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Polyps in the gallbladder – what to do?

Polyps represent growth of the surface epithelium of the gallbladder, can be single and large 1-2 cm or to form a mesh of small tumors with a height of 1-2 mm. Polyps have a benign nature, but their presence increases the risk of cancer degeneration of cells and development of gallbladder cancer.

Capture important data on polyps and cancer of the on the following figures:

  • Cancer of the gallbladder are rare and range from 0.27 to 0.41% of all cancers.
  • Gallbladder cancer is two times more common among women than among male patients.
  • The risk of cancer increases with age increases, ranging from 45 years and reaches its peak at 56-70 years of age.
  • To trigger the development of gallbladder cancer can surgery of the biliary tract develops in 1-5% of all cases.
  • Among other cancers of the digestive tract gallbladder cancer is in fifth place after such diseases as cancer of the pancreas, stomach, intestines (rectum and colon)

The content of the article:


Symptoms of polyps in gallbladder

Any manifestations of the disease will depend on where is located the tumor. The most unfavorable situation is its growth in the neck of the bladder or within its duct. This creates an obstacle to the bile in the intestinethe causes of the patient development of such diseases as obstructive jaundice. When polyphonie overgrowth are localized in the different departments of the gallbladder, there are no specific symptoms the patient is experiencing.

However, to suspect its presence in the body of indirect evidence:

  • Pain. They appear in response to excessive stretching of the walls of the authority by the polyp, and in the bile which stagnates his fault. Such stagnant processes lead to the fact that multiple receptors located in the serous membrane of the body is constantly annoyed. In addition, pain can arise from too frequent reductions of the walls of the gallbladder. The nature of the pain dull and aching. They tend to give in the right upper quadrant, is present on a periodic basis. Provocateurs pain there may be alcohol-containing drinks, fatty food and strong stress. That is why patients do not associate the discomfort with polyps, referring to their appearance at the expense of other factors, e.g., malnutrition.

  • Staining of the skin and mucous membranes yellow. This indication is a result of obstructive jaundice, which occurs when compression of a polyp of the bile ducts. Not being able to go naturally, the bile begins to seep through the bladder wall and enter the blood stream. The patient begins to experience skin itching, the skin becomes dry and contracted, the urine darkens, may start vomiting bile mass and temperature to rise.

  • Renal colic. If the polyp has a very long leg and located in the cervical area of the affected organ, when it is torsion or the clip may develop hepatic colic. This occurs most often in marked reduction of the body. When torsion has occurred, the person experiences sudden pain that is sharp cramping, increased heart rate, increasing blood pressure. In this case the patient can not choose for themselves a more or less comfortable posture in order to pacify the discomfort. The latter symptom is a clear indicator of biliary colic.

  • Dyspeptic symptoms. About the presence of polyp often show dyspeptic symptoms. The degree of severity varies. Typical manifestations are: bitter taste in morning and nausea, vomiting after eating. All these manifestations due to recurrent or regular congestion occurring in thebody. In addition, because the polyp is a violation of the production of bile. Its deficiency adversely affects the digestive process, so the patient can begin to lose weight.

However, all of the above symptoms rarely cause the patient to contact the medical institutions, and especially to undergo ultrasound examination, which can detect existing tumors.


Causes polyps in the gallbladder

There are four reasons that presumably can begin to develop polyphonie growths in the gallbladder:

  • The factor of heredity and anomalies of genetic development. So, on the growth and development of polosnyj growths is influenced by heredity. This files most often inherited adenomatous education and papillomas. Established that even if the identification of close relatives other tumors, the risk of development of gallbladder polyps grow. In addition, a genetic predisposition to dyskinesia of the bile ducts is the direct cause leading to the development of polyposis. Nevertheless, it is impossible to say that genetic predisposition is the cause of the formation of the tumor. She grows and develops under the influence of other factors. Positive family history in this case is an additional provocateur for the manifestation of the disease.
  • The gallbladder diseases of inflammatory Genesis. Chronic cholecystitis are the most common reason is the development and growth of the polyp. In on in the background cholecystitis is stagnation of bile, its wall thickens and undergoes deformation. The granulation tissue of the bladder begins to respond to the inflammatory process. This reaction is manifested in the form of proliferation of its cells. In the end, the person formed pseudo polyps of inflammatory origin.

  • Disruptions of metabolic processes. The most common reason for the proliferation of cholesterol pseudopolyps are disorders of lipid metabolism. As a result, in the bloodstream begins to circulate a significant amount of cholesterol. Excess is gradually deposited on the walls of blood vessels, and also on storage of bile. This leads to the formation of pseudopolyps composed of cholesterol. In addition, such formation can occur even with a normal concentration of lipids in the blood, due to part of the bile cholesterol. When conductingultrasound studies are most often discovered such pseudoprime. The longer a person is a native speaker, the bigger they become. Their growth contributes to the absence of any concerns the person of the symptoms.

  • Diseases of the hepatobiliary system. Any disease of the biliary tract contribute to the disruption of the balance between optimally required for digestion by the amount of bile, and its secreted for this process. As its deficiency or excess disrupts the process of digestion. This leads to various pathologies of the gastrointestinal tract, including, provoking the development of polyps.

Comorbidities with gallbladder polyps

The gallbladder polyps can cause disease in adjoining organs – the liver and pancreas. So, polyps are a potential hotbed for the growth of infections that give rise to the inflammatory process. This causes the cholecystitis, spasms of the biliary tract, pancreatitis and other diseases. In addition, by themselves, inflammatory processes in the gallbladder may contribute to the pathological expansion of its mucosa.

What diseases occur when the gallbladder polyps?

  • Dyskinesia spasms of the duct or gallbladder. Dyskinesia, wearing a hypertensive character, which increases the tone of the gall bladder, is more common in women and usually closely associated with the menstrual cycle. Hypotonic dyskinesia (insufficient intensity of the contractions of the gall bladder) is common among middle aged or older. Dyskinesia leads to obstruction of the outflow of bile, which if chronic can cause cholecystitis or deposition of stones in the gallbladder, and in addition, creates conditions for the formation of polyps. Also, the disease can be caused by dysfunction of the sphincter of Oddi, which separates the biliary tract from the duodenum 12.

  • Cholelithiasis is the formation of cholesterol stones in the liver, bile ducts or gall bladder caused by impaired lipid metabolism. The formation of cholesterol gallstones starts with disruption of the chemical composition of bile, a lack of bile acids and phospholipids, but there is a glut of cholesterol, fatty acids. The causes of this disease may be obesity, an unbalanced diet, stagnation of bile, infection of the gallbladder and biliary tract. Simultaneously, can experience cholesterol gallbladder polyps and other tumors of its mucosa.
  • Acute and chronic pancreatitis –inflammatory disease of the pancreas, which in 65-60% of cases observed in dyskinesia, spasm or dysfunction of the sphincter of Oddi, colic and gallstones. Other causes of pancreatitis spread of the inflammatory process caused by infection from the gall bladder and its duct in the pancreas, alcohol and food, causing increased pancreatic secretion.
  • Acute or chronic cholecystitis – inflammation of the gallbladder, which in 90% of cases is observed in the presence of stones and deposits of cholesterol, as well as with their offset and enters bile duct. In addition to gallstones, cholecystitis can be associated with infectious disease, parasitic infestation, tumors in the gallbladder.

What are polyps in the gallbladder?

  • Cholesterol polyps – tumours of education, which consists of deposits of cholesterol from calzinirovnie inclusions, initially develops under the mucosa of the gall bladder, then expands, forming the polyp. Usually observed in people with disorders of fat metabolism at an elevated level of low-density lipoproteins and decrease the concentration of HDL (high density lipoproteins). Are often found by chance during the examination, as their education and growth asymptomatic.
  • Inflammatory polyps – cause of their formation is inflammatory process which may develop as a consequence of bacterial infection. The inner shell of the gall bladder formed by the growth of granulomatous tissue in the form of the tumor.
  • Adenomatous polyps are true tumors, benign, but with increased risk of malignant transformation. Cause adenomatous polyps and papillomas is the growth of glandular tissue in 10% of cases, they are transformed into cancer formation, which raises concerns among physicians and requires constant control over their growth and immediate treatment.
  • Papilloma – benign tumor, usually small in size and characteristic papillary growths.

  • Diagnosis of polyps in the gallbladder

    Detection of abnormal growths in the gallbladder is made possible thanks to the development of radiology since the thirties of the twentieth century. Since modern medicine is in this respect made a few stepsforward and patients available more accurate and safe diagnostic methods.

    In most medical institutions for the diagnosis of polyps using ultrasound and endoscopic ultrasonography:

    • Ultrasound can detect single or multiple polyps of gallbladder mucosa. They appear on the screen of the device associated with the walls of the bubble formations rounded shape without acoustic shadow. When changing the position of the patient's body polyps do not move.
    • Ultrasonography is the study of duodenal ulcer and gall bladder using a flexible endoscope. The device swallowed by the patient, at the end there is a ultrasonic sensor, which is the study of the walls of the gallbladder for the presence of growths. Important role in the detection of different parts plays the operating frequency of the transducer – the higher it is, the more detailed the resulting image. This method allows to obtain a better image, respectively, and diagnostics more accurate.

    In addition, in some hospitals, available research with the help of MRI, called magnetic resonance cholangiography. It is the most advanced at the moment, the method by which the practitioner can not only see, localize and estimate the size of tumors, but also to identify related entities that occur during malignancy polyp. To evaluate the amount of contrast agent accumulated by tumor tissues, can also prescribe multislice computed tomography.

    Due to the breadth of application of modern methods of diagnosis was made statistics of cases of gallbladder polyps that showed that approximately 4% of the population are permanent carriers, of which the majority (60 %) – women aged 30 years and above.


    Answers to popular questions

    • Can dissolve a polyp in the gallbladder? In 95% of cases detected polyps are cholesterol formations loose, conservative treatment with choleretic drugs, which include Ursosan and Ursofalk. Medications that thin the bile, contribute to the resorption of polyps submucosal layer of the gallbladder.
    • Is it possible to remove just the polyps, maintaining a functioning gallbladder? To remove a polyp without damaging of the gallbladder wall is impossible, therefore, even if the doctor will keep the body, its function will be disturbed and the polyps over time will appear again, perhaps in greater quantities than before the surgery. From this practice has been abandoned for quite some time. Already in the 70 years of the lastcentury, has ceased to perform the operations that preserve the gall bladder, after removal of tumors. In addition, one time was a popular method of stone fragmentation (lithotripsy). However, this therapeutic method proved meaningless, as after a while 99% of patients developed recurrent disease. In the future they helped only surgical intervention with removal of the organ. Therefore, the best method of treatment is surgery, namely laparoscopic cholecystectomy.

      However, removal of the gallbladder is not the only way, most tumors amenable to conservative treatment. The patient is required to undergo regular inspection twice a year to prevent canceration of polyps and beginning the cancer process. The danger of proliferation of more than 10mm, which did not stop growth; if a small polyp increased and become twice the original size, this may indicate early malignancy. Tumors with a broad base, with no severe feet are more prone to malignant transformation. When polyps more than a centimeter prescribe surgery to remove the gallbladder.In other cases, you can do choleretic drugs and correction of diet, lifestyle.

    • Could it hurt a polyp in the gallbladder? Pain in the gallbladder polyps are usually associated with formation of cholesterol stones are the symptoms of cholecystitis. Usually polyps in gallbladder do not cause pain.
    • Is it possible to visit a bath or sauna when polyps in the gallbladder? When polyps in the gallbladder it is impossible to heat the area of the body, so it is not recommended to go to the bath or sauna, to spend much time in the sun.

    What to do if you found out polyps in the gallbladder?

    In 95% of the tumors diagnosed as polyps, in fact, represent cholesterol stones – loose stones that can dissolve under the action of bile.

    The treatment is carried out henodeauxiholeva and ursodeoksiholevaya acid, which stimulate the mechanism of bile, and improve the quality of bile that helps dissolve cholesterol stones. Prescribed three-month course of treatment, the dosage is calculated according to 10 mg per 1 kg of patient weight, take in the evening two hours after the last meal. Treatment of bile acids combine with the diet table number 5

    After treatment controlultrasound and draw conclusions about the need for surgery. If growth slows formations, reducing their number or size, then conservative treatment is effective in the instant case.


    Treatment of polyps in gallbladder without operation

    You first need to go to the doctor-gastroenterologist and conduct all necessary diagnostic testing, to determine the type of polyps, their size and risk of malignancy.

    Cholesterol polyps – most common type of tumors in the gallbladder, with timely treatment do not pose a big danger.

    Cholesterol polyps are found in the form of a grid of small inclusions 1-2mm, common diffuse on the inner wall of the body or can be up to 4 mm on ultrasonography look like outgrowths with smooth contours and a broad base. Polyps larger than 4 mm have a thin foot.

    Most often recommended to drink one of the following drugs:

    • Ursofalk, which contributes to the destruction of the deposits consisting of cholesterol.
    • Simvastatin, reduce blood levels of lipoproteins and cholesterol.
    • Gepabene and no-Spa, are used as auxiliary drugs that help relax the smooth muscles of the gallbladder. With the body removed the spasm, bile has a chance to pass through the ducts and to take part in the process of digestion.
    • Holiver increases the ability of the gallbladder to secrete bile and eliminates congestion.
    • Ursosan helps to eliminate cholesterol stones, if you do not lose the ability to functioning of the gallbladder.

    Multiple cholesterol polyps may actually be not growths, and loose cholesterol stones, which subsequently cause pain in the patient. Common complaints at the same time – the feeling of heartburn, nausea and pain in the right hypochondrium, symptoms of cholecystitis, is caused by cholesterol stones.

    Treatment for cholesterol polyps can be carried out by a conservative if the height of the expansion – not more than 10 mm.

    A surgical operation to remove polyps or the entire gallbladder is assigned only in extreme cases, if the tumors are many and they are constantly growing. In most cases, the doctors are trying to save the body, because lack of it can cause digestive disorders and hinder the absorption of fatty foods.

    Surgery forpolyps in the gallbladder

    Cancer tense situation of today requires careful control over any tumors in the body, otherwise there is the risk of cancer of the degeneration of the tissues. If a course of conservative treatment has not given result, or during the first diagnosis was detected large polyps, shown the surgery.

    Indications for surgical treatment of polyps:

    • High growth rate of polyps – two mm per year;
    • The size of tumors between 10 mm;
    • A large number of growths with a wide base without legs.

    The size of polyps less than 1 mm operation is not necessary, but routine inspection is required monthly for six months and then once every three months. If the tumors don't increase in size, then further diagnosis is carried out every six months.

    Types of operations on the gall bladder:

    • Video laparoscopic cholecystectomy (LCE) is considered as the most patient-friendly, uses modern technology of endoscopy.
    • Laparoscopic cholecystectomy – removal of gall bladder without incision as in traditional cholecystectomy with the use of instruments for endoscopic operations. It is considered the "gold standard" of modern surgery, but in five percent of cases surgery to bring to an end fails and is a traditional cholecystectomy.
    • Traditional cholecystectomy (TAE) by open surgery, access is via upper midline incision or incision by Kocher in the right hypochondrium. The disadvantage of this method, in comparison with laparoscopic cholecystectomy is traumatic – incision cuts through skin, fat, white line of the abdomen and the peritoneum.
    • Endoscopic polypectomy is used to remove polyps of the gall bladder with organ preservation. This type of operation is performed using the diathermy loop, which bind to the stalk of a polyp and cut it. Education without legs is removed by fragmentation. Through the loop an electric charge in order to coagulate vessels, which helps to avoid bleeding. This method is used to remove polyps in the bowel, but it is rarely used in the treatment of polyposis of the gallbladder, the consequences can be unpredictable.

    Preparing for a cholecystectomy

    Before surgerythe patient must undergo comprehensive diagnostic testing to avoid possible complications and to choose the optimal method of cholecystectomy.

    What diagnostic procedure needs to be done before operation:

    • Ultrasound examination of the liver, gall bladder and pancreas, which enables the identification of comorbidities and inflammatory processes, to assess the number of polyps, their size and type, to determine the presence of stones in the gallbladder and liver;
    • Computer tomography allows to estimate the condition of the tissues surrounding the gall bladder, to determine the condition of its mucous membrane, the presence of adhesions and scars, to examine the state of his wall for thickening and knotty formations;
    • MRI is one of the most reliable methods for the study of polyps and stones in the gallbladder, allowing time to detect adhesions, inflammation, pathology of the biliary tract;
    • Laboratory studies of bile for the presence of blood cells, calcium bilirubinate, cholesterol, epithelial cells, assessment of its rheological properties. Bilirubinate the calcium found in the duodenal contents may be calcareous deposits in the gall bladder, the presence of epithelial cells in the bile can be a sign of inflammatory processes. Also need to explore the bile to the presence of protozoan parasites – Giardia.

    • Diagnostics of the cardiovascular and respiratory systems with x-ray and EKG can correctly assign treatment; heart failure is a serious contraindication for some methods of cholecystectomy.

    The preparatory procedures necessary for the patient immediately before surgery:

    • Excluded from the diet products, blood thinners, stop taking medications that affect blood clotting, e.g. aspirin is necessary to minimize the risk of bleeding during surgery.
    • On the day of surgery not to consume food and liquids excludes even water.
    • The night before the operation it is necessary to clean the bowel using an enema or a laxative;
    • Immediately before the operation, carefully hold the body hygiene, using antibacterial soap.

    Is it possible to live without a gall bladder?

    All human organs can be divided into vital (brain, heart, liver, etc.) and organs, without which life is possible, but the functionality of some systems will be broken. Suchorgans include the spleen, gallbladder, Appendix and stomach. Despite the fact that a person could live without those organs when following a strict diet and limiting stress on the body, to remove them without good need not recommended.

    Gallbladder removal is performed only in case of pathology threaten the organism as a whole. So, a large number of polyps with accelerated growth rate and increased risk of malignancy may lead to cancer of the gallbladder with metastases in other organs. In this case, removal of the gallbladder, or cholecystectomy is a matter of life and death. This is an absolute indication for surgery.

    There are also relative indications for operation: when the pathology of the gall bladder are not life threatening, but significantly reduce its quality. For example, if the polyps in gallbladder cause pain or are a source of infection. If people are constantly forced to fear pain or the potential risk of malignant transformation of polyps and cancer, it is better to do the surgery. After a successful surgery and rehabilitation period the patient has a chance to return to normal life.

    Rules of conduct after gallbladder removal

    After surgery, the patient will have to change. The fact that, due to the gallbladder, bile accumulates in the liver, and the increase in its concentration. In the absence of this organ of the digestive juice goes directly into the intestine, and its concentration remains quite low. Removal of the gallbladder also affects the activity of enzymes – it is significantly reduced. So that the body could adapt to the new way of digestion without using the dial on, it takes about two years.

    The first six months after surgery, you should very strictly follow diet:

    • First rule – there can be only boiled or steamed food.
    • The second rule is to eat small pieces slowly and carefully chewing it. This will give the liver time to activate all the necessary enzymes and incorporation into the work.
    • The third rule is to reduce the amount of the lump of food intake, but increase the number of servings. Otherwise your digestive system will not have time to cope with its functions, will appear nausea, heaviness in the intestines. Another negative consequence of breaking this rule is a stagnation of bile, which can occur in the ducts after removal of the bladder.

    After six months of strict temperance in diet will include fresh fruits and vegetables, and lean meatsand fish. Although from the excessively sour, spicy and rich essential oils products (onion, garlic, radish, lemons, sour berries, pineapple , etc.) must be abandoned in the next 12-18 months.

    Two years after gallbladder removal digestive system becomes strong enough, the patient was able to return to his usual diet, excluding refractory fats (heavy meat and fat), while the second and third rules best to stick to a lifetime.

    Physical activity after surgery gallbladder removal

    After two or three months of the postoperative period the patient is strongly encouraged to engage in regular walks, which occupies at least an hour a day. This is the first and most affordable way to avoid the stagnation of bile.

    Six months later, the patient can join the pool or go swimming in the warm time of year on your own – regular gentle massage with water almost completely eliminates the risk of stagnation.

    At the same time is permitted to engage in morning exercises, but not for the abdominal muscles. The significant tension of the muscular system doctors is considered safe only a year after the operation.

    The problem with the microflora after cholecystectomy

    The decrease in the concentration of bile also affects the microflora of the small intestine, the microbes get an opportunity to intensively proliferate and provoke attacks of diarrhea, flatulence and constipation. To prevent the reproduction of conditionally pathogenic and pathogenic microflora will change the nature of power (exclude from the diet of sweets), maintain beneficial microflora a regular intake of prebiotics and foods with bifidobacteria and lactobacilli. To solve this problem you can also refer to a gastroenterologist for consultation regarding the selection of medications that destroy intestinal microbes without harming the body.


    Diet for polyps in gallbladder after removal

    In diseases associated with insufficiency of the liver and gallbladder, the doctor is required to appoint a diet table number 5 or according to its basic requirements without diet, for example, simply says, "no fried, spicy, smoked, marinated", etc. In any case, patients with polyps in the gall bladder need to know how to keep yourhealth, shielding yourself from the heavy to the liver products.

    Dietary tables were invented by the founder of medical dietetics, the Soviet scientist Manuel Pevzner. Despite its venerable age of studies conducted to develop diets in 30-50-ies of the 20 century in the USSR and later in CIS countries are assigned to the dietary tables, and to this day, as their effectiveness is time-tested and leaves no doubt.

    Diet №5 consists of products that provides a full daily serving of protein, carbohydrate and calorie restriction of fat intake. By eating certain types of food the patient's condition may worsen, why they should be excluded from the diet. Also limited to eating, overly stimulate the pancreas and the secretion of the stomach.

    The ultimate goal of the diet is not only the weakening of the chemical load on the liver, but also the speedy removal of cholesterol caused by improvement of intestinal motility and choleretic properties of food components.
    The diet should be followed so to maintain optimal daily calorie intake (for an adult is from 2200 to 2600 calories, depending on the severity of physical labor performed on a regular basis). In addition to caloric intake, it is essential that the amount of food, as even a light and liquid foods taken in large amounts, can overload the gall bladder.

    Upon detection of polyps in the gallbladder, which often happens by accident with comprehensive examination on the first stages of the disease do not have to go to the doctor. The patient can stick to this diet on their own, not to bring the disease to the need of surgical intervention and to increase the effectiveness of conservative treatment.

    What can I eat?

    • Flour – the bread is black and white, only yesterday's baking or dried to crackers. It is permissible from time to time to pamper yourself for a cracker or biscuit. No more than two times in a week is allowed to eat a well-baked biscuits or cakes without butter in the dough;
    • Meat – only lean. If it's beef, then boiled, you can also have a tongue and ham. If the bird – diet (chicken, Turkey), preferably only the fillet (breast), but cooked is allowed, there are other meaty parts. Fish should be steamed or boiled, the eggs and milt can be added only in small amounts as a flavor enhancer. When possible, boiled meat and fish to improve the taste is additionally bake.
    • Eggs boiled soft-boiled, to drink no more than one a day. It is best to make a omelet. Ifthe omelette is large, divide it into pieces and there is so much to only get one egg a day (for example, a dish of four eggs to divide into four parts and more than one a day not to eat);
    • Vegetables greens can be eaten raw or boiled. Good to use vegetables as side dishes and full meals, especially if it's beets and carrots;

    • Cereals, cooked in water or milk, and pasta;
    • Fruits and berries – just sweet and preferably within the jelly or compote, sour fruits are eliminated from the diet. Bake and steamed fruit is not prohibited;
    • Dairy products can be eaten no more than 200 grams per day. It can be low-fat raw foods (cheese, yogurt, milk, yogurt, mild cheese). Also allowed to cook their casseroles, dumplings, soufflés, cheesecakes, cheese.
    • Vegetable oil – not more than two tablespoons a day, use only as a dressing in vegetables, salads and other ready meals.
    • Among the sweets, you should choose natural honey, jam, marshmallow, marmalade, but not more than 70 g per day;
    • Sauces based on milk, berries and fruits;
    • Drinks: infusion of rose hips, herbal preparations with choleretic effect;
    • Among spices to give preference to the greens (dill, parsley, Basil), Bay leaf, cinnamon and cloves.

    Food is broken down into small portions, the number of techniques every day for at least five. You can't eat cold or very hot food, it can cause irritation of the intestinal mucosa. Daily drink at least 1.5 liters of fluid to drink before each meal, it promotes the release of bile, preventing its accumulation and stagnation. To minimize the amount of salt. Food should be shredded before use.

    What not to eat?

    • Banned refractory fats and foods containing them – bacon, mutton, pork; a small amount of butter in the diet;
    • Smoked, spicy, pickled, canned food;
    • Among the greens and vegetables to eliminate from the diet spinach, onions, garlic, turnips, radishes and sorrel;

    • All legumesproducts;
    • Among milk products, sour cream is prohibited;
    • Butter cakes;
    • Chocolate, cocoa and ice cream;
    • Any carbonated beverages;
    • Vinegar, spices;
    • Limiting the intake of salt is not more than 10 g per day;
    • Any alcohol.