Pathophysiology
B. Definition of Lymph Node Metastasis
Prevalence
Etiological Factors
Clinical Manifestations
Pathophysiology
C. Definition of Liver Metastasis
Prevalence
Etiological Factors
Clinical Manifestations
Pathophysiology
D. Definition of Liver Metastasis
Prevalence
Etiological Factors
Clinical Manifestations
Pathophysiology
III. Medical management
IV. Nutritional Screening
V. Diet Order/Prescription
a. Computation of Desirable Body Weight (DBW)
b. Computation of Body Mass Index (BMI)
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c. Computation of Total Energy Requirement (TER)

d. Meal/Diet Plan
e. Sample Menu
VI. Principle and Rationale of Diet
VII. Patients Progress
VIII. Prognosis
IX. Conclusion and Recommendations
X. Glossary and Abbreviation of Terms
XI. Bibliography and Reference
 1

I. General Information

Name: Mrs. Adela A. Cabasa

Sex: Female
Civil Status: Widowed
Birthdate: November 12, 1927
Age: 90 years old
Nationality: Filipino
Religion: Roman Catholic
Weight: 62.4 kg.
Height: 145 cm
Occupation: Business Woman
Address: 5-F Rallos, Cebu City
Date of Admission: February 17, 2017
Attending Physician: Dr. Viola E. Villegas and Dr. A Singid
 2

A. Social History

Mrs. Adela Cabasa is a 90 years-old female from F. Rallos, Cebu City. She
was once a fish market vendor. She does not smoke or drink alcoholic
beverages. After her children got married, she now lives with a caretaker who
cooks her food and carrying out the day-to-day chores. She walks around the
home, do the shopping, pay the bills and goes to church prior to admission.

B. Medical History

The patient has a history of hypertension and she has osteoarthritis. Two
days prior to admission, the patient was noted to have a right upper quadrant
abdominal mass. It was non-tender on examination. She noticed that the lump is
growing. She did not feel any pain and remain on her usual diet. There was no
jaundice and fever. An ultrasound was done and was advised to be admitted.

C. Diagnosis

She was diagnosed with gallbladder cancer stage IV with lymph node and
liver metastasis and hypertensive cardiovascular disease.

The primary impression was Pancreatic Cancer. It was revised after the
multiple CT scan of the whole abdomen.

It showed a lobulated heterogeneously enhancing soft tissue mass (3.1 x

4.3) arising from the anterior gallbladder wall abutting the liver. Enlarged
periportal, portocaval, mesenteric retroperitoneal and peripancreatic head lymph
nodes (up to 2 cm). After liver and gallbladder biopsy, they found a multiple
hypodense hepatic masses (up to 3.7 cm) throughout the liver. The patient has a
small amount of ascites. The distended gallbladder has a multiple (innumerable)
calcified cholelithiasis (0.2 to 0.4 cm) with thickened gallbladder walls (up to 0.5
cm). The pancreatic neck appeared to have small (0.8 and 1.1 cm) simple cysts.

The result also showed an atherosclerosis of the abdominal aorta and iliac
arteries and mild spondylosis of the thoraco lumbar vertebra. The patient
underwent a percutaneous cholecystectomy and liver and gallbladder biopsy.

D. Diet History

The patient loves to eat home-cooked foods. They always avoid outside
foods and prepare foods at home. They rarely go to a fast food restaurant. She
does not prefer to eat fatty foods. But one of her favorite snack is Chicharon.
And because she is very near to market, she prepares fresh lean meat and fish
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and vegetables. She is very meticulous to the freshness and chooses the best
ingredients. She wants her food to always taste good so, they add commercial
seasonings or flavor enhancers in every dishes.

In her age, she can still recognize the taste of the food. During the
hospitalization, she refuses to eat the food from the hospital since her diet
includes low salt. She also complains that the food is already cold.

The patient follows a no breakfast meal pattern. She eats between 10AM
to 11AM as her brunch meal, snacks between 2PM to 3PM and eats dinner as
early as 5PM. She is allergic to chicken and milk. She loves to eat fish and selects
those from large varieties. For every meal, there should be one vegetable dish.
She also eats sweet foods occasionally.

Usual Food Intake

Food Lists Brunch Lunch PM Dinner

Snacks
Soup Fish Broth from
Tinolang Isda
Meat/Substitute 1 slice/ 1 1 slice of
mbs Fried Tinolang Isda
Fish (41kcal)
(86kcal)
Vegetable 1 cup Utan 1 cup Vegetable
Bisaya Saut (122kcal)
(32kcal)
Rice/Substitute 2 slice bread 1 cup rice 2 pieces 1 cup
(100kcal) (100kcal) bread rice(100kcal)
(100kcal)
Fruit/Dessert 1 piece 1 piece banana
apple M (80)
(40)
Fat 1 tsp.
Canola oil
Beverage Nescafe 3 in 1
Brown 'n
Creamy
(71kcal)
TOTAL 171 Kcal 258 kcal 100 kcal 343 kcal

Total: 872 kcal

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E. Clinical and Biochemical Tests Results

Blood Pressure

DAYS IN AM PM
DATE REMARKS
HOSPITAL 12 4 8 12 4 8
Admission Feb. 140 High
17, 70
2017
1 Feb. 110 100 100 90 100 100 Normal
18, 70 60 70 60 60 60
2017
2 Feb. 90 90 170 100 120 120 High
19, 70 70 80 70 70 60
2017
3 Feb. - 120 110 120 110 100 Normal
20, 70 80 70 60 60
2017
4 Feb. 120 110 110 110 130 90 High
21, 80 80 60 60 70 60
2017
5 Feb. 100 110 110 100 120 120 Normal
22, 70 70 80 60 60 60
2017
6 Feb. 100 110 100 120 110 110 Normal
23, 60 60 60 60 80 70
2017
7 Feb. 90 100 100 100 110 - Normal
24, 60 60 70 60 60
2017
8 Feb. 110 120 110 120 110 110 Normal
25, 80 80 60 60 60 70
2017
9 Feb. 100 100 120 110 120 100 Normal
26, 60 60 70 70 80 70
2017
10 Feb. 100 100 100 - 110 100 Normal
27, 80 80 70 60 60
2017
11 Feb. 120 110 110 120 100 100 Normal
28, 70 70 70 70 60 60
2017
12 March 100 120 110 110 100 100 Normal
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1, 60 60 60 70 70 60
2017
13 March - - 120 - 120 120 Normal
2, 80 60 70
2017
14 March - 120 100 100 110 110 Normal
3, 80 60 60 80 70
2017
15 March 110 100 100 100 120 120 Normal
4, 80 70 80 80 80 80
2017
16 March 100 110 100 110 - - Normal
5, 60 70 60 70
2017
17 March - 110 100 100 110 90 Normal
6, 80 60 60 70 60
2017
18 March 110 120 - 120 Normal
7, 80 80 80
2017

Indications:

The ideal or normal blood pressure is less than 120 mmHg (systolic) and
120
less than 80 mmHg (diastolic). The blood pressure of the patient is mostly 80
which is already in its borderline. Between 120-139 (systolic) or between 80-89
140
(diastolic) will indicate prehypertension. means Stage 1 hypertension. The
70
higher pressure puts an extra strain on the patients heart and blood vessels.
Over time, this extra strain increases the risk of a heart attack or stroke. The
170
patients blood pressure reached to or stage 2 hypertension (Mayo Clinic,
80
n.d.).
 6

LABORATORY NORMAL
DATE RESULTS UNIT REMARKS
EXAMINATIONS VALUES
Feb. CBC (COMPLETE BLOOD COUNT)
17, HEMOGLOBIN 10 g/dL 12.3 15.3 Low
2017 HEMATOCRIT 28.2 % 35.9 44.6 Low
MONOCYTES 14 % 0.00 8.00 High
RED BLOOD CELLS 3.02 /uL 4.50 5.10 Low
10^6
RDW 12.5 % 14.0 18.0 Low
PLATELET COUNT 177 /uL 140.0 High
440.0 10^3
Feb. URINALYSIS ROUTINE
18, (CHEMICAL EXAMINATION)
2017 BLOOD LARGE Not normal
LEOKOCYTE LARGE Not Normal
URINALYSIS ROUTINE
(MICROSCOPIC EXAMINATION)
RED CELLS 134.8 /uL 0-11 High
PUS CELLS 135.6 /uL 0-11 High
BACTERIA 8.0 /uL 10-111 Low
URINALYSIS ROUTINE
(CONVENTIONAL)
RED CELLS 24.26 /hpf 02 High
PUS CELLS 24.41 /hpf 02 High
EPITHELIAL CELLS 9.63 /hpf 02 High

BACTERIA 1.44 /hpf 0 20 Normal

Feb. CA 19 9 37.74 u/mL 0 37.0 High
18,
2017
March CBC (COMPLETE BLOOD COUNT)
2, HEMOGLOBIN 11.1 g/dL 12.3 15.3 Low
2017 HEMATOCRIT 31.9 % 35.9 44.6 Low
MONOCYTES 12 % 0.00 8.00 High
RED BLOOD CELLS 3.38 /uL 4.50 5.10 Low
10^6
March POTASSIUM, 3.6 mmol/L 3.5 5.1 Normal
2, SERUM
2017 SGOT 128 U/L 15 41 High
March URIC ACID 1.8 mg/dL 2.6 8.0 Low
3, CALCIUM 8.2 mg/dL 8.4 10.2 Low
2017 TOTAL PROTEIN 5.5 g/dL 6.50 Low
8.10
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ALBUMIN 2.3 g/dL 3.5 5.0 Low

PHOSPHATASE, 213 U/L 38 126 High
ALKALINE
TOTAL BILIRUBIN 0.8 mg/dL 0.3 1.2 High

PROTEIN A:G 0.72 1.2 2.5 Low

RATIO

Results Indications
Low Hemoglobin The measures in these three areas are
Low Hematocrit lower than normal. The patient has
Low Red Blood Cell Count anemia. Anemia causes fatigue and
weakness. Anemia has many causes,
including low levels of certain vitamins
or iron, blood loss, or an underlying
condition.

High Monocytes A heightened percentage of monocytes

in the patients blood can be caused
by:

chronic inflammatory disease,

such as inflammatory bowel
disease
a parasitic or viral infection
a bacterial infection in the heart
a collagen vascular disease such
as rheumatoid arthritis
Low RDW One reason for a low RDW level is
macrocytic anemia. Macrocytic anemia
is a blood disorder in which not enough
red blood cells are produced, but the
ones that are present are large.
Another cause of a low RDW level is
microcytic anemia. Microcytic anemia is
a condition in which abnormally small
red blood cells are present. In these
two disorders the red blood cells do not
vary much in size because they are
either all small or all large.
High Platelet Count Higher than normal (thrombocytosis) is
 8

often a sign of an underlying medical

condition, or it may be a side effect
from medication.
Large Leokocytes Sign that there may be an infection in
the urinary system.
Large Red Blood Cell Megaloblastic anemia is a group of
disorders characterized by abnormally
large red blood cells.
High Pus Cells Pus cells are white blood cells that
signify infection in the body.
High Epithelial Cells May indicate bladder infection or a
serious condition of the kidneys.
High SGOT Highly sensitive markers of liver
damage due to various diseases or
injury.
Low Uric Acid Low uric acid levels may be associated
with a molybdenum deficiency, copper
toxicity, and a worsening of multiple
sclerosis.
Low Calcium Hypocalcemia is a condition in which
there are lower-than-average calcium
levels in the body. It is may be the
result of low calcium production or
insufficient calcium circulation in your
body. A deficiency of magnesium or
vitamin D is linked to most cases of
hypocalcemia.
Low Total Protein Low total protein may indicate:

bleeding
liver disorder
kidney disorder
malnutrition
malabsorption conditions, such
as celiac disease or
inflammatory bowel disease
 9

High Phosphatase, Alkaline Higher than normal levels of ALP in the

patients blood may indicate a problem
with the liver or gall bladder. This could
include hepatitis (infection), cirrhosis
(scarring), liver cancer, gallstones, or a
blockage in your bile ducts.

High Total Bilirubin High bilirubin may be due to problems

with the liver, bile ducts, or gallbladder.
Examples include:

liver diseases, like hepatitis

biliary stricture, where part of
the bile duct is too narrow to
allow fluid to pass
cancer of the gallbladder or
pancreas
gallstones

Low PROTEIN A:G RATIO Low level of albumin/globulin ratio

indicates:

Conditions causing
underproduction or loss of
albumins, like in nephrotic
syndrome, liver cirrhosis, etc
Source: www.healthline.com
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I. Information About the Disease

A. Definition/Nature of the Disease

Anatomy and Physiology of the Gallbladder

The gallbladder is a small, hollow, pear-shaped pouch about 8cm long and
about 2.5cm wide. It lies underneath the right side of the liver, in the upper
abdomen. The gallbladder and bile ducts form the biliary tract. It is also called as
biliary tree or biliary system (Cancer Research UK, 2014).
 11

The gallbladder serves as a reservoir or a storage sac for bile while it is

not being used for digestion (Healthline Medical team, 2014). It has the ability to
hold about 50 milliliters of bile which can be emptied via the cystic duct
(gallbladder duct) into the common bile duct (Healthhype, n.d.).

Bile is a greenish yellow, thick, sticky fluid that aids the digestion of lipids
in the small intestine. The composition of gallbladder bile is 97% water, 0.7%
bile salts, 0.2% bilirubin, 0.51% fats (cholesterol, fatty acids and lecithin), and
200 meq/l inorganic salts. Bile flows out of the liver through the right and left
hepatic ducts, which come together to form the common hepatic duct. This duct
then joins with a duct coming from the gallbladder, called the cystic duct, to
form the common bile duct. The pancreatic duct joins the common bile duct just
where it empties into the duodenum through the sphincter of Oddi. Between
meals, bile salts are stored in the gallbladder, and only a small amount of bile
flows into the intestine. When food that enters the duodenum, a hormone called
cholecystokinin is released, signaling the gallbladder to contract and secrete bile
into the small intestine through the common bile duct. As a result, bile flows into
the duodenum and mixes with food contents (Ruiz, n.d.).

Bile has two important functions: It assists in the digestion and absorption
of fats, and it is responsible for the elimination of certain waste products from
 12

the body, particularly hemoglobin from destroyed red blood cells and excess
cholesterol. Specifically, bile is responsible for the following actions:

Bile salts make cholesterol, fats, and fat-soluble vitamins more soluble
(more dissolved), which aids in their absorption.
Bile salts stimulate the secretion of water by the large intestine to help
move the contents along.
Bilirubin (the main pigment in bile) is excreted in bile as a waste product
of destroyed red blood cells, giving stool a green-brown color.
Drugs and other waste products are excreted in bile and later eliminated
from the body.
Various proteins that play important roles in bile's absorptive function are
secreted in bile (Ruiz, n.d.).

Bile salts are reabsorbed by the last portion of the small intestine,
extracted by the liver, and resecreted into bile. This recirculation of bile salts is
known as the enterohepatic circulation. All the bile salts in the body circulate
about 10 to 12 times a day. During each pass, small amounts of bile salts reach
the large intestine, where some are reabsorbed and the rest are excreted in the
stool (Ruiz, n.d.).

The gallbladder is not an essential part of the body. The body can still
digest food without it. It is often removed by a surgical procedure known as a
cholecystectomy in cases of gallbladder disease or gallstones. (Cancer Research
UK, 2014).

A. Definition of Gallbladder Adenocarcinoma Stage IVA

Cancer develops when healthy cells in the gallbladder become abnormal

and grow too quickly (Chhabra, n.d.). Gallbladder cancer is a rare cancer of the
digestive system in which malignant (cancer) cells form in the tissues of the
gallbladder. When gallbladder cancer is discovered at its earliest stages, the
chance for a cure is very good. But it is difficult to detect and diagnose because
there often are no noticeable signs in the early stages. When there are
symptoms they often resemble other illnesses. Also, the relatively hidden nature
of the gallbladder makes it easier for gallbladder cancer to grow without being
detected. Gallbladder cancer can be cured only if it is found before it has spread,
when it can be removed by surgery. Primary gallbladder cancer starts in the
 13

innermost layer and spreads through the outer layers as it grows (Mayo Clinic,
2014).

About 9 out of 10 gallbladder cancers are adenocarcinomas. An

adenocarcinoma is a cancer that starts in the cells with gland-like properties that
line many internal and external surfaces of the body (including the inside the
digestive system). The gallbladder is attached to the under surface of the liver,
hence a cancer of the gallbladder has a tendency to spread to the liver at the
earliest. In gallbladder cancer, involvement of the liver is a part of the disease
process due to its closeness to the gallbladder.

The patient has a Gallbladder Cancer stage IVA. The cancer has already
spread to a main blood vessel of the liver or to 2 or more nearby organs or areas
other than the liver. Cancer has spread to nearby lymph nodes (Burke, 2015).

Source: International Cancer Prevention Institute http://www.cancerprevent.org/about-cancer.php

Carcinogenesis or tumor formation results from the multi-step process of

initiation, promotion and progression. Usually, when a carcinogen enters the cell,
the body is able to deactivate the carcinogen and eliminate it. In carcinogenesis,
when a carcinogen is introduced in the body, such as virus, chemical, or an
unknown agent, it becomes activated within the cells and binds it into the DNA
 14

(initiation stage). The cell will attempt to eliminate the carcinogen from the DNA
by cutting out the damaged portion thus allowing the cell to function as before.
The ability of the cell to reproduce new normal cells of its own kind depends on
the undamaged DNA. However, if the cell reproduces and divides into two cells
before the DNA is repaired, then the altered DNA structure is passed on to the
new daughter cells. It is this altered DNA passed on from cell generation that is
thought to be responsible for the growth of cancer cells (stage of promotion).
Transformed cell may remain dormant from a period of time until activated by
promoting agents. Diets are believed to be inhibitors or enhancers of
carcinogenesis. The formation or progression of the neoplasm from the initiated
cells characterized the promotion stage of carcinogenesis (Ruiz, Claudio &
Castro, 2004, pp. 12-2).

Prevalence

Statistics showed that around 189.1 persons per 100,000 Filipinos today
will eventually have cancer and one of every five Filipinos who live to age 74 will
get cancer (Ruiz, Claudio & Castro, 2004, pp. 12-1).

Gallbladder cancer is more common in women than in men. About 7 out

of every 10 cases diagnosed are in women. It has been estimated that more
than one in ten cases of gallbladder cancer in men and almost a fifth of cases in
women are due to being overweight. For men, the deadliness of gallbladder and
biliary tract cancer in Philippines peaks at age 80+. It kills men at the lowest rate
at age 25-29. Women are killed at the highest rate from gallbladder and biliary
tract cancer in Philippines at age 80+. It was least deadly to women at age 20-
24. At 25.7 deaths per 100,000 women in 2013, the peak mortality rate for
women was higher than that of men, which was 16.7 per 100,000 men (Global
Health Data Exchange, n.d.).

Etiological Factors

a. Modifiable Factors
Gallstones and inflammation Gallstones (cholelithiasis) and
inflammation of the gallbladder (cholecystitis) are the most
common risk factors for gallbladder cancer. Gallstones are hard
lumps, like little rocks, that form in the gallbladder. They are mostly
 15

cholesterol, mixed with other substances found in bile. About 8 out

of 10 people with gallbladder cancer (80%) have gallstones or an
inflamed gallbladder at diagnosis.

Primary sclerosing cholangitis (PSC) Primary sclerosing

cholangitis is a type of inflammation of the bile ducts. It is a rare
condition. People who have this condition have a slightly increased
risk of developing cancer of the gallbladder.

Smoking and chemicals Cigarettes and some industrial

chemicals contain nitrosamines. These are chemicals that can
damage DNA and increase the risk of developing cancer. There is
more about DNA damage and cancer in the how cells and tissues
grow section. People who smoke or work in the metal or rubber
industry are more likely to develop gallbladder cancer.

Pancreas and bile duct abnormalities Some abnormalities of

the pancreas and bile duct increase your risk of getting gallbladder
cancer. These include outgrowths along the bile duct (choledochal
cysts) and an abnormality of the join between the bile duct and the
pancreas. Choledochal cysts are there from birth in affected people.
They are sacs that connect to the bile duct and fill up with bile.
They grow slowly and can end up holding up to 2 litres of bile. The
cells that line the sacs can be abnormal and occasionally show
precancerous changes. Having this condition increases your risk of
getting gallbladder cancer in the future. Doctors call an abnormality
of the area where the bile duct joins with the pancreas an
anomalous pancreatobiliary duct junction. It means that pancreatic
juices and enzymes can go back up into the common bile duct.
These digestive juices irritate and inflame the bile duct wall. Over
time, this can weaken it.

Gallbladder polyps These small growths are not cancer. They

develop on the surface lining of the gallbladder. But some may
develop into cancer over a long period of time. The larger the polyp
the greater that risk that it will become cancerous.
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Obesity Being overweight causes changes in hormones in the

body, particularly for women. It could be this change in the bodys
hormone balance that increases the risk of gallbladder cancer.

Diabetes A number of studies show you may have an increased

risk of gallbladder cancer or cancer of the bile duct if you have
diabetes. This is only a very small increase in risk.

Infection Salmonella infection can increase the risk of

gallbladder cancer in people who have gallstones. A few small
studies show that Helicobacter pylori bacteria may also increase the
risk of gallbladder cancer.

b. Non Modifiable Factors

Age - As with most cancers, gallbladder cancer is more common in
older people than in younger people. It is more common in people
older than 70 than it is in younger people.

Family history of gallbladder cancer Studies show that

people with a first degree relative with gallbladder cancer are five
times more likely to develop gallbladder cancer than people who do
not have a relative with it. As gallbladder cancer is so rare, even if
the risk is increased five times, the risk is still very small.

Ethnicity The risk of developing gallbladder cancer is very

different for people living in different parts of the world, and for
different racial groups. This is likely to be due to factors affecting
these populations such as infection, gallstones, or inflammation
caused by abnormalities in the bile duct or pancreas. North India
has the highest rate of gallbladder cancer in the world (Cancer
Research UK).

Clinical manifestations

When symptoms do occur, they include the following:

Jaundice (yellowing of the skin and whites of the eyes)

Abdominal pain
Nausea and vomiting
 17

Bloating
A lump in the abdomen
Fever

Jaundice, anorexia, and weight loss often indicate more advanced disease
(American Society of Clinical Oncology (ASCO), 2015).

The following are warning signs and symptoms (CAUTION US):

C Change in bowel or bladder habits;

A A sore that does not heal;

U Unusual bleeding or discharge;

T Thickening or lump in breast or elsewhere;

I Indigestion or difficulty in swallowing

O Obvious change in wart or mole;

N Nagging cough or hoarseness

U Unexplained anemia; and

S Sudden unexplained weight loss (Ruiz, Claudio & Castro, 2004, pp.
12-3).

Pathophysiology

Gallbladder cancer arises in the setting of chronic inflammation. In the

vast majority of patients (>75%), the source of this chronic inflammation is
cholesterol gallstones. The presence of gallstones as seen from the patients CT
scan results increases the risk of gallbladder cancer ((Burke, 2015).

However, chronic gallbladder inflammation is likely only part of the cause

of the malignant transformation seen in gallbladder cancer. Obesity may
contribute to gallbladder cancer through its association with gallstones, its
association with increased endogenous estrogens, or through the ability of fat
cells to secrete a large number of inflammatory mediators (Burke, 2015).

Scientist theorized that environmental or lifestyle factors play an important

role in the development of cancer. Data from epidemiological and laboratory
 18

studies revealed that 10-7% or an average of 35% of all cancer deaths may be
linked to diet. Unhealthy eating habits that comprise mainly of red meats, high
fat foods (especially saturated fats), and salt- cured foods are associated with
increased cancer risk. Susceptibility to cancer escalates when this diet is poor in
protective foods such as fruits and vegetables that are high in phytochemicals,
antioxidant nutrients, and dietary fiber (Ruiz, Claudio & Castro, 2004, pp. 12-1).

Graphic shows typical appearance for gallbladder carcinoma with hepatic invasion .

B. Definition of Lymph Node Metastasis

Lymph nodes are small, bean-shaped organs which produce and store
blood cells that help fight disease and infection. Also known as lymph glands,
lymph nodes remove cell waste and fluids from lymph (lymphatic fluid), and
store lymphocytes (white blood cells). Lymph nodes are part of the lymphatic
 19

system and are located throughout the body, including the neck, armpits,
abdomen and groin.

Source: Cancer Research UK

The patient has been diagnosed with lymph node metastasis after the
biopsy. (Canadian Cancer Society, n.d.). There are lymph glands around the
gallbladder. The lymph nodes are often the first place that cancer cells spread to
when they break away from a tumour. (Chhabra, n.d.).
 20

Source: Cancer Research UK

Source: The Lancet Oncology http://dx.doi.org/10.1016/S1470-2045(03)01021-0

Prevalence

Only about 1 out of 5 gallbladder cancers is found in the early stages,

where the cancer has not yet spread beyond the gallbladder (Chhabra, n.d.).
 21

At diagnosis, the gallbladder is often destroyed by the cancer, and

approximately 50% of patients have regional lymph node metastases (Burke,
2015).

Etiological Factors

a. Modifiable Factors
Cancer (Primary) - Pain or swelling in the area of the lymph
nodes is a common symptom of cancer that starts in the lymphatic
system, such as non-Hodgkin lymphoma and Hodgkin lymphoma.
Cancer that starts in another part of the body and spreads to the
lymph nodes is called a metastasis. Even when cancer spreads to
the lymph nodes, it is still named after the area of the body where
it started.

Infections - Viral infections (from [HIV], Hepa-B or Hepa-C virus

and Epstein-Barr virus) or bacterial infections (from H. pylori)
increase the chances of B or T cells abnormalities.

b. Non Modifiable Factors

Age - Older people have greater chances of acquiring lymph node
metastases.

Clinical Manifestations

The most common symptom is enlarged or swollen lymph nodes. Other

symptoms might include breathlessness or backache, for example if there are
enlarged lymph nodes deep inside the chest or abdomen. Sometimes there are
no symptoms and the secondary cancer might be picked up by a routine scan
(Macmillan Cancer Support, n.d.).

Pathophysiology

When cancer cells break away from a tumor, they can travel to other
areas of the body through either the bloodstream or the lymph system. Cancer
cells can travel through the bloodstream to reach distant organs. If they travel
through the lymph system, the cancer cells may end up in lymph nodes. Either
 22

way, most of the escaped cancer cells die or are killed before they can start
growing somewhere else. But one or two might settle in a new area, begin to
grow, and form new tumors. This spread of cancer to a new part of the body is
called metastasis. In order for cancer cells to spread to new parts of the body,
they have to go through several changes. They first have to become able to
break away from the original tumor and then attach to the outside wall of a
lymph vessel or blood vessel. Then they must move through the vessel wall to
flow with the blood or lymph to a new organ or lymph node. When cancer grows
inside lymph nodes, it usually affects the lymph nodes near the tumor itself. The
CT scan results showed that the lymph node metastasis is very near to the
primary site of the cancer. These are the nodes that have been doing most of
the work to filter out or kill the cancer cells (American Cancer Society, 2015).

Source: http://www.ladycarehealth.com/symptoms-of-cancer-in-the-lymph-nodes/

C. Definition of Liver Metastasis

Complications of Gall Bladder Cancer from the Diseases include abdominal

mass, liver metastases and cholestatic jaundice (Right Diagnosis, n.d.).

The patient has been found out to have a liver metastasis. It is a

cancerous tumor that has spread to the liver from a cancer that started in
another place in the body. It is also called secondary liver cancer. Primary liver
 23

cancer originates in the liver and most commonly affects individuals who have
risk factors such as hepatitis or cirrhosis. Most of the time, cancer in the liver is
secondary, or metastatic. The cancer cells found in a metastatic liver tumor are
not liver cells. They are the cells from the part of the body where the primary
cancer began. Other names for this condition include liver metastases or stage IV
or advanced cancer. There may be no symptoms in the early stages of liver
metastasis. In later stages, cancer can cause the liver to swell or obstruct the
normal flow of blood and bile (Rice n.d.).

We also found out that the most common malignancies associated with
the development of ascites include cancers of the colon/rectum, ovary, breast,
lung, pancreas, liver, and lymphoma. Approximately 50% of patients with
malignant ascites are related to liver metastases (Kristler, 2015).

Prevalence

The liver is the second most common site of metastasis (spread of

cancer), after the lymph nodes. Liver metastases have been found in 30-70% of
patients who are dying of cancer. In the Western world, metastasis to the liver is
more common than primary liver cancer. Liver metastases are most commonly
seen in patients aged 50-70 (Nawaz & Mcdonald, 2013).

The three most deadly cancers in Philippines during 2013 were "tracheal,
bronchus and lung cancer", liver cancer, and colon and rectum cancer
respectively. Though this was the trend in Philippines overall, different
demographic groups are affected differently and is likely much different between
men and women at different ages in life (Global Health Data Exchange, n.d.).

According to the Department of Health (DOH), Liver cancer is the 3rd

leading sites for both sexes. It rank 2nd among males and 9th among females.
In 1998, an estimated 5,249 new cases, 3,906 cases in males and 1,343 cases in
females, and about 4,403 deaths are expected to occur every year. The
incidence in males is practically 2 that of females. Incidence increases at age
40.
 24

Etiological Factors

Cancer (primary) The risk for cancer spreading to the liver

depends on the location (site) of the original cancer. A liver
metastasis may be present when the original (primary) cancer is
diagnosed. Or it may occur months or years after the primary
tumor is removed. It commonly spreads to the liver because it
provides a suitable environment for the growth of tumour cells.
Gaps in the lining of liver blood vessels allow tumour cells to get
close to the functional cells of the liver (hepatocytes). The liver also
has a rich blood supply, supplying tumour cells with the nutrients
and oxygen they require to grow.

Clinical manifestations

There may be no symptoms in the early stages of liver metastasis. In later

stages, cancer can cause the liver to swell or obstruct the normal flow of blood
and bile. When this happens, the following symptoms may occur:

loss of appetite
weight loss
dark-colored urine
abdominal swelling or bloating
jaundice, a yellowing of the skin or the whites of the eyes
pain in the right shoulder
pain in the upper right abdomen
nausea
vomiting
confusion
sweats and fever
enlarged liver

Patients with ascites can complain of increasing abdominal girth,

generalized abdominal pain and shortness of breath (Kristler, 2015).
 25

Pathophysiology

The risk that cancer will spread, or metastasize, to the liver depends on
the location of the original cancer. The patients gallbladder cancer is most likely
to spread to the liver. Liver metastases are foreign tissue growing within the
liver. They either grow expansively (as a mass) or infiltratively (spreading
through surrounding tissues). Physically, they grow and compress the
surrounding liver tissue. A connective tissue rim is usually formed around the
metastasis, and surrounding tissue is wasted away. Large metastases may even
compress branches of the portal vein. Because they grow so quickly, liver
metastases, like primary tumours, may outgrow their blood supply, resulting in
death of the center of the lesion (Nawaz & Mcdonald, 2013).

There are six steps in the metastasis process. Not all cancers follow this
process, but most do.

Local invasion: Cancer cells move from the primary site into nearby
normal tissue.

Intravasation: Cancer cells move through the walls of nearby lymph

vessels and blood vessels.

Circulation: Cancer cells migrate through the lymphatic system and the
bloodstream to other parts of the body.

Arrest and extravasation: Cancer cells stop moving when they reach a
distant location. They then move through the capillary (small blood vessel)
walls and invade nearby tissue.

Proliferation: Cancer cells grow at the distant location and create small
tumors called micrometastases.

Angiogenesis: Micrometastases stimulate the creation of new blood

vessels, which supply the nutrients and oxygen needed for tumor growth
(Rice, n.d.).
 26

Source: http://library.med.utah.edu/WebPath/LIVEHTML/LIVER002.html

NORMAL LIVER

Source: https://radiopaedia.org/articles/hepatic-metastases-1

Liver Metastasis

D. Hypertensive Cardiovascular Disease

High blood pressure is the major contributor to hypertensive

cardiovascular problem. When blood pressure increases, it places pressure on
blood vessels. This causes the heart to have to pump harder, which overtime
 27

affects the heart muscle causing it to enlarge. High blood pressure can also
cause stroke and heart problem due to the increased amount of oxygen that is
needed by the heart. It also contributes to blood vessel walls thickening, which
can worsen atherosclerosis, increasing the risks of stroke and heart attacks.
When left untreated hypertensive cardiovascular problem can cause angina,
heart attack, stroke, heart failure, arrhythmias and sudden death (Forte and
Forte, 2017).

Prevalence

According to the Department of Health (DOH), cardiovascular disease

(CVD) is one of the top killers in the Philippines, causing more than half of all
deaths annually. Hypertension and diseases of the heart are among the ten
leading causes of illnesses each year. These diseases are collectively known as
Lifestyle Related Non-communicable diseases (NCDs), as defined in the National
Objectives for health, particularly because these diseases have common risk
factors which are to large extent related to unhealthy lifestyle.

In the Philippines, about 30 percent of all the deaths are caused by heart
and vascular disease and one in every four Filipino adults (25.7 percent) has
hypertension, according to Philippine Society of Hypertension.

In the elderly population, as many as 68% of heart failure cases are

attributed to hypertension. Community-based studies have demonstrated that
hypertension may contribute to the development of heart failure in as many as
50-60% of patients. In patients with hypertension, the risk of heart failure is
increased by 2-fold in men and by 3-fold in women (Riaz and Ali, 2014).

Etiological Factors

a. Modifiable Factors
Overweight or obese- The more the patient gain weigh the more
blood is needed to supply of oxygen and nutrients to your tissues.
As the volume of blood circulated through the blood vessels
increases, so does the pressure on the artery walls.

Not being physically active- People who are inactive tend to

have higher heart rates. The higher the heart rate, the harder the
 28

heart must work with each contraction and the stronger the force
on the arteries. Lack of physical activity also increases the risk of
being overweight.

Drinking too much alcohol- Over time, heavy drinking can

damage the heart. Having more than two drinks a day for men and
more than one drink a day for women may affect your blood
pressure.
.
Stress- High levels of stress can lead to a temporary increase in
blood pressure.

Certain chronic conditions- Certain chronic conditions also may

increase your risk of high blood pressure, such as kidney disease,
diabetes and sleep apnea.

Using tobacco- Not only does smoking or chewing tobacco

immediately raise your blood pressure temporarily, but the
chemicals in tobacco can damage the lining of your artery walls.
This can cause your arteries to narrow, increasing the blood
pressure. Secondhand smoke also can increase your blood
pressure.

Too much salt (sodium) in the diet- Too much sodium in the
diet can cause the body to retain fluid, which increases blood
pressure.

Too little potassium in the diet- Potassium helps balance the

amount of sodium in your cells. If the body don't get enough
potassium from the diet or retain enough potassium, you may
accumulate too much sodium in your blood.

Too little vitamin D in the diet- Vitamin D may affect an

enzyme produced by your kidneys that affects your blood pressure.
(Mayo Clinic, n.d.)
 29

b. Non Modifiable Factors

Age- The risk of high blood pressure increases as a person age.

Through early middle age, or about age 45, high blood pressure is
more common in men. Women are more likely to develop high
blood pressure after age 65.

Race- High blood pressure is particularly common among blacks,

often developing at an earlier age than it does in whites. Serious
complications, such as stroke, heart attack and kidney failure, also
are more common in blacks.

Family history- High blood pressure tends to run in families.

(Mayo Clinic, n.d.)

Clinical Manifestations

Hypertension is defined as a systolic blood pressure (SBP) of 140 mm Hg

or more, or a diastolic blood pressure (DBP) of 90 mm Hg or more. There may be
certain symptoms to look out for:

Fatigue or confusion
Vision problems
Chest pain
Difficulty breathing
Irregular heartbeat
Blood in the urine
Pounding in your chest, neck, or ears
Severe headache (Beckerman, 2016).

Pathophysiology

Hypertension (high blood pressure) is a disease of vascular regulation

resulting from malfunction of arterial pressure control mechanisms (central
nervous system, rennin-angiotensinaldosterone system, extracellular fluid
volume) the cause is unknown, and there is no cure. The basic explanation is
that blood pressure is elevated when there is increased cardiac output plus
increased peripheral vascular resistance. One of the most serious health
problems related to untreated high blood pressure is atherosclerosis, or plaque
 30

build-up in the arteries. When those blockages occur in the arteries that supply
blood to the heart muscle, the end result is called coronary artery disease
(Klodas, 2016).

Classification of BP for adults aged

18 years or older has been as follows:

Normal: Systolic lower than 120 mm Hg,

diastolic lower than 80 mm Hg

Prehypertension: Systolic 120-139 mm

Hg, diastolic 80-89 mm Hg

Stage 1: Systolic 140-159 mm Hg,

diastolic 90-99 mm Hg

Stage 2: Systolic 160 mm Hg or

greater, diastolic 100 mm Hg or greater

Source: Blood Pressure UK

 31

II. Medical Management

She was monitored accordingly and medications were adjusted and some
are added as prescribed. She also had undergone chemotherapy.

Medicine (Brand Dose and

Rationale
Name)/Strength Directions
Clopidogrel 1 tab once a For the reduction of
(Platexan) 75 mg/tab day atherosclerotic events (myocardial
infarction, stroke, and vascular
death) in patients with
atherosclerosis documented by
recent stroke, recent myocardial
infarction, or established
peripheral arterial disease.
Amlodipine (Amvasc) 1 and a half Use for treating high blood
5mg/tab tab once a pressure and angina (chest pain).
day It may be used alone or with
other medicines. Amlodipine is a
calcium channel blocker. It works
by widening blood vessels to
reduce chest pain and high blood
pressure. It also widens arteries in
the heart, which increases blood
flow to the heart.
Febuxostat (Urinorm) 1 tab once a It is used to treat hyperuricemia
40mg/tab day (high uric acid in the blood) in
patients with gout. Febuxostat is a
xanthine oxidase inhibitor. It
works by causing less uric acid to
be produced by the body.
FeSO4 + FA (lberet 1 tab once a Ferrous sulfate and folic acid is
Activ) day before used to treat iron deficiency
breakfast anemia (a lack of red blood cells
caused by having too little iron in
the body).
Ferrous sulfate is a type of iron.
You normally get iron from the
foods you eat. In your body, iron
becomes a part of your
hemoglobin and myoglobin.
Hemoglobin carries oxygen
through your blood to tissues and
 32

organs. Myoglobin helps your

muscle cells store oxygen.
Folic acid helps your body
produce and maintain new cells,
and also helps prevent changes to
DNA that may lead to cancer.
CaCO3 + Vit b 1 tab once a Treating or preventing calcium
(Caltrate plus) day deficiency. Calcium carbonate
with vitamin d is a dietary
supplement. It works by providing
extra calcium to the body.
Omega 3 fatty acid 1 tab once a Treating patients who have very
day high triglyceride levels. It is used
in addition to a low-fat diet.

Omega-3 fatty acids is a lipid-

regulating agent. Exactly how it
works is not known. It may
decrease the production of
triglycerides in the liver.
Centrum Silver 1 tab once a Treating or preventing low levels
day of vitamins and minerals in the
body.
Ondansetron 1 tab twice a Blocks the actions of chemicals in
8mg/tab day the body that can trigger nausea
and vomiting. It is used to
prevent nausea and vomiting that
may be caused by surgery, cancer
chemotherapy, or radiation
treatment.
Hyoscine 1 tab three It is used to relieve stomach and
Butylbromide time a day bowel cramps which cause pain
(Buscopan) 10mg/tab and discomfort associated with
your digestive tract, and in
Irritable Bowel Syndrome.
Omeprazole 1 tab once a Belongs to group of drugs called
40mg/tab day proton pump inhibitors. It
decreases the amount of acid
produced in the stomach.
Omeprazole is used to treat
symptoms of gastroesophageal
reflux disease (GERD) and other
conditions caused by excess
stomach acid. It is also used to
 33

promote healing of erosive

esophagitis (damage to your
esophagus caused by stomach
acid). It may also be given
together with antibiotics to treat
gastric ulcer caused by infection
with helicobacter pylori (H.
pylori).
Rebamipide 1 tab three An amino acid derivative of 2-
(Mucosta) 100mg/tab times a day (1H)-quinolinone, is used for
mucosal protection, healing of
gastroduodenal ulcers, and
treatment of gastritis. It works by
enhancing mucosal defense,
scavenging free radicals, and
temporarily activating genes
encoding cyclooxygenase-2
Etoricoxibe (Arcoxia) 1 tab once a It helps to reduce the pain and
120mg/tab day swelling (inflammation) in the
joints and muscles of people 16
years of age and older with
osteoarthritis, rheumatoid
arthritis, ankylosing spondylitis
and gout.
Nystatin bottle Swallow 1ml Nystatin is an antifungal
4x/day for medication that fights infections
mouth caused by fungus. When taken by
mouth is used to treat yeast
infections in the mouth or
stomach
Senekot 1 tab once a Senokot is a stimulant laxative. It
day if with works by irritating bowel tissues,
constipation resulting in bowel movements.

Metoclopramide 1 tab every 8 Metoclopramide increases muscle

10mg/tab hours contractions in the upper digestive
tract. This speeds up the rate at
which the stomach empties into
the intestines. It is used short-
term to treat heartburn caused by
gastroesophageal reflux in people
who have used other medications
without relief of symptoms.
 34

Ciprofloxacin 1 and a half It is an antibiotic that fights

500mg/tab tab twice a bacteria in the body. Ciprofloxacin
day is used to treat different types of
bacterial infections. It is also used
to treat people who have been
exposed to anthrax or certain
types of plague.
Spironolactone 1 tab twice a It is a potassium-sparing diuretic
(Aldactone) day (water pill) that prevents your
25mg/tab body from absorbing too much
salt and keeps your potassium
levels from getting too low. It is
used to diagnose or treat a
condition in which you have too
much aldosterone in your body.
Aldosterone is a hormone
produced by your adrenal glands
to help regulate the salt and
water balance in your body.

Spironolactone also treats fluid

retention (edema) in people with
congestive heart failure, cirrhosis
of the liver, or a kidney disorder
called nephrotic syndrome. This
medication is also used to treat or
prevent hypokalemia (low
potassium levels in the blood).
Ademetionine 1 tab twice a Effective in relieving the pain of
(Transmetil) day osteoarthritis.
500mg/tab

Indapamide (Natrilix) 1 tab once a Generally used in the treatment of

1.5mg day hypertension, as well as
decompensated heart failure.

Source: www.drugs.com
 35

III. Nutritional Screening

The patient did not lose weight within the last two (2) months. There is
no change in her dietary intake. No complains of nausea, vomiting or diarrhea.
The patient is recovering from the surgery which causes her unable to stand.
There are no signs of muscle wasting. The patient has a small amount of ascites
as seen in her laboratory results.

Total SGA grade = 1

 36

Patients BMI is 29.8 (overweight) = 1

Albumin is 2.3 = 1
Total Lymphocytes Count (TLC) = 0

To compute TLC,

WBC = 9.5

% lymphocytes = 27

9, 500 (. 27) = 2, 565

The total score of 3 indicates that the patient is high risk of malnutrition.
The overall nutritional status of the patient is "severe malnutrition."

IV. Diet Order/Prescription

Diet as Tolerated, Low salt, 4g NaCl and low fat

A. Computation of Desirable Body Weight (DBW)

Height: 49

NDAP Method
Female
5 ft. = 106
4

= 106 8
98
=
2.2
= . .
 37

B. Computation of Body Mass Index (BMI)

= 2
= 4 12
= 48 + 9
57
=
39.37
= 1.4478 (1.4478)
= 2.0961 2
62.4
=
2.0961
= .

C. Computation of Total Energy Requirement (TER)

=
= 44.55 27.5
= 1225.125
Distribution:
Cho= 1200 x .60 = 720 4 = 180g
Chon= 1200 x .15 = 180 4 = 45g
Fat= 1200 x .25 = 300 9 = 35g

D. Meal/Diet Plan

Food Lists Exchanges CHO CHON FAT Energy/Kcal

Vegetable 3 9 3 - 48
Fruit 3 30 - - 120
Sugar 1 5 - - 84
Rice 6 138 12 - 600
Meat 4 - 32 4 164
(Low Fat)
Fat 5 - - 25 225
Total 182g 47g 34g 1,241 kcal
 38

Food Lists Breakfast AM Lunch PM Dinner

Snacks Snacks
Vegetable 2 1
Fruit 1 1 1
Sugar 1
Rice 1 1 2 1 1
Meat 1 2 1
Fat 2 2 1

E. Sample Menu
Sample Menu

BREAKFAST
Fresh fruit or dessert Apple, 1 piece
Meat, Egg or substitute Baked fish, 1 piece
Rice, cereal or bread, Rice, cup
Hot beverage Coffee, 1 cup

Lunch
Soup From Utan Bisaya
Meat, fish, poultry, or substitute Fried Fish, 1
Vegetable Utan Bisaya, 1 cup
Rice or substitute Brown Rice, 1 cup
Fruit or dessert Banana, 1 piece

Supper
Soup Soup from Pork
Nilaga, 1 cup
Meat, fish, poultry, or substitute Pork Nilaga,
1 matchbox size
Vegetable Chopsuey, cup
Rice or substitute Brown rice, cup
Fruit or dessert Grapes, 10 pieces

Snacks
AM -
PM Sweet Potato,
cup
 39

V. Principle and Rationale of Diet

Excessive alcohol consumption should be avoided as well as cigarette smoking.

Maintaining proper weight is also important to reduce the risks of developing
hypertensive cardiovascular problem.

The AHA/ASA recommends a diet that is low in sodium, is high in potassium, and
promotes the consumption of fruits, vegetables, and low-fat dairy products for
reducing BP and lowering the risk of stroke. Other recommendations include
increasing physical activity (30 minutes or more of moderate intensity activity on
a daily basis) and losing weight (for overweight and obese persons).

VI. Patients Progress

On March 2, 2017, the patient was seen and examined. No febrile

episodes. No dizziness and shortness of breath. No chest pain. No abdominal
discomfort. No dysuria. She was also checked for probable ascites.

The patient is awake, alert but in respiratory distress.

Skin: soft, warm to touch, good mobility and turgor.

Heent: anteric sclerae, slightly pale palbebral conjunctivae

Neck: (-) lymphadenopathy

C/L: equal chest expansion, clear breath sounds

CVS: distinct heart sounds, (-) murmur, regular rate and rhythm

ABD: soft, normoactive bowel sounds, (-) tenderness

EXT: strong peripheral pulses, CRT< 2 SEC

Catheter was removed. Patients blood pressure 100/80, other parameters

normal. Other medications started. Patients condition improved and as seen fit
to discharge. Take home medications were issued and instructions are really
good.
 40

VII. Prognosis

Prognosis for gallbladder cancer is generally found to be poor for patients

diagnosed with gallbladder cancer in the final stage. A marked improvement has
been found in the overall 5-year survival rates by the advent of gallbladder
cancer staging. The fact that gallbladder cancer often remains undetected as
well as inaccurately detected is an unfortunate fact.

How well the patients do depend on the location of the original cancer
and how much it has spread to the liver or anywhere else. In rare cases, surgery
to remove the liver tumors leads to a cure. This is usually only possible when
there are a limited number of tumors in the liver.

In most cases, cancer that has spread to the liver cannot be cured. People
whose cancer has spread to the liver often die of their disease. However,
treatments may help shrink tumors, improve life expectancy, and relieve
symptoms.

Prognostic factors include:

success of any surgical removal that may have been performed

cancerous state of lymph nodes surrounding the portal veins
extent of disease outside the liver
number of metastases

Most individuals diagnosed with hypertension will have increasing blood

pressure (BP) as they age. Untreated hypertension is notorious for increasing the
risk of mortality and is often described as a silent killer. Mild to moderate
hypertension, if left untreated, may be associated with a risk of atherosclerotic
disease in 30% of people and organ damage in 50% of people within 8-10 years
after onset (Alexander and Maron, 2017).

VIII. Conclusion and Recommendations

A person afflicted with cancer may experience nutritional deterioration. Short

term goals include providing optimal nutritional support by treating symptoms of
the patient. It is also important for the patient to maintain a desirable body
 41

weight, correct vitamin and mineral abnormalities and fluid/electrolyte

imbalances. Long term goals should be based on long term medical goals.
Search!!!!!!!!

It is important to educate patients about the nature of their disease and the
risks associated with untreated hypertension. In addition, dietary modifications
and the importance of regular exercise, taking medications regularly, weight loss,
and avoiding medications and foods that can potentially elevate blood pressure
should be emphasized.

The patient has an irritable bowel syndrome. The patient may have a high-
fiber diet (25-30 grams of dietary fiber or an additional of 2-3 servings of foods
rich in dietary fiber). A balanced diet containing different kinds of fiber can help
regulate the bowels, aid in the prevention of heart disease and protect against
cancer of the colon and rectum. Foods that contain fiber also tend to contain
other cancer-fighting nutrients, such as antioxidant vitamins A, C, E and the
mineral selenium.

The patient must increase fluid intake. uti, hypertension rt sodium.

Search!!!!

High pottasium search!!!!!!! 146 NDAP

Exercise as tolerated.

Problems in bowel

Nausea in chemo

Maintain or adopt a healthy lifestyle. If your blood pressure goal isn't reached
in about a month, talk to your doctor about taking one or more medications.

IX. Glossary and Abbreviation of Terms

Ascites- gastroenterological term for an accumulation of fluid in the

peritoneal cavity that exceeds 25 mL.
 42

Atherosclerosis- hardening and narrowing of the arteries -- silently and

slowly blocks arteries, putting blood flow at risk. Its the usual cause of heart
attacks, strokes, and peripheral vascular disease -- what together are called
cardiovascular disease.

Biopsy- is the removal of cells or tissues so they can be examined under a

microscope.

Cholecystectomy- surgical removal of the gallbladder.

Cholelithiasis- presence of gallstones in the gallbladder.

Hemoglobin - transports oxygen from our lungs to the cells in our body.
The hemoglobin molecule contains iron, an essential mineral found in our
diet.

Sclerosis- an induration or hardening, especially of a part from

inflammation, or in disease of the interstitial substance.

Spondylosis- degenerative changes in the disc called degenerative disc

disease, in which spinal discs begin to thin, lose moisture, and break down.

SGOT- serum glutamic-oxaloacetic transaminase

RDW- Red Cell Distribution

TLC Total Lymphocytes Count

X. Bibliography and References

About the Gallbaldder. (2014, June 4). Cancer Research UK. Retrieved March
17, 2017, from http://www.cancerresearchuk.org/about-
cancer/type/gallbladder-cancer/about/about-the-gallbladder

Alexander, M.R. & Maron, D.J. (2017). Hypertension. Medscape. Retrieved

March 28, 2017, from http://emedicine.medscape.com/article/241381-
overview#a6
 43

Beckerman, J. (2016). Symptoms of High Blood Pressure. WebMD. Retrieved

April 4, 2017, from http://www.webmd.com/hypertension-high-blood-
pressure/guide/hypertension-symptoms-high-blood-pressure

Burke, M.D. (2015). Gallbladder Cancer. Medscape. Retrieved March 17,

2017, from http://emedicine.medscape.com/article/278641-overview

Complications of Gallbladder Cancer.(n.d.). Right Diagnosis. Retrieved March

17, 2017 from,
http://www.rightdiagnosis.com/g/gall_bladder_cancer/complic.htm

Diza F. (n.d.). Cardiovascular Disease. Department of Health. Retrieved March

28, 2017, from http://www.doh.gov.ph/cardiovascular-disease

Forte, E. & Forte, V. (2017). What is Hypertensive Cardio Vascular Problem?

Mediterranean Book. Retrieved March 28, 2017, from
http://www.mediterraneanbook.com/2011/02/09/hypertensive-cardio-
vascular-disease/

Gallbladder and Biliary Tract Cancer in Philippines. (n.d.). Global Health Data
Exchange. Retrieved March 29, 2017, from http://global-disease-
burden.healthgrove.com/l/35906/Gallbladder-and-Biliary-Tract-Cancer-in-
Philippines#Overview&s=3D2kvJ

Gallbladder. (2014). Healthline. Retrieved March 17, 2017, from

http://www.healthline.com/human-body-maps/gallbladder

Gallbladder Cancer. (2014). Mayo Clinic. Retrieved March 17, 2017, from
http://www.mayoclinic.org/diseases-conditions/gallbladder-
cancer/basics/definition/con-20023909

Gallbladder Cancer: Symptoms and Signs. (2015). Cancer.Net. Retrieved

March 17, 2017, from http://www.cancer.net/cancer-types/gallbladder-
cancer/symptoms-and-signs

Gallbladder Location, Anatomy, Parts, Function, Pictures. (n.d.). Healthhype.

Retrieved March 17, 2017, from http://www.healthhype.com/gallbladder-
location-anatomy-parts-function-pictures.html

High blood Pressure (hypertension). (n.d.) Mayo Clinic. Retrieved March 28,
2017, from http://www.mayoclinic.org/diseases-conditions/high-blood-
pressure/basics/risk-factors/con-20019580
 44

Klodas, E. (2016). High Blood Pressure and Atherosclerosis. WebMD.

Retrieved March 28, 2017, from http://www.webmd.com/hypertension-high-
blood-pressure/guide/atherosclerosis#2

Kristler, C.A. (2015). Malignant Ascites: Diagnosis and Management. Cancer

Therapy Advisor. Retrieved April 4, 2017, from
http://www.cancertherapyadvisor.com/general-oncology/malignant-ascites-
cancer-diagnosis-management/article/411203/

Lapea, C.G. (2012). 30% of PHL deaths due to heart, vascular disease;
25.7% of Pinoys hypertensive. GMA Network. Retrieved March 28, 2017, from
http://www.gmanetwork.com/news/story/269935/lifestyle/healthandwellness/
30-of-phl-deaths-due-to-heart-vascular-disease-25-7-of-pinoys-hypertensive

Liver Cancer. (n.d.). Department of Health. Retrieved March 29, 2017, from
http://www.doh.gov.ph/node/362

Liver Metastasis. (n.d.). Canadian Cancer Society. Retrieved March 17, 2017,
from http://www.cancer.ca/en/cancer-information/cancer-type/metastatic-
cancer/liver-metastases/?region=on

Lymph Node and cancer. (2015). American Cancer Society. Retrieved March
17, 2015, from https://www.cancer.org/cancer/cancer-basics/lymph-nodes-
and-cancer.html

Nawaz, K. A. & Macdonald, S. (2013). Liver, Metastases. eMedicine. Retrieved

March 17, 2017, from http://www.emedicine.com/radio/topic394.htm

Pathophysiology of Hypertension. (2008). Nursing Crib. Retrieved March 28,

2017, from http://nursingcrib.com/pathophysiology/pathophysiology-of-
hypertension/

Riaz, K. & Ali, Y.S. (2014). Hypertensive Heart Disease. Medscape. Retrieved
March 28, 2017, from http://emedicine.medscape.com/article/162449-
overview

Rice, S.C. (n.d.). Liver Metastasis. Healthline. Retrieved March 17, 2017, from
http://www.healthline.com/health/liver-metastases

Ruiz, A. (n.d.). Gallbladder and Biliary Tract. Merck Manual. Retrieved March
17, 2017, from http://www.merckmanuals.com/home/digestive-
disorders/biology-of-the-digestive-system/gallbladder-and-biliary-tract
 45

Ruiz, A.J., Claudio, V.S. & Castro, E.E. (2004). Medical Nutrition Therapy for
Filipinos. Manila, Philippines: Merriam & Webster Bookstore, Inc.

Secondary Cancer in the Lymph Node. (n.d.). Macmillan Cancer Support.

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