DIET PADA

KOLELITHIASIS &
KOLESISTITIS
Outline
 Anatomi & Fisiologi
 Metabolisme bilirubin
 Definisi kolelithiasis & kolesistitis
 Etiologi & patogenesis kolelithiasis & kolesistitis
 Manifestasi klinik & komplikasi
 Penatalaksanaan klinik
 Jenis, tujuan, dan syarat diet
 Pemilihan bahan
Anatomi & Fisiologi
Kandung empedu
 Membran berotot berbentuk buah pir
 Fundus, badan & leher
 Dinding:
 Lapis serosa peritoneal
 Otot polos
 Mukosa
Getah empedu
 Cairan alkalis, hasil sekresi sel hati.
 Sehari disekresi ½ -1 liter
 Susunan getah empedu:
 Garam empedu (2/3 berat bersih empedu)
 Pigmen empedu, terutama bilirubin
 Kolesterol, lesitin, garam, dan air
Garam empedu
 Kombinasi dari: asam dan kolesterol seperti asam
kolat, asam amino tamin dan glisin
 Fungsi garam empedu:
 Mengaktifkan lipase pankreas
 Merangsang sekresi pankreas
 Membantu absorpsi lemak dengan membentuk misel
Pigmen empedu
 Terutama bilirubin
 Bilirubin merupakan hasil pemecahan Hb dalam
limpa dan sumsum tulang
 Pigmen ini memberikan warna pada feses
Kolelithiasis
 Terbentuknya batu empedu (lithos), yang bila
masuk ke dalam duktus koledokhus (saluran
empedu):
 Sumbatan  penyaluran empedu ke duodenum
terhambat
 Gangguan pencernaan dan absorpsi lemak
 3 jenis batu
 Batu kolesterol kolesterol, bilirubin, garam kalsium
 Batu pigmen  polimer bilirubin dan garam kalsium
 Batu campuran
Faktor risiko terjadinya
kolelithiasis
Risiko terjadinya batu kolesterol:
 Obesitas

 Gender wanita

 Usia tua

 Kehamilan  multiple pregnancy

 Diabetes mellitus

 Faktor etnik

 Obat-obatan (obat penurun lipid, kontrasepsi oral, estrogen)

 Gangguan saluran pencernaan (inflammatory bowel disease)

 Riwayat keluarga
 Bakteri  infeksi kronik ringan  perubahan pada
mukosa kandung empedu  mempengaruhi
kemampuan absorpsi  kelebihan absorpsi air dan
asam empedu  presipitasi kolesterol  terbentuk
batu
 Diet tinggi lemak dalam jangka waktu lama
Faktor risiko terjadinya
kolelithiasis
Risiko terjadinya batu pigmen:
 Usia

 Berat badan kurang

 Asupan lemak dan protein kurang

 Sirosis hati

 Berhubungan dengan hemolisis kronik  anemia sickle cell,

thalassemia
 Infeksi saluran empedu

 Alkoholisme

 Parenteral nutrition jangka panjang  biliary stasis

Pembentukan kolelithiasis
 The etiology of the formation of gallstones has been
under investigation for years. In the process of bile
salts secretion, approximately one-tenth as much free
cholesterol is also secreted into the bile.
 Cholesterol is insoluble in water, but the bile salts and
lecithin keep it in solution in the form of micelles.
Because bile salts and lecithin are concentrated with
cholesterol in the gallbladder, cholesterol remains in
solution. In abnormal conditions, however,
cholesterol precipitates as gallstones.
Pembentukan kolelithiasis
 Inflammation of the gallbladder epithelium often
results from low-grade chronic infection;
 this changes the absorptive characteristics of the
gallbladder mucosa, sometimes allowing excessive
absorption of water, bile salts, or other substances
that are necessary to keep the cholesterol in
solution.
Pembentukan kolelithiasis (lanj.)
 As a result, cholesterol begins to precipitate,
usually forming many small crystals of cholesterol
on the surface of the inflamed mucosa. These, in
turn, act as nidi (points of origin) for further
precipitation of cholesterol, and the crystals grow
larger and larger.
 Occasionally, tremendous numbers of sand-like
stones develop, but much more frequently they
coalesce to form a few large gallstones, or even a
single stone that fills the entire gallbladder.
Pembentukan kolelithiasis
Obstruksi Bilier
 When a gallstone passes from the gallbladder
through the cystic duct and lodges in the common
bile duct, or in the head of the pancreas, this
condition is called choledocholithiasis.
 The bile is no longer carried to the duodenum and
the excretion of bile pigments into the urine gives
the urine a dark color. The feces are no longer
colored by bile pigments and hence become grayish
(clay colored).
Obstruksi bilier
 Additionally, maldigestion and malabsorption of fat
develop.
 Patients usually experience severe right upper quadrant
pain (biliary colic).
 If uncorrected, backed-up of bile can result in jaundice
and liver damage (secondary biliary cirrhosis).
 A stone blocking the ampulla of Vater may transiently
obstruct the pancreatic duct, triggering an attack of
acute pancreatitis.
Obstruksi bilier
 Biliary obstruction is treated with endoscopic
retrograde sphincterotomy, a medical procedure
used to remove gallstones from the common bile
duct.
 In this procedure, the surgeon enters the bile duct
via the ampulla of Vater from the duodenum. For
infections, antibiotics are provided, along with
analgesics and antiemetics for nausea and
vomiting.
Kolesistitis
 Peradangan kandung empedu, dapat bersifat akut
atau kronik
 Etiologi: penyumbatan saluran empedu karena batu
 Tanda dan gejala:
 Demam
 Nyeri abdomen kanan atas sampai kolik
 Mual, muntah, flatulens
 Sering disertai ikterus (jaundice)
Kolesistitis kronik
 Kolesistitis kronik  inflamasi kandung empedu
dalam jangka waktu yang lama
 Terjadi karena serangan ringan kolesistitis akut
yang berulang
 Menyebabkan penebalan dinding kandung empedu
 mengecil  kehilangan fungsinya:
mengentalkan dan menyimpan empedu
 Faktor risiko: wanita, usia>40 tahun, adanya batu
empedu dan riwayat kolesistitis akut
Kolangitis
 Cholangitis is an inflammation of the biliary ducts,
usually secondary to obstruction of the common bile
duct leading to infection. The infection can ascend
into the hepatic ducts, then into the biliary canaliculi,
hepatic veins, and perihepatic lymphatics, leading to
sepsis.
 It is a life threatening complication of biliary
obstruction, particularly in the elderly. Initial therapy
generally consists of antibiotics, fluid resuscitation,
and correction of blood clotting.
Manifestasi klinik kolelithiasis & kolesistitis

 Hampir 2/3 pasien dengan kolelithiasis tidak

menunjukkan gejala (asimtomatik)
 Gangguan pencernaan & penyerapan lemak
 Nausea & vomitus
 Dispepsia sampai kolik
 Steatorea
 Gangguan metabolisme bilirubin
 Bilirubinemia  ikterik
 Feses pucat
Komplikasi
 Sirosis bilier sekunder
 Pankreatitis  jika duktus pankreas tersumbat
Penatalaksanaan klinik kolelitiasis
 Operasi pengambilan batu (lithotomi)
 Operasi pengangkatan kandung empedu
 Pemberian agen pelarut :
 Garam empedu
 Chenodeoxycholic acid
 Ursodeoxycholic acid
 Extracorporeal shock wave lithotripsy (ESWL)
 Endoscopic retrograde cholangiopancreatography
(ERCP)  jika batu sudah bermigrasi ke saluran
empedu
Nutritional implications
 Symptomatic gallstones and acute attacks require a
diet low in fat to relieve symptoms before surgery.
 Patients experiencing an acute attack of cholangitis
should take nothing by mouth (NPO) for twelve
hours before surgery.
 Indigestion, decreased ability to digest fat, and
increased abdominal gas can contribute to
decreased food intake and altered nutritional status.
Nutritional Implications
 After surgery, patients adjust rapidly to a regular
diet since bile from the liver continues to enter the
duodenum via the common bile duct.
 Diarrhea may occur after surgery, probably due to
bile in the large intestines. Other causes for the
diarrhea should be excluded before nutrition
intervention is suggested.
Nutrition Assessment
 For the patient with gallbladder disorders, weight and
weight history should be obtained, and a 24-hour
recall, diet history, or food diary should be used to
determine intake and tolerance of specific foods or
nutrients (e.g., fatty foods).
 Albumin and prealbumin levels should be assessed
if the patient is NPO and/or has a concurrent
infection.
 Medication for treatment of gallstones, infection, and
pains should be noted.
Nutrition Diagnosis
Possible nutrition diagnoses for biliary disorders
include:
 inadequate oral food/beverage intake;

 altered GI function; food-medication interaction;

 if the patient has an infection—increased nutrient

needs.
Nutrition Intervention
 A low-fat nutrition prescription (<30% energy as
fat) with a modest protein content may assist in
controlling symptoms until surgery is performed to
remove the gallstones.
 Small, frequent feedings may also help improve the
total nutrient intake to meet patients’ needs.
Nutrition Intervention
 An acute attack almost always occurs in connection with an
obstruction. When it does occur, the gallbladder should be kept
as inactive as possible, which is achieved through an NPO order
and complete bowel rest until symptoms lessen, with nutrition
administered parenterally as needed. The diet is advanced as
tolerated to liquids, though only low-fat liquids are typically
used.
 Due to poor absorption of fat, a water-soluble form of vitamins
A, D, E, and K may be necessary.
 Post surgery diarrhea may be managed through increased fiber
intake to increase fecal bulk, and patient avoidance of foods that
are known to cause diarrhea.
Terapi Diet
 Tidak ada terapi diet spesifik untuk mencegah kolelitiasis pada
individu yang rentan
 D. Prabedah
 H-4 diet sisa rendah bentuk lunak
 H-3 diet sisa rendah bentuk saring
 H-1/2 diberi bubur tanpa sayur
 Puasa 12-18 jam sebelum operasi
 D. Pascabedah
 DPB 1: m cair jernih
 DPB 2: m cair kental
 DPB 3: m saring, rendah sisa
 DPB 4: m lunak
Pada pengangkatan kandung empedu

 Pada pasien yang mengalami pengangkatan

kandung empedu, asupan makanan per oral setelah
bising usus kembali dan setelah pasien dapat
menoleransi pelepasan NGT
 Dengan tidak adanya kandung empedu, cairan
empedu langsung disekresikan oleh hati ke usus.
Terjadi dilatasi saluran empedu
Pada kolesistitis akut
 Asupan per oral dihentikan, parenteral nutrition
 Ketika asupan per oral boleh diberikan lagi, diet
rendah lemak untuk mengurangi stimulasi pada
kandung empedu
 Formula rendah lemak terhidrolisis atau diet rendah
lemak per oral dengan 30-45 gram lemak dapat
diberikan
Pada kolesistitis kronik
 Diet rendah lemak jangka panjang (25-30% dari
total kalori)
 Pembatasan yang lebih ekstrim tidak dianjurkan
karena lemak dalam usus penting untuk stimulasi
dan drainase saluran empedu
 Hindari makanan yang menyebabkan flatulens,
kembung
 Pemberian bentuk larut air dari vitamin-vitamin
larut lemak jika ada malabsorpsi lemak
Tujuan Diet Pasca Bedah
 Agar status gizi cepat kembali normal
 Mempercepat penyembuhan luka
 Meningkatkan daya tahan tubuh

 Prinsip diet:
 Memberikan kebutuhan dasar (cairan, energi, protein)
 Mengganti kehilangan protein, glikogen dan besi
 Memperbaiki keseimbangan elektrolit dan cairan
Tujuan Diet Kolelithiasis & Kolesistitis

 Mencapai & mempertahankan status gizi optimal

 Memberi istirahat pada kandung empedu

 Menurunkan BB bila overweight

 Mengatasi malabsorpsi lemak
 Memberi makanan yang mudah dicerna
Syarat Diet
 Energi sesuai kebutuhan
Overweight  AMB dihitung berdasarkan BBI
Kolesistitis  FS = 1.2
 Protein 1 – 1.25 g/kgBBI
atau 10-15% dari total kebutuhan energi
Syarat Diet
Kebutuhan lemak
 Lemak dalam makanan berperan dalam:

 Menurunkan massa makanan

 Membantu penyerapan vit A, D, E, K
 Pencernaan dan penyerapan lemak memerlukan
empedu
 Jumlah lemak yang diberikan:
 Akut, kolesistitis : lemak rendah
 Kronis : lemak 20-25% kebutuhan energi
 Steatorea  lemak dalam bentuk MCT
Syarat Diet
 Vitamin dan mineral cukup
 Serat tinggi, terutama dalam bentuk pektin 
mengikat asam empedu
 Mudah dicerna, tidak merangsang, tak bergas, porsi
kecil, frekuensi sering
 Konsistensi sesuai keadaan penderita
Jenis Diet pada Kolelithiasis & Kolesistitis

 Akut  Lemak Rendah 1  Buah/minuman

manis
 Lemak rendah 2  Cincang / lunak / biasa

 Lemak rendah 3  Lunak / biasa

Bahan Makanan Sehari Diet RL

RL 1 RL 2 RL 3
996 kkal 1400 kkal 1900 kkal
Serealia & umbi-umbian - 2 SP 5 SP
Daging lemak rendah/sedang - 3 SP 3 SP
Kacang-kacangan - 2 SP 2 SP
Sayuran - 2 SP 2 ½ SP
Buah/sari buah 10 SP 4 SP 2 SP
Minyak/margarin - 2 SP 2 SP
Susu skim/formula - - 1 SP
Gula/sirup 15 SP 8 SP 8 SP
Monitoring and Evaluation
 Adherence to, as well as, tolerance of the diet
should be determined.
 If the patient is NPO and/or has an infection,
weight and biochemical labs should be monitored
as needed, based on nutritional status.
Click icon to add picture

TERIMA KASIH
Kasus
 Ny. Emma, 32 tahun, pegawai swasta. BB 58 kg, TB 160 cm.
Sudah beberapa hari ini mengeluh badan terasa lemas, sakit
perut bagian kanan, kedua mata kelihatan kuning, mual pada
pagi dan malam hari. Os mempunyai kebiasaan minum obat-
obatan analgesik tanpa resep dokter. Pasien masuk RS dengan
panas tinggi 39ºC. Setelah dilakukan pemeriksaan didapatkan
hasil sebagai berikut: TD 110/70 mmHG, SGOT 50 U/L, SGPT
45 U/L, Kolesterol total 200 mg/dL, bilirubin 1 mg/dL. USG
gambaran positif kolelitiasis. Hasil recall diketahui rata-rata
asupan os sebagai berikut: energi 2000 kkal, protein 62 gram,
lemak 87 gram, karbohidrat 258 gram. Diagnosis medis:
kolesistitis akut dengan kolelitiasis.