Cholecystitis
Cholecystitis is defined as inflammation of the gallbladder that occurs most commonly because of an obstruction of the cystic duct from cholelithiasis. 90% of cases involve stones in the cystic duct (ie, calculous cholecystitis).
Risk factors for cholecystitis mirror those for cholelithiasis and include increasing age, female sex, certain ethnic groups, obesity or rapid weight loss, drugs, and pregnancy.
http://emedicine.medscape.com/article/171886-overview
Pathophysiology
• Fixed obstruction or passage of gallstones into the gallbladder neck or cystic duct causes acute inflammation of the gallbladder wall.
• The impacted gallstone causes bile to become trapped in the gallbladder, which causes irritation and increases pressure in the gallbladder.
• Trauma caused by the gallstone stimulates prostaglandin synthesis (PGI2, PGE2), which mediates the inflammatory response. This can result in secondary bacterial infection leading to necrosis and gallbladder perforation. [3]
The pathophysiology of acalculus cholecystitis is poorly understood, but it is probably multi-factorial. Functional cystic duct obstruction is often present and related to biliary sludge or bile inspissation caused by dehydration or bile stasis (due to trauma or systemic illness). Occasionally, extrinsic compression may play a role in the development of bile stasis. Some patients with sepsis may have direct gallbladder wall inflammation and localised or generalised tissue ischaemia without obstruction.
Jaundice occurs in up to 10% of patients and is caused by inflammation of contiguous biliary ducts (Mirizzi's syndrome).
(Mirizzi's syndrome is an unusual presentation of gallstones that, when lodged in either the cystic duct or the Hartmann pouch of the gallbladder, externally compressed the common hepatic duct (CHD), causing symptoms of obstructive jaundice.)
Acute cholecystitis may resolve spontaneously 5 to 7 days after symptom onset. The impacted stone becomes dislodged with re-establishment of cystic duct patency. If cystic duct patency is not re-established inflammation and pressure necrosis may develop leading to mural and mucosal haemorrhagic necrosis. Untreated acute cholecystitis can lead to suppurative, gangrenous, and emphysematous cholecystitis.
http://bestpractice.bmj.com/best-practice/monograph/78/basics/pathophysiology.html
Cholangitis
Acute cholangitis is a bacterial infection superimposed on an obstruction of the biliary tree most commonly from a gallstone, but it may be associated with neoplasm or stricture.
Frequency
United States
Cholangitis is relatively uncommon. It occurs in association with other diseases that cause biliary obstruction and bactibilia (eg, after endoscopic retrograde cholangiopancreatography [ERCP], 1-3% of patients develop cholangitis). Risk is increased if dye is injected retrograde.
The condition mostly occurs in adults, with a reported median age at onset of 50-60 years.
http://emedicine.medscape.com/article/774245-overview
http://emedicine.medscape.com/article/184043-overview
Recurrent pyogenic cholangitis (Oriental cholangiohepatitis, hepatolithiasis) is characterized by intrahepatic brown pigment stone formation. This disorder occurs in Southeast Asia. It consists of sludge and bacterial debris in the bile ducts. Undernutrition and parasitic infestation (eg, Clonorchis sinensis, Opisthorchis viverrini) increase susceptibility. Parasitic infestation can cause obstructive jaundice with intrahepatic ductal inflammation, proximal stasis, stone formation, and cholangitis. Repeating cycles of obstruction, infection, and inflammation lead to bile duct strictures and biliary cirrhosis. The extrahepatic ducts tend to be dilated, but the intrahepatic ducts appear straight because of periductal fibrosis.
http://www.merck.com/mmpe/sec03/ch030/ch030e.html
Incidence: rare under age 40 years
http://www.fpnotebook.com/Surgery/GI/ActGlstnChlngts.htm
we come in many different colors and flavors (:
Wednesday, July 28, 2010
Ascending Cholangitis History
Abdominal pain – 70% of patients
• In the right upper side or middle of the upper abdomen
• May come and go
• Pain is sharp, crampy, or dull
• Pain may move to the back or below the right shoulder blade
Fever – 90% of cases
Jaundice – 60% of cases
Rigors(uncontrollable shaking) and a feeling of uneasiness (malaise), pruritis, acholic or hypocholic stools - stools look clay like
Charcot's triad - abdominal pain, jaundice, and fever - 15–20% of cases.
Reynolds' pentad includes the findings of Charcot's triad with hypotension (30% of cases) and mental confusion (10-20% of cases). This combination of symptoms indicates worsening of the condition and the development of septicemia – less common than Charcot’s triad
In the elderly, the presentation may be atypical; they may directly collapse due to septicemia without first showing typical features.
Consider cholangitis in any patient who appears septic, especially in patients who are elderly, jaundiced, or who have abdominal pain.
Most patients complain of RUQ pain; however, some patients (ie, elderly persons) are too ill to localize the source of infection.
• The patient's medical history may be helpful. For example, a history of the following increases the risk of cholangitis:
• Gallstones, CBD stones
• Recent cholecystectomy
• Endoscopic manipulation or ERCP, cholangiogram
• History of cholangitis
• History of HIV or AIDS: AIDS-related cholangitis is characterized by extrahepatic biliary edema, ulceration, and obstruction. The etiology is uncertain, but it may be related to cytomegalovirus or Cryptosporidium infections. The management of this condition is described below, although decompression is usually not necessary.
• In the right upper side or middle of the upper abdomen
• May come and go
• Pain is sharp, crampy, or dull
• Pain may move to the back or below the right shoulder blade
Fever – 90% of cases
Jaundice – 60% of cases
Rigors(uncontrollable shaking) and a feeling of uneasiness (malaise), pruritis, acholic or hypocholic stools - stools look clay like
Charcot's triad - abdominal pain, jaundice, and fever - 15–20% of cases.
Reynolds' pentad includes the findings of Charcot's triad with hypotension (30% of cases) and mental confusion (10-20% of cases). This combination of symptoms indicates worsening of the condition and the development of septicemia – less common than Charcot’s triad
In the elderly, the presentation may be atypical; they may directly collapse due to septicemia without first showing typical features.
Consider cholangitis in any patient who appears septic, especially in patients who are elderly, jaundiced, or who have abdominal pain.
Most patients complain of RUQ pain; however, some patients (ie, elderly persons) are too ill to localize the source of infection.
• The patient's medical history may be helpful. For example, a history of the following increases the risk of cholangitis:
• Gallstones, CBD stones
• Recent cholecystectomy
• Endoscopic manipulation or ERCP, cholangiogram
• History of cholangitis
• History of HIV or AIDS: AIDS-related cholangitis is characterized by extrahepatic biliary edema, ulceration, and obstruction. The etiology is uncertain, but it may be related to cytomegalovirus or Cryptosporidium infections. The management of this condition is described below, although decompression is usually not necessary.
ABDOMEN III: GASTROINTESTINAL TRACT
TASK 1 & 2: Chesvin
TASK 3: Da Wei
TASK 4: Nabeela
TASK 5: Rebekah
TASK 6: Wen Jye
TASK 7: Tim
TASK 8: Xinyi & Yi Zhen
TASK 9: Nabila
TASK 10: Phey Chien
TASK 11: Fahad & Nic
TASK 3: Da Wei
TASK 4: Nabeela
TASK 5: Rebekah
TASK 6: Wen Jye
TASK 7: Tim
TASK 8: Xinyi & Yi Zhen
TASK 9: Nabila
TASK 10: Phey Chien
TASK 11: Fahad & Nic
Cholecystitis Role Play: History Taking
History:
PAIN: sharp, cramping, dull,
WHEN: come and go, acute
WHERE: begin at epigastric, then localized at right hyppchondrium; radiate to the back or below the right scapula
Aggregating factors: Breathing deeply , after meal (esp: large meal or high fat meal)
Associated symptoms: Chills
GIT system review:
Abdominal pain AS ABOVE
Appetite YES
Weight NO
Nausea YES
Vomiting YES
Vomiting blood (haematemesis) NO
Heartburn NO
Difficulty swallowing (dysphagia) NO
Bloating (Abdominal fullness) YES (at RUQ)
Change in bowel habit NO
Blood in stools/ bowel motion NO
Black-tar like stools (malaena) YES
Fevers YES (above 38’c)
Jaundice YES
Itch NO
Overseas travel NO
References:
http://www.nlm.nih.gov/medlineplus/ency/article/000264.htm
http://emedicine.medscape.com/article/171886-overview
http://www.mayoclinic.com/health/cholecystitis/DS01153/DSECTION=symptoms
PAIN: sharp, cramping, dull,
WHEN: come and go, acute
WHERE: begin at epigastric, then localized at right hyppchondrium; radiate to the back or below the right scapula
Aggregating factors: Breathing deeply , after meal (esp: large meal or high fat meal)
Associated symptoms: Chills
GIT system review:
Abdominal pain AS ABOVE
Appetite YES
Weight NO
Nausea YES
Vomiting YES
Vomiting blood (haematemesis) NO
Heartburn NO
Difficulty swallowing (dysphagia) NO
Bloating (Abdominal fullness) YES (at RUQ)
Change in bowel habit NO
Blood in stools/ bowel motion NO
Black-tar like stools (malaena) YES
Fevers YES (above 38’c)
Jaundice YES
Itch NO
Overseas travel NO
References:
http://www.nlm.nih.gov/medlineplus/ency/article/000264.htm
http://emedicine.medscape.com/article/171886-overview
http://www.mayoclinic.com/health/cholecystitis/DS01153/DSECTION=symptoms
Management of Cholecystitis and Cholangitis
Management of Cholecystitis
Medical Care
For acute cholecystitis, initial treatment includes bowel rest, intravenous hydration, analgesia, and intravenous antibiotics. Bacteria that are commonly associated with cholecystitis include E coli and Bacteroides fragilis and Klebsiella, Enterococcus, and Pseudomonas species. Emesis can be treated with antiemetics and nasogastric suction.
Antiemetics:
o Promethazine (Phenergan, Prorex, Anergan). For symptomatic treatment of nausea in vestibular dysfunction. Antidopaminergic agent
o Prochlorperazine (Compazine). May relieve nausea and vomiting by blocking postsynaptic mesolimbic dopamine receptors through anticholinergic effects
Analgesics:
o Meperidine (Demerol) DOC. Analgesic with multiple actions similar to those of morphine. May produce less constipation, smooth muscle spasm, and depression of cough reflex than similar analgesic doses of morphine. Doesn’t affect sphincter of Oddi as much
o Vicodin
Antibiotics
o Ciprofloxacin (Cipro) Fluoroquinolone that inhibits bacterial DNA synthesis and, consequently, growth, by inhibiting DNA gyrase and topoisomerases, which are required for replication, transcription, and translation of genetic material.
o Meropenem (Merrem) Bactericidal broad-spectrum carbapenem antibiotic that inhibits cell-wall synthesis. Effective against most gram-positive and gram-negative bacteria.
o Imipenem and cilastatin (Primaxin) For treatment of multiple organism infections in which other agents do not have wide spectrum coverage or are contraindicated due to potential for toxicity.
Surgical Care
Laparoscopic cholecystectomy is the standard of care for the surgical treatment of cholecystitis.
For elective laparoscopic cholecystectomy, the rate of conversion from a laparoscopic procedure to an open surgical procedure is approximately 5%. Some considerations regarding cholecystectomy include the following:
•Immediate cholecystectomy or cholecystotomy is usually reserved for complicated cases in which the patient has gangrene or perforation.
•Early operation within 72 hours of admission has both medical and socioeconomic benefits and is the preferred approach for patients treated by surgeons with adequate experience in laparoscopic cholecystectomy.
•For patients at high surgical risk, placement of a sonographically guided, percutaneous, transhepatic cholecystostomy drainage tube coupled with the administration of antibiotics may provide definitive therapy.
•Contraindications for laparoscopic cholecystectomy include the following:
oHigh risk for general anesthesia
oMorbid obesity
oSigns of gallbladder perforation, such as abscess, peritonitis, or fistula
oGiant gallstones or suspected malignancy
oEnd-stage liver disease with portal hypertension and severe coagulopathy
Treatment for gall stones
Cholesterol gallstones can sometimes be dissolved by oral ursodeoxycholic acid, but it may be required that the patient takes this medication for up to two years. Gallstones may recur however, once the drug is stopped. Obstruction of the common bile duct with gallstones can sometimes be relieved by endoscopic retrograde sphincterotomy (ERS) following endoscopic retrograde cholangiopancreatography (ERCP). Gallstones can be broken up using a procedure called lithotripsy (extracorporeal shock wave lithotripsy) which is a method of concentrating ultrasonic shock waves onto the stones to break them into tiny pieces. They are then passed safely in the feces. However, this form of treatment is only suitable when there are a small number of gallstones.
ERCP: technique that combines the use of endoscopy and fluoroscopy to diagnose and treat certain problems of the biliary or pancreatic ductal systems. Through the endoscope, the physician can see the inside of the stomach and duodenum, and inject dyes into the ducts in the biliary tree and pancreas so they can be seen on x-rays.
Cholangitis
Prehospital Care
Diagnosis of cholangitis is not a prehospital diagnosis. Mild cholangitis may present with abdominal pain, jaundice, and fever. When transporting these patients to the hospital, place the patient on a monitor and insert an intravenous (IV) line.
In unstable patients with cholangitis, prehospital care should include the following:
•Immediate assessment of ABCs
•Monitoring (eg, pulse oximetry, cardiac monitor, frequent blood pressure measurements, blood glucose measurement)
•Stabilization (eg, oxygen, administration of IV fluids to unstable patients)
•Rapid transport
Emergency Department Care
•After assessment of the ABCs, place the patient on a monitor with pulse oximetry, provide oxygen via nasal canula, and obtain an ECG.
•Provide fluid resuscitation with IV crystalloid solution (eg, 0.9% normal saline).
•Administer parenteral antibiotics empirically after blood cultures are drawn. Do not delay administration of antibiotics if blood cultures cannot be drawn.
•Standard therapy for cholangitis consists of broad-spectrum antibiotics with close observation to determine the need for emergency decompression of the biliary tree.
•Patients should be nothing by mouth (NPO). Place a Foley catheter in ill patients to monitor urine output.
•In severely ill patients, treatment is immediate biliary decompression. The method depends on the degree of illness. In the past, drainage was performed surgically. Today, options of percutaneous or endoscopic drainage exist in addition to medical management with antibiotics. Endoscopic drainage has been shown to decrease mortality rates from 30% to 10%.
•Maintain medical therapy and consider elective surgery with patients who show improvement. Patients who are being medically managed and do not improve or who deteriorate should rapidly be referred to undergo either ERCP, sphincterotomy, or percutaneous drainage. See the management algorithm below.
•The mainstay of therapy is drainage. ERCP is the best method to accomplish biliary drainage.
Medication
It is critical that antibiotics are administered early in the management of cholangitis. In the ED, empiric antibiotic therapy should cover against gram-negative aerobic enteric organisms (eg, E coli, Klebsiella species, Enterobacter species), gram-positive organisms (eg, Enterococcus and Streptococcus species), and anaerobes (eg, Bacteroides fragilis, Clostridium perfringens). There is an increase of up to 85% in infectious complications when biliary cultures are not susceptible to the empiric antibiotics.
Many newer combinations have been shown to be effective as either a single agent or combination therapy. Combinations include extended-spectrum cephalosporin, metronidazole, and ampicillin. Single-agent regimens include piperacillin and tazobactam; mezlocillin; imipenem; meropenem; ticarcillin and clavulanate; or ampicillin and sulbactam, which can also be combined with metronidazole.
In patients with few comorbidities and who are well-appearing, using a single agent such as cefoxitin (second-generation cephalosporin) may be appropriate. However, cefoxitin’s anaerobic coverage is poor. Newer-generation fluoroquinolones (eg, moxifloxacin) also have broad gram-positive and gram-negative coverage and better anaerobic activity, but they are poorly effective against Pseudomonas species. In patients with multiple comorbidities or who are ill-appearing, broad-spectrum antimicrobials with pseudomonal and enterococcal coverage are recommended.
Medical Care
For acute cholecystitis, initial treatment includes bowel rest, intravenous hydration, analgesia, and intravenous antibiotics. Bacteria that are commonly associated with cholecystitis include E coli and Bacteroides fragilis and Klebsiella, Enterococcus, and Pseudomonas species. Emesis can be treated with antiemetics and nasogastric suction.
Antiemetics:
o Promethazine (Phenergan, Prorex, Anergan). For symptomatic treatment of nausea in vestibular dysfunction. Antidopaminergic agent
o Prochlorperazine (Compazine). May relieve nausea and vomiting by blocking postsynaptic mesolimbic dopamine receptors through anticholinergic effects
Analgesics:
o Meperidine (Demerol) DOC. Analgesic with multiple actions similar to those of morphine. May produce less constipation, smooth muscle spasm, and depression of cough reflex than similar analgesic doses of morphine. Doesn’t affect sphincter of Oddi as much
o Vicodin
Antibiotics
o Ciprofloxacin (Cipro) Fluoroquinolone that inhibits bacterial DNA synthesis and, consequently, growth, by inhibiting DNA gyrase and topoisomerases, which are required for replication, transcription, and translation of genetic material.
o Meropenem (Merrem) Bactericidal broad-spectrum carbapenem antibiotic that inhibits cell-wall synthesis. Effective against most gram-positive and gram-negative bacteria.
o Imipenem and cilastatin (Primaxin) For treatment of multiple organism infections in which other agents do not have wide spectrum coverage or are contraindicated due to potential for toxicity.
Surgical Care
Laparoscopic cholecystectomy is the standard of care for the surgical treatment of cholecystitis.
For elective laparoscopic cholecystectomy, the rate of conversion from a laparoscopic procedure to an open surgical procedure is approximately 5%. Some considerations regarding cholecystectomy include the following:
•Immediate cholecystectomy or cholecystotomy is usually reserved for complicated cases in which the patient has gangrene or perforation.
•Early operation within 72 hours of admission has both medical and socioeconomic benefits and is the preferred approach for patients treated by surgeons with adequate experience in laparoscopic cholecystectomy.
•For patients at high surgical risk, placement of a sonographically guided, percutaneous, transhepatic cholecystostomy drainage tube coupled with the administration of antibiotics may provide definitive therapy.
•Contraindications for laparoscopic cholecystectomy include the following:
oHigh risk for general anesthesia
oMorbid obesity
oSigns of gallbladder perforation, such as abscess, peritonitis, or fistula
oGiant gallstones or suspected malignancy
oEnd-stage liver disease with portal hypertension and severe coagulopathy
Treatment for gall stones
Cholesterol gallstones can sometimes be dissolved by oral ursodeoxycholic acid, but it may be required that the patient takes this medication for up to two years. Gallstones may recur however, once the drug is stopped. Obstruction of the common bile duct with gallstones can sometimes be relieved by endoscopic retrograde sphincterotomy (ERS) following endoscopic retrograde cholangiopancreatography (ERCP). Gallstones can be broken up using a procedure called lithotripsy (extracorporeal shock wave lithotripsy) which is a method of concentrating ultrasonic shock waves onto the stones to break them into tiny pieces. They are then passed safely in the feces. However, this form of treatment is only suitable when there are a small number of gallstones.
ERCP: technique that combines the use of endoscopy and fluoroscopy to diagnose and treat certain problems of the biliary or pancreatic ductal systems. Through the endoscope, the physician can see the inside of the stomach and duodenum, and inject dyes into the ducts in the biliary tree and pancreas so they can be seen on x-rays.
Cholangitis
Prehospital Care
Diagnosis of cholangitis is not a prehospital diagnosis. Mild cholangitis may present with abdominal pain, jaundice, and fever. When transporting these patients to the hospital, place the patient on a monitor and insert an intravenous (IV) line.
In unstable patients with cholangitis, prehospital care should include the following:
•Immediate assessment of ABCs
•Monitoring (eg, pulse oximetry, cardiac monitor, frequent blood pressure measurements, blood glucose measurement)
•Stabilization (eg, oxygen, administration of IV fluids to unstable patients)
•Rapid transport
Emergency Department Care
•After assessment of the ABCs, place the patient on a monitor with pulse oximetry, provide oxygen via nasal canula, and obtain an ECG.
•Provide fluid resuscitation with IV crystalloid solution (eg, 0.9% normal saline).
•Administer parenteral antibiotics empirically after blood cultures are drawn. Do not delay administration of antibiotics if blood cultures cannot be drawn.
•Standard therapy for cholangitis consists of broad-spectrum antibiotics with close observation to determine the need for emergency decompression of the biliary tree.
•Patients should be nothing by mouth (NPO). Place a Foley catheter in ill patients to monitor urine output.
•In severely ill patients, treatment is immediate biliary decompression. The method depends on the degree of illness. In the past, drainage was performed surgically. Today, options of percutaneous or endoscopic drainage exist in addition to medical management with antibiotics. Endoscopic drainage has been shown to decrease mortality rates from 30% to 10%.
•Maintain medical therapy and consider elective surgery with patients who show improvement. Patients who are being medically managed and do not improve or who deteriorate should rapidly be referred to undergo either ERCP, sphincterotomy, or percutaneous drainage. See the management algorithm below.
•The mainstay of therapy is drainage. ERCP is the best method to accomplish biliary drainage.
Medication
It is critical that antibiotics are administered early in the management of cholangitis. In the ED, empiric antibiotic therapy should cover against gram-negative aerobic enteric organisms (eg, E coli, Klebsiella species, Enterobacter species), gram-positive organisms (eg, Enterococcus and Streptococcus species), and anaerobes (eg, Bacteroides fragilis, Clostridium perfringens). There is an increase of up to 85% in infectious complications when biliary cultures are not susceptible to the empiric antibiotics.
Many newer combinations have been shown to be effective as either a single agent or combination therapy. Combinations include extended-spectrum cephalosporin, metronidazole, and ampicillin. Single-agent regimens include piperacillin and tazobactam; mezlocillin; imipenem; meropenem; ticarcillin and clavulanate; or ampicillin and sulbactam, which can also be combined with metronidazole.
In patients with few comorbidities and who are well-appearing, using a single agent such as cefoxitin (second-generation cephalosporin) may be appropriate. However, cefoxitin’s anaerobic coverage is poor. Newer-generation fluoroquinolones (eg, moxifloxacin) also have broad gram-positive and gram-negative coverage and better anaerobic activity, but they are poorly effective against Pseudomonas species. In patients with multiple comorbidities or who are ill-appearing, broad-spectrum antimicrobials with pseudomonal and enterococcal coverage are recommended.
Tuesday, July 27, 2010
Investigations of Choleycystitis and Cholangytis
Cholecystitis
Laboratory Studies
Although laboratory criteria are not reliable in identifying all patients with cholecystitis, the following findings may be useful in arriving at the diagnosis:
Full Blood Count
Leukocytosis with a left shift may be observed in cholecystitis.
Liver Function Test
Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels are used to evaluate the presence of hepatitis and may be elevated in cholecystitis or with common bile duct obstruction.
Bilirubin and alkaline phosphatase assays are used to evaluate evidence of common duct obstruction.
An elevated alkaline phosphatase level is observed in 25% of patients with cholecystitis
Amylase levels
Amylase/lipase assays are used to evaluate the presence of pancreatitis. Amylase may also be elevated mildly in cholecystitis..
Urinalysis is used to rule out pyelonephritis and renal calculi.
All females of childbearing age should have pregnancy testing.
Imaging Studies
Radiography (without contrast)
Gallstones may be visualized in 10-15% of cases. This finding only indicates cholelithiasis, with or without active cholecystitis.
Subdiaphragmatic free air cannot originate in the biliary tract, and, if present, it indicates another disease process.
Gas limited to the gallbladder wall or lumen represents emphysematous cholecystitis, usually because of gas-forming bacteria, such as Escherichia coli and clostridial and anaerobic streptococci species. Emphysematous cholecystitis is associated with an increased mortality rate and occurs most commonly in males with diabetes and with acalculous cholecystitis.
A diffusely calcified gallbladder (ie, porcelainized) most commonly is associated with carcinoma, although one retrospective study by Towfigh found no association between partial calcification of the gallbladder and carcinoma.
Other findings may include renal calculi, intestinal obstruction, or pneumonia.
Ultrasonography
Ultrasonography provides greater than 95% sensitivity and specificity for the diagnosis of gallstones more than 2 mm in diameter. Ultrasonography is 90-95% sensitive for cholecystitis and is 78-80% specific. Ultrasonographic findings that are suggestive of acute cholecystitis include the following: pericholecystic fluid, gallbladder wall thickening greater than 4 mm, and sonographic Murphy sign. The presence of gallstones also helps to confirm the diagnosis.
Ultrasonography is performed best following a fast of at least 8 hours because gallstones are visualized best in a distended bile-filled gallbladder.
Hepatobiliary scintigraphy (hepatoiminodiacetic acid [HIDA]/diisopropyl iminodiacetic acid [DISIDA])
HBS has been found to be up to 95% accurate in diagnosing acute cholecystitis.If the gallbladder is not visualized, intravenous morphine administration can improve the accuracy of HBS by increasing resistance to flow through the sphincter of Oddi, resulting in filling of the gallbladder if the cystic duct is patent. The addition of morphine also reduces the number of false-positive scan results observed in patients who are critically ill and immobilized with viscous bile.
CT scan and MRI
The sensitivity and specificity of CT scan and MRI for predicting acute cholecystitis have been reported to be greater than 95%.7 Spiral CT scan and MRI (unlike endoscopic retrograde cholangiopancreatography [ERCP]) have the advantage of being noninvasive, but they have no therapeutic potential and are most appropriate in cases where stones are unlikely.
Findings suggestive of cholecystitis include wall thickening (>4 mm), pericholecystic fluid, subserosal edema (in the absence of ascites), intramural gas, and sloughed mucosa.
CT scan and MRI are also useful for viewing surrounding structures if the diagnosis is uncertain.
Cholangytis
Laboratory Studies
Complete blood count
Leukocytosis: In patients with cholangitis, 79% had a WBC greater than 10,000/mL, with a mean of 13.6. Septic patients may be leukopenic.
Electrolyte panel with renal function may be performed.
Calcium level is necessary to check if pancreatitis, which can lead to hypocalcemia, is a concern.
Liver Function Test
Expect liver function test results to be consistent with cholestasis, hyperbilirubinemia (88-100%), and increased alkaline phosphatase level (78%).
Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels are usually mildly elevated.
Prothrombin time and activated partial thromboplastin time: Do not expect either to be elevated unless sepsis is associated with disseminated intravascular coagulation or underlying cirrhosis exists. A coagulation profile may be required if the patient needs operative intervention.
C-reactive protein level and erythrocyte sedimentation rate are typically elevated.3
Blood cultures (2 sets): Between 20% and 30% of blood cultures are positive. Many exhibit polymicrobial infections.
Urinalysis result is usually normal.
Blood type, screen, and crossmatch: With urgent operating room dispatch, patients need to have blood available.
Lipase: Involvement of the lower CBD may cause pancreatitis and an elevated lipase level. One third of patients have a mildly elevated lipase level.
Pancreatic enzyme elevations suggest that bile duct stones caused the cholangitis, with or without gallstone pancreatitis.6
Biliary cultures (not performed in the ED): Send biliary cultures if the patient has biliary drainage by interventional radiology or endoscopy.
Imaging Studies
Imaging studies are important to confirm the presence and cause of biliary obstruction and to rule out other conditions. Ultrasonography and CT scanning are the most commonly used first-line imaging modalities.
Ultrasonography is excellent for gallstones and cholecystitis. It is highly sensitive and specific for examining the gallbladder and assessing bile duct dilatation. However, it often misses stones in the distal bile duct.7
Transabdominal ultrasonography is the initial imaging study of choice.
Ultrasonography can differentiate intrahepatic obstruction from extrahepatic obstruction and image dilated ducts.
Advantages to sonography include the ability to be performed rapidly at the bedside by the ED physician, capacity to image other structures (eg, aorta, pancreas, liver), identification of complications (eg, perforation, empyema, abscess), and lack of radiation.
Disadvantages to sonography include operator and patient dependence, cannot image the cystic duct, and decreased sensitivity for distal CBD stones.
A normal sonogram does not rule out acute cholangitis.
Endoscopic retrograde cholangiopancreatography (ERCP) is both diagnostic and therapeutic and is considered the criterion standard for imaging the biliary system.
ERCP should be reserved for patients who may require therapeutic intervention.
Patients with a high clinical suspicion for cholangitis should proceed directly to ERCP.
ERCP has a high success rate (98%) and is considered safer than surgical and percutaneous intervention.
Diagnostic use of ERCP carries a complication rate of approximately 1.38% and a mortality rate of 0.21%. The major complication rate of therapeutic ERCP is 5.4%, and it has a mortality rate of 0.49%.
Complications include pancreatitis, bleeding, and perforation.
CT is adjunctive to and may replace ultrasonography. Spiral or helical CT improves imaging of the biliary tree. CT cholangiography uses a contrast agent that is taken up by the hepatocytes and secreted into the biliary system. This enhances the ability to visualize radiolucent stones and increases detection of other biliary pathology.
Dilated intrahepatic and extrahepatic ducts and inflammation of the biliary tree are imaged.
Gallstones are poorly visualized with traditional CT scan.
Advantages of CT include the following:
Other pathologies that are causes or complications of cholangitis (eg, ampullary tumors, pericholecystic fluid, liver abscesses) can be imaged.
Pathology that must be distinguished from cholangitis also can be observed (eg, right-sided diverticulitis, papillary necrosis, some evidence of pyelonephritis, mesenteric ischemia, ruptured appendix).
Detection of biliary pathology with CT cholangiography approaches that of ERCP.
Disadvantages of CT include poor imaging of gallstones, allergic reaction to contrast, exposure to ionizing radiation, and diminished ability to visualize the biliary tree with elevated serum bilirubin level.
Magnetic resonance cholangiopancreatography (MRCP) is a noninvasive imaging modality that is increasingly being used in the diagnosis of biliary stones and other biliary pathology.
MRCP is accurate for detecting choledocholithiasis, neoplasms, strictures, and dilations within the biliary system.
Limitations of MRCP include the inability for invasive diagnostic tests such as bile sampling, cytologic testing, stone removal, or stenting.
It has limited sensitivity for small stones (<6 name="0721">
Biliary scintigraphy (hepatic 2,6-dimethyliminodiacetic acid [HIDA] and diisopropyl iminodiacetic acid [DISIDA])
HIDA and DISIDA scans are functional studies of the gallbladder.
Obstruction of the CBD causes nonvisualization of the small intestine. A HIDA scan with complete biliary obstruction does not visualize the biliary tree.
Advantages include its ability to assess function and positive results may appear before the ducts are enlarged sonographically.
One disadvantage is that high bilirubin levels (>4.4) may decrease the sensitivity of the study. Recent eating or no food in 24 hours also may affect the study. In addition, anatomic imaging for other structures is lacking. The study takes several hours, so it is not recommended in critically ill or unstable patients.
Laboratory Studies
Although laboratory criteria are not reliable in identifying all patients with cholecystitis, the following findings may be useful in arriving at the diagnosis:
Full Blood Count
Leukocytosis with a left shift may be observed in cholecystitis.
Liver Function Test
Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels are used to evaluate the presence of hepatitis and may be elevated in cholecystitis or with common bile duct obstruction.
Bilirubin and alkaline phosphatase assays are used to evaluate evidence of common duct obstruction.
An elevated alkaline phosphatase level is observed in 25% of patients with cholecystitis
Amylase levels
Amylase/lipase assays are used to evaluate the presence of pancreatitis. Amylase may also be elevated mildly in cholecystitis..
Urinalysis is used to rule out pyelonephritis and renal calculi.
All females of childbearing age should have pregnancy testing.
Imaging Studies
Radiography (without contrast)
Gallstones may be visualized in 10-15% of cases. This finding only indicates cholelithiasis, with or without active cholecystitis.
Subdiaphragmatic free air cannot originate in the biliary tract, and, if present, it indicates another disease process.
Gas limited to the gallbladder wall or lumen represents emphysematous cholecystitis, usually because of gas-forming bacteria, such as Escherichia coli and clostridial and anaerobic streptococci species. Emphysematous cholecystitis is associated with an increased mortality rate and occurs most commonly in males with diabetes and with acalculous cholecystitis.
A diffusely calcified gallbladder (ie, porcelainized) most commonly is associated with carcinoma, although one retrospective study by Towfigh found no association between partial calcification of the gallbladder and carcinoma.
Other findings may include renal calculi, intestinal obstruction, or pneumonia.
Ultrasonography
Ultrasonography provides greater than 95% sensitivity and specificity for the diagnosis of gallstones more than 2 mm in diameter. Ultrasonography is 90-95% sensitive for cholecystitis and is 78-80% specific. Ultrasonographic findings that are suggestive of acute cholecystitis include the following: pericholecystic fluid, gallbladder wall thickening greater than 4 mm, and sonographic Murphy sign. The presence of gallstones also helps to confirm the diagnosis.
Ultrasonography is performed best following a fast of at least 8 hours because gallstones are visualized best in a distended bile-filled gallbladder.
Hepatobiliary scintigraphy (hepatoiminodiacetic acid [HIDA]/diisopropyl iminodiacetic acid [DISIDA])
HBS has been found to be up to 95% accurate in diagnosing acute cholecystitis.If the gallbladder is not visualized, intravenous morphine administration can improve the accuracy of HBS by increasing resistance to flow through the sphincter of Oddi, resulting in filling of the gallbladder if the cystic duct is patent. The addition of morphine also reduces the number of false-positive scan results observed in patients who are critically ill and immobilized with viscous bile.
CT scan and MRI
The sensitivity and specificity of CT scan and MRI for predicting acute cholecystitis have been reported to be greater than 95%.7 Spiral CT scan and MRI (unlike endoscopic retrograde cholangiopancreatography [ERCP]) have the advantage of being noninvasive, but they have no therapeutic potential and are most appropriate in cases where stones are unlikely.
Findings suggestive of cholecystitis include wall thickening (>4 mm), pericholecystic fluid, subserosal edema (in the absence of ascites), intramural gas, and sloughed mucosa.
CT scan and MRI are also useful for viewing surrounding structures if the diagnosis is uncertain.
Cholangytis
Laboratory Studies
Complete blood count
Leukocytosis: In patients with cholangitis, 79% had a WBC greater than 10,000/mL, with a mean of 13.6. Septic patients may be leukopenic.
Electrolyte panel with renal function may be performed.
Calcium level is necessary to check if pancreatitis, which can lead to hypocalcemia, is a concern.
Liver Function Test
Expect liver function test results to be consistent with cholestasis, hyperbilirubinemia (88-100%), and increased alkaline phosphatase level (78%).
Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels are usually mildly elevated.
Prothrombin time and activated partial thromboplastin time: Do not expect either to be elevated unless sepsis is associated with disseminated intravascular coagulation or underlying cirrhosis exists. A coagulation profile may be required if the patient needs operative intervention.
C-reactive protein level and erythrocyte sedimentation rate are typically elevated.3
Blood cultures (2 sets): Between 20% and 30% of blood cultures are positive. Many exhibit polymicrobial infections.
Urinalysis result is usually normal.
Blood type, screen, and crossmatch: With urgent operating room dispatch, patients need to have blood available.
Lipase: Involvement of the lower CBD may cause pancreatitis and an elevated lipase level. One third of patients have a mildly elevated lipase level.
Pancreatic enzyme elevations suggest that bile duct stones caused the cholangitis, with or without gallstone pancreatitis.6
Biliary cultures (not performed in the ED): Send biliary cultures if the patient has biliary drainage by interventional radiology or endoscopy.
Imaging Studies
Imaging studies are important to confirm the presence and cause of biliary obstruction and to rule out other conditions. Ultrasonography and CT scanning are the most commonly used first-line imaging modalities.
Ultrasonography is excellent for gallstones and cholecystitis. It is highly sensitive and specific for examining the gallbladder and assessing bile duct dilatation. However, it often misses stones in the distal bile duct.7
Transabdominal ultrasonography is the initial imaging study of choice.
Ultrasonography can differentiate intrahepatic obstruction from extrahepatic obstruction and image dilated ducts.
Advantages to sonography include the ability to be performed rapidly at the bedside by the ED physician, capacity to image other structures (eg, aorta, pancreas, liver), identification of complications (eg, perforation, empyema, abscess), and lack of radiation.
Disadvantages to sonography include operator and patient dependence, cannot image the cystic duct, and decreased sensitivity for distal CBD stones.
A normal sonogram does not rule out acute cholangitis.
Endoscopic retrograde cholangiopancreatography (ERCP) is both diagnostic and therapeutic and is considered the criterion standard for imaging the biliary system.
ERCP should be reserved for patients who may require therapeutic intervention.
Patients with a high clinical suspicion for cholangitis should proceed directly to ERCP.
ERCP has a high success rate (98%) and is considered safer than surgical and percutaneous intervention.
Diagnostic use of ERCP carries a complication rate of approximately 1.38% and a mortality rate of 0.21%. The major complication rate of therapeutic ERCP is 5.4%, and it has a mortality rate of 0.49%.
Complications include pancreatitis, bleeding, and perforation.
CT is adjunctive to and may replace ultrasonography. Spiral or helical CT improves imaging of the biliary tree. CT cholangiography uses a contrast agent that is taken up by the hepatocytes and secreted into the biliary system. This enhances the ability to visualize radiolucent stones and increases detection of other biliary pathology.
Dilated intrahepatic and extrahepatic ducts and inflammation of the biliary tree are imaged.
Gallstones are poorly visualized with traditional CT scan.
Advantages of CT include the following:
Other pathologies that are causes or complications of cholangitis (eg, ampullary tumors, pericholecystic fluid, liver abscesses) can be imaged.
Pathology that must be distinguished from cholangitis also can be observed (eg, right-sided diverticulitis, papillary necrosis, some evidence of pyelonephritis, mesenteric ischemia, ruptured appendix).
Detection of biliary pathology with CT cholangiography approaches that of ERCP.
Disadvantages of CT include poor imaging of gallstones, allergic reaction to contrast, exposure to ionizing radiation, and diminished ability to visualize the biliary tree with elevated serum bilirubin level.
Magnetic resonance cholangiopancreatography (MRCP) is a noninvasive imaging modality that is increasingly being used in the diagnosis of biliary stones and other biliary pathology.
MRCP is accurate for detecting choledocholithiasis, neoplasms, strictures, and dilations within the biliary system.
Limitations of MRCP include the inability for invasive diagnostic tests such as bile sampling, cytologic testing, stone removal, or stenting.
It has limited sensitivity for small stones (<6 name="0721">
Biliary scintigraphy (hepatic 2,6-dimethyliminodiacetic acid [HIDA] and diisopropyl iminodiacetic acid [DISIDA])
HIDA and DISIDA scans are functional studies of the gallbladder.
Obstruction of the CBD causes nonvisualization of the small intestine. A HIDA scan with complete biliary obstruction does not visualize the biliary tree.
Advantages include its ability to assess function and positive results may appear before the ducts are enlarged sonographically.
One disadvantage is that high bilirubin levels (>4.4) may decrease the sensitivity of the study. Recent eating or no food in 24 hours also may affect the study. In addition, anatomic imaging for other structures is lacking. The study takes several hours, so it is not recommended in critically ill or unstable patients.
Complications of Cholangitis
o Liver failure, hepatic abscesses, and microabscesses- chronic inflammation of the bile ducts throughout your liver can lead to tissue scarring (cirrhosis), liver cell death and, eventually, the inability of your liver to function properly.
o Bacteremia (25-40%); gram-negative sepsis
o Acute renal failure
o Repeated infections. If scarring of the bile ducts impairs the flow of bile out of the liver, you may experience frequent infections in the bile ducts.
o Bacteremia (25-40%); gram-negative sepsis
o Acute renal failure
o Repeated infections. If scarring of the bile ducts impairs the flow of bile out of the liver, you may experience frequent infections in the bile ducts.
Complications of cholecystitis
• Gallbladder distention. If your gallbladder becomes inflamed due to bile buildup, it may stretch and swell beyond its normal size (hydrops), which can cause pain and increase the risk of a tear (perforation) in your gallbladder, as well as infection and tissue death.
• Infection (sepsis, cholangitis). If bile builds up within your gallbladder, causing cholecystitis, the bile may become infected (empyema). This infection can increase the risk of a tear in your gallbladder that could allow the infection to spread to your blood or to other parts of your body.
• Perforation. A tear (perforation) in your gallbladder may be caused by gallbladder distention or gangrene that occurs as a result of cholecystitis. When perforation is localized, it may be seen as pericholecystic fluid by ultrasound. Abscess formation is common. Free perforation also can occur, releasing bile and inflammatory matter intraperitoneally, causing peritonitis.
- Gallstone ileus
o When perforation occurs next to a hollow viscus, a gallbladder enteric fistula can be formed.
o Fistulas into the duodenum are most common. When gallstones are passed directly through the fistula into the small bowel, if they are greater than 2.5 cm, they can obstruct the ileocecal valve. This causes gallstone ileus.
• Pancreatitis - The most common cause of acute pancreatitis is the presence of gallstones - small, pebble-like substances made of hardened bile - that cause inflammation in the pancreas as they pass through the common bile duct
• Hepatitis
• Infection (sepsis, cholangitis). If bile builds up within your gallbladder, causing cholecystitis, the bile may become infected (empyema). This infection can increase the risk of a tear in your gallbladder that could allow the infection to spread to your blood or to other parts of your body.
• Perforation. A tear (perforation) in your gallbladder may be caused by gallbladder distention or gangrene that occurs as a result of cholecystitis. When perforation is localized, it may be seen as pericholecystic fluid by ultrasound. Abscess formation is common. Free perforation also can occur, releasing bile and inflammatory matter intraperitoneally, causing peritonitis.
- Gallstone ileus
o When perforation occurs next to a hollow viscus, a gallbladder enteric fistula can be formed.
o Fistulas into the duodenum are most common. When gallstones are passed directly through the fistula into the small bowel, if they are greater than 2.5 cm, they can obstruct the ileocecal valve. This causes gallstone ileus.
• Pancreatitis - The most common cause of acute pancreatitis is the presence of gallstones - small, pebble-like substances made of hardened bile - that cause inflammation in the pancreas as they pass through the common bile duct
• Hepatitis
Monday, July 26, 2010
Definition of Cholangitis and Epidemiology of Cholecystitis.
Definition of Cholangitis
- Can be broken down into its Greek origins: Chol- (bile), -ang- (vessel), -itis (inflammation)
- Inflammation or infection of the biliary tract.
- Most commonly caused by choledocolithiasis.
- Characterised by Charcot's triad: Fever, jaundice, and right upper quadrant pain
- Types
- Ascending cholangitis
- Primary sclerosing cholangitis (PSC) is a chronic, progressive,inflammatory disease characterized by fibrosis of the bile ducts. The cause is unknown, but a hypersensitivity reaction is implicated. Patients present with abnormalities of liver function tests and progressive intermittent obstructive jaundice, which may be associated with fever chills, night sweats, pain, and itching
- Secondary sclerosing cholangitis (SSC) is a chronic cholestatic biliary disease, characterized by inflammation, obliterative fibrosis of the bile ducts, stricture formation and progressive destruction of the biliary tree that leads to biliary cirrhosis.
- Cholangiohepatitis, or recurrent pyogenic cholangitis (RPC), is characterized by a recurrent syndrome of bacterial cholangitis that occurs in association with intrahepatic pigment stones and intrahepatic biliary obstruction.
Cholecystitis Epidemiology
Frequency
United States
An estimated 10-20% of Americans have gallstones, and as many as one third of these people develop acute cholecystitis. Cholecystectomy for either recurrent biliary colic or acute cholecystitis is the most common major surgical procedure performed by general surgeons, resulting in approximately 500,000 operations annually.
International
Cholelithiasis, the major risk factor for cholecystitis, has an increased prevalence among people of Scandinavian descent, Pima Indians, and Hispanic populations, whereas cholelithiasis is less common among individuals from sub-Saharan Africa and Asia.3,4
Mortality/Morbidity
- Most patients with acute cholecystitis have a complete remission within 1-4 days. However, 25-30% of patients either require surgery or develop some complication.
- Patients with acalculous cholecystitis have a mortality rate ranging from 10-50%, which far exceeds the expected 4% mortality rate observed in patients with calculous cholecystitis. Emphysematous cholecystitis has a mortality rate approaching 15%.
- Perforation occurs in 10-15% of cases.
Race
- Pima Indian and Scandinavian people have the highest prevalence of cholelithiasis and, consequently, cholecystitis.
- Populations at the lowest risk reside in sub-Saharan Africa and Asia.
- In the United States, white people have a higher prevalence than black people.
Sex
- Gallstones are 2-3 times more frequent in females than in males, resulting in a higher incidence of calculous cholecystitis in females.
- Elevated progesterone levels during pregnancy may cause biliary stasis, resulting in higher rates of gallbladder disease in pregnant females.
- Acalculous cholecystitis is observed more often in elderly men.
Age
The incidence of cholecystitis increases with age. The physiologic explanation for the increasing incidence of gallstone disease in the elderly population is unclear. The increased incidence in elderly men has been linked to changing androgen-to-estrogen ratios.
Definition of Cholangitis and Epidemiology of Cholecystitis.
Definition of Cholangitis
- Can be broken down into its Greek origins: Chol- (bile), -ang- (vessel), -itis (inflammation)
- Inflammation or infection of the biliary tract.
- Most commonly caused by choledocolithiasis.
- Characterised by Charcot's triad: Fever, jaundice, and right upper quadrant pain
- Types
- Ascending cholangitis
- Primary sclerosing cholangitis (PSC) is a chronic, progressive,inflammatory disease characterized by fibrosis of the bile ducts. The cause is unknown, but a hypersensitivity reaction is implicated. Patients present with abnormalities of liver function tests and progressive intermittent obstructive jaundice, which may be associated with fever chills, night sweats, pain, and itching
- Secondary sclerosing cholangitis (SSC) is a chronic cholestatic biliary disease, characterized by inflammation, obliterative fibrosis of the bile ducts, stricture formation and progressive destruction of the biliary tree that leads to biliary cirrhosis.
- Cholangiohepatitis, or recurrent pyogenic cholangitis (RPC), is characterized by a recurrent syndrome of bacterial cholangitis that occurs in association with intrahepatic pigment stones and intrahepatic biliary obstruction.
Cholecystitis Epidemiology
Frequency
United States
An estimated 10-20% of Americans have gallstones, and as many as one third of these people develop acute cholecystitis. Cholecystectomy for either recurrent biliary colic or acute cholecystitis is the most common major surgical procedure performed by general surgeons, resulting in approximately 500,000 operations annually.
International
Cholelithiasis, the major risk factor for cholecystitis, has an increased prevalence among people of Scandinavian descent, Pima Indians, and Hispanic populations, whereas cholelithiasis is less common among individuals from sub-Saharan Africa and Asia.3,4
Mortality/Morbidity
- Most patients with acute cholecystitis have a complete remission within 1-4 days. However, 25-30% of patients either require surgery or develop some complication.
- Patients with acalculous cholecystitis have a mortality rate ranging from 10-50%, which far exceeds the expected 4% mortality rate observed in patients with calculous cholecystitis. Emphysematous cholecystitis has a mortality rate approaching 15%.
- Perforation occurs in 10-15% of cases.
Race
- Pima Indian and Scandinavian people have the highest prevalence of cholelithiasis and, consequently, cholecystitis.
- Populations at the lowest risk reside in sub-Saharan Africa and Asia.
- In the United States, white people have a higher prevalence than black people.
Sex
- Gallstones are 2-3 times more frequent in females than in males, resulting in a higher incidence of calculous cholecystitis in females.
- Elevated progesterone levels during pregnancy may cause biliary stasis, resulting in higher rates of gallbladder disease in pregnant females.
- Acalculous cholecystitis is observed more often in elderly men.
Age
The incidence of cholecystitis increases with age. The physiologic explanation for the increasing incidence of gallstone disease in the elderly population is unclear. The increased incidence in elderly men has been linked to changing androgen-to-estrogen ratios.
Sunday, July 25, 2010
Cholecystitis and Cholangitis
Definition of Cholecystitis
• It is defined as inflammation of the gallbladder.
• The Inflammation can be sterile or bacterial. (50-75% of cases)
• Occur most commonly due to obstruction of the cystic duct from cholelithiasis(gallstones, 90%). Remaining 10% are a calculous.
• More common in females by 2-3 times and increases with age.
• "fair, female, fat, and fertile" RF of cholecystitis.
• It is said that less common in Asia because of decrease choleithiasis incidence. If there are pigmented stones are more common compared to cholesterol stones.
Pathophysiology of Cholangitis
• Etiology – Biliary tract obstruction, Elevated intraluminal pressure, Infection of bile, Biliary tract manipulation/stents and Autoimmune (chronic liver disease).
• Biliary tract obstruction +Bacterial ascend from duodenum or portal venous blood Diminish host antibacterial defences Increase small bowel bacterial colonization
• Increase biliary pressure Push infection into biliary canaliculi, hepatic veins and lymphatics Bacteremia (25-40%),
• Autoimmune Inflammation and fibrosis of the intrahepatic and extrahepatic bile ducts Portal hypertension and cirrhosis.
• It is defined as inflammation of the gallbladder.
• The Inflammation can be sterile or bacterial. (50-75% of cases)
• Occur most commonly due to obstruction of the cystic duct from cholelithiasis(gallstones, 90%). Remaining 10% are a calculous.
• More common in females by 2-3 times and increases with age.
• "fair, female, fat, and fertile" RF of cholecystitis.
• It is said that less common in Asia because of decrease choleithiasis incidence. If there are pigmented stones are more common compared to cholesterol stones.
Pathophysiology of Cholangitis
• Etiology – Biliary tract obstruction, Elevated intraluminal pressure, Infection of bile, Biliary tract manipulation/stents and Autoimmune (chronic liver disease).
• Biliary tract obstruction +Bacterial ascend from duodenum or portal venous blood Diminish host antibacterial defences Increase small bowel bacterial colonization
• Increase biliary pressure Push infection into biliary canaliculi, hepatic veins and lymphatics Bacteremia (25-40%),
• Autoimmune Inflammation and fibrosis of the intrahepatic and extrahepatic bile ducts Portal hypertension and cirrhosis.
Wednesday, July 21, 2010
Cholesterol Levels
This is just some additional useful info! :D
Total Cholesterol Level
Less than 200 mg/dL: Desirable level that puts you at lower risk for coronary heart disease. A cholesterol level of 200 mg/dL or higher raises your risk.
200 to 239 mg/dL: Borderline high
240 mg/dL and above: High blood cholesterol. A person with this level has more than twice the risk of coronary heart disease as someone whose cholesterol is below 200 mg/dL.
HDL Cholesterol Level
Less than 40 mg/dL(for men), Less than 50 mg/dL(for women):Low HDL cholesterol. A major risk factor for heart disease.
60 mg/dL and above: High HDL cholesterol. An HDL of 60 mg/dL and above is considered protective against heart disease.
If your total cholesterol is 200 mg/dL or more, or your HDL cholesterol is less than 40 mg/dL (for men) and less than 50 mg/dL (for women), you need to have a lipoprotein profile done to determine your LDL cholesterol and triglyceride levels.
LDL Cholesterol Level
Less than 100 mg/dL Optimal
100 to 129 mg/dL Near or above optimal
130 to 159 mg/dL Borderline high
160 to 189 mg/dL High
190 mg/dL and above Very high
Triglyceride Level
Less than 150 mg/dL Normal
150–199 mg/dL Borderline high
200–499 mg/dL High
500 mg/dL and above Very high
http://www.americanheart.org/presenter.jhtml?identifier=4500
Total Cholesterol Level
Less than 200 mg/dL: Desirable level that puts you at lower risk for coronary heart disease. A cholesterol level of 200 mg/dL or higher raises your risk.
200 to 239 mg/dL: Borderline high
240 mg/dL and above: High blood cholesterol. A person with this level has more than twice the risk of coronary heart disease as someone whose cholesterol is below 200 mg/dL.
HDL Cholesterol Level
Less than 40 mg/dL(for men), Less than 50 mg/dL(for women):Low HDL cholesterol. A major risk factor for heart disease.
60 mg/dL and above: High HDL cholesterol. An HDL of 60 mg/dL and above is considered protective against heart disease.
If your total cholesterol is 200 mg/dL or more, or your HDL cholesterol is less than 40 mg/dL (for men) and less than 50 mg/dL (for women), you need to have a lipoprotein profile done to determine your LDL cholesterol and triglyceride levels.
LDL Cholesterol Level
Less than 100 mg/dL Optimal
100 to 129 mg/dL Near or above optimal
130 to 159 mg/dL Borderline high
160 to 189 mg/dL High
190 mg/dL and above Very high
Triglyceride Level
Less than 150 mg/dL Normal
150–199 mg/dL Borderline high
200–499 mg/dL High
500 mg/dL and above Very high
http://www.americanheart.org/presenter.jhtml?identifier=4500
Ornish Diet
This diet was originated by Dr. Dean Ornish M.D., in his book, 'A Program for Reversing Heart Disease.' It is a diet was part of a lifestyle improvement program that has scientifically been proven to reverse heart disease. The diet that Ornish designed was similar to the regimen developed in the 1970s by Nathan Pritikin to combat heart disease. Both diets emphasize foods that are very low in fat and yet filling, including high-fiber grains and legumes (beans and peas). It does allow non-fat dairy foods and processed or refined foods in moderation.
Dr. Ornish presents two diets: the Reversal Diet and the Prevention Diet. The Reversal Diet is for people with known heart disease who want to reverse its effects and lower their heart attack risk. The Prevention Diet is recommended for people who do not have heart disease, but whose cholesterol levels are above 150, or for people with a ratio of total cholesterol to high-density lipoprotein (HDL or "good" cholesterol) that is less than 3.0.
Both the Reversal and Prevention Diets are vegetarian diets. The diet supplies only 10% of calories from fat. It excludes cholesterol and saturated fat, including all animal products (except egg whites and nonfat dairy products), nuts, seeds, avocados, chocolate, olives, and coconuts. Oils are eliminated except a small amount of canola oil for cooking, and oil that supplies omega-3 essential fatty acids. The Ornish diet also prohibits caffeine, but allows a moderate intake of alcohol, sugar, and salt. There is no restriction on the calorie intake so long as the diet is confined within the recommended foods.
Ornish states that his diet alone is not sufficient for reversing heart disease, but is only one part of an overall program that includes exercise, yoga, meditation, stress reduction, and lifestyle changes. In fact, patients are encouraged to confront emotional aspects of their healing as well as physical concerns like diet and high cholesterol.
From this program Dr. Ornish has developed The Dean Ornish Life Choice Program, introduced in his book 'Eat More, Weigh Less.' It is marketed as a weight-loss diet. Like the Reversal and Prevention Diets, the Life Choice Program is vegetarian and very low in fat.
Description of the Diet
• All foods containing cholesterol and saturated fats are prohibited from the diet. Saturated fats are found in meat, dairy products, oils, nuts, seed, and avocados, which are all forbidden by the Ornish diet.
• The level of fat in the diet is reduced to only 10% of the total calories. This level is much lower than the diet recommended by the American Heart Association, which recommends up to 30% of calories from fat. The typical American diet is up to 50% fat.
• The Ornish diet is vegetarian diet. All meats are eliminated from the diet.
• Egg whites and nonfat dairy products are permitted.
• The Ornish diet is 10% fat, 20% protein, and 70% carbohydrates. The typical American diet is 45% fat, 25% protein and 30% carbohydrates, with nearly 500 mg of cholesterol per day.
• The Ornish diet consists mainly of complex carbohydrates. These are present in fruits, vegetables, grains and beans.
• The Ornish diet restricts but does not eliminate simple carbohydrates such as sugar, honey, and alcohol. They contain lots of calories but little fiber or nutrients.
• The Ornish diet emphasizes high-fiber foods, which includes most complex carbohydrates. High-fiber diets have been shown to reduce cholesterol and have other beneficial effects.
• The Ornish diet is slightly lower in protein than that found in a typical American diet.
• The Ornish program teaches ways to ensure an adequate supply of complete proteins from vegetable sources in the diet. This is done by combining rice and beans, tofu and rice, pasta and beans, baked beans and wheat bread, or oatmeal with nonfat yogurt over the course of a day. Egg whites are another source of protein on the Ornish diet.
• People are allowed to eat as much food as they wish, as long as the 10%-of-calories-from-fat rule is maintained, and as long as only approved foods are eaten.
• Eat small meals throughout the day rather than eating three big meals.
http://www.holistic-online.com/Remedies/weight/weight_diet-ornish-diet.htm
Dr. Ornish presents two diets: the Reversal Diet and the Prevention Diet. The Reversal Diet is for people with known heart disease who want to reverse its effects and lower their heart attack risk. The Prevention Diet is recommended for people who do not have heart disease, but whose cholesterol levels are above 150, or for people with a ratio of total cholesterol to high-density lipoprotein (HDL or "good" cholesterol) that is less than 3.0.
Both the Reversal and Prevention Diets are vegetarian diets. The diet supplies only 10% of calories from fat. It excludes cholesterol and saturated fat, including all animal products (except egg whites and nonfat dairy products), nuts, seeds, avocados, chocolate, olives, and coconuts. Oils are eliminated except a small amount of canola oil for cooking, and oil that supplies omega-3 essential fatty acids. The Ornish diet also prohibits caffeine, but allows a moderate intake of alcohol, sugar, and salt. There is no restriction on the calorie intake so long as the diet is confined within the recommended foods.
Ornish states that his diet alone is not sufficient for reversing heart disease, but is only one part of an overall program that includes exercise, yoga, meditation, stress reduction, and lifestyle changes. In fact, patients are encouraged to confront emotional aspects of their healing as well as physical concerns like diet and high cholesterol.
From this program Dr. Ornish has developed The Dean Ornish Life Choice Program, introduced in his book 'Eat More, Weigh Less.' It is marketed as a weight-loss diet. Like the Reversal and Prevention Diets, the Life Choice Program is vegetarian and very low in fat.
Description of the Diet
• All foods containing cholesterol and saturated fats are prohibited from the diet. Saturated fats are found in meat, dairy products, oils, nuts, seed, and avocados, which are all forbidden by the Ornish diet.
• The level of fat in the diet is reduced to only 10% of the total calories. This level is much lower than the diet recommended by the American Heart Association, which recommends up to 30% of calories from fat. The typical American diet is up to 50% fat.
• The Ornish diet is vegetarian diet. All meats are eliminated from the diet.
• Egg whites and nonfat dairy products are permitted.
• The Ornish diet is 10% fat, 20% protein, and 70% carbohydrates. The typical American diet is 45% fat, 25% protein and 30% carbohydrates, with nearly 500 mg of cholesterol per day.
• The Ornish diet consists mainly of complex carbohydrates. These are present in fruits, vegetables, grains and beans.
• The Ornish diet restricts but does not eliminate simple carbohydrates such as sugar, honey, and alcohol. They contain lots of calories but little fiber or nutrients.
• The Ornish diet emphasizes high-fiber foods, which includes most complex carbohydrates. High-fiber diets have been shown to reduce cholesterol and have other beneficial effects.
• The Ornish diet is slightly lower in protein than that found in a typical American diet.
• The Ornish program teaches ways to ensure an adequate supply of complete proteins from vegetable sources in the diet. This is done by combining rice and beans, tofu and rice, pasta and beans, baked beans and wheat bread, or oatmeal with nonfat yogurt over the course of a day. Egg whites are another source of protein on the Ornish diet.
• People are allowed to eat as much food as they wish, as long as the 10%-of-calories-from-fat rule is maintained, and as long as only approved foods are eaten.
• Eat small meals throughout the day rather than eating three big meals.
http://www.holistic-online.com/Remedies/weight/weight_diet-ornish-diet.htm
Pritikin's Diet
Definition
The Pritikin diet is a heart-healthy high-carbohydrate, low-fat, moderate-exercise lifestyle diet developed in the 1960s.
Origins
Nathan Pritikin, the originator of the Pritikin Diet, was diagnosed with heart disease at the age of 42. In the late 1950s when Pritikin was diagnosed, about 40% of calories in the average American diet came from fats. Pritikin was given little medical guidance on how lifestyle changes might slow his heart disease. Although educated as an engineer, Pritikin devised his own heart-healthy diet, which he followed rigorously. Based on his experience, he opened the Pritikin Longevity Center in Florida in 1975. Here people could come and immerse themselves for one or more weeks in the Pritikin Eating Plan.
Nathan Pritikin developed cancer and committed suicide in 1985 at the age of 69. At his autopsy, doctors discovered no signs of heart disease, a fact they attributed to his rigorous life-long adherence to his diet. Robert Pritikin, Nathan’s son, took over the Longevity Center enterprises after Nathan’s death. While maintaining the core of the original diet, Robert updated some of the concepts in his book The Pritikin Principle: The Calorie Density Solution. published in 2000.
Description
The Pritikin Plan is a diet that is high in whole grains and dietary fiber, low in cholesterol, and very low in fats. Fewer than 10% of calories come from fats. This is much lower than the average twenty-first century American diet, in which about 35% of calories come from fats. It is about half the amount of fats recommended in the federal Dietary Guidelines for Americans 2005. The diet is also lower in protein than suggested in the federal guidelines. However, in general, the Pritikin Plan reflects many recommendations in the Dietary Guidelines for Americans 2005. It results in low calorie, nutritionally balanced meals. In addition, the Pritikin plan calls for 45 minutes daily of moderate exercise such as walking, another recommendation in line with mainstream medical advice.
The newest version of the Pritikin Plan calls for avoiding foods that are calorie dense. These are foods that pack a lot of calories into a small volume of food (e.g. oils, cookies, cream cheese). Instead, Plan followers are encouraged to choose low-calorie foods that provide a lot of bulk (e.g. broccoli, carrots, dried beans). This way, dieters can eat a lot of food and feel full without taking in a lot of calories. The plan does not limit the amount of healthy fruits and vegetables a dieter can eat, and it suggests that dieters divide their food among five or six smaller meals during the day.
The Pritikin Plan is based on eating a particular number of servings of each group of foods as follows:
• at least five ½-cup servings of whole grains such as wheat, oats, and brown rice or starch vegetables such as potatoes, and dried beans and peas. Refined grain products (white flour, regular pasta, white rice) are limited to two servings daily, with complete elimination of refined grain products considered optimal.
• at least four 1-cup servings of raw vegetables or ½-cup servings of cooked vegetables. Dark green, leafy, and orange or yellow vegetables are preferred.
• at least three servings of fruit, one of which can be fruit juice.
• two servings of calcium-rich foods such as nonfat milk, nonfat yogurt or fortified and enriched soymilk.
• no more than one 3.5 cooked serving of animal protein. Fish and shellfish are preferred. Lean poultry should optimally be limited to once a week and lean beef to once a month. This diet is easily adapted to vegetarians by replacing animal protein with protein from soy products, beans, or lentils.
• no more than one caffeinated drinks daily. Instead drink water, low-sodium vegetable juices, grain-based coffee substitutes (e.g. Postum) or caffeine-free teas.
• no more than four alcoholic drinks per week for women and no more than seven for men, with red wine preferred over beer or distilled spirits.
• no more than seven egg whites per week
• no more than 2 ounces (about 1/4 cup) of nuts daily
Other foods such as unsaturated oils, refined sweeteners (e.g. concentrated fruit juice, corn syrup), high-sodium condiments (e.g. soy sauce), and artificial sweeteners (e.g. Splenda) are “caution” foods. They are not recommended, but if they are used, the Plan gives guidance in how to limit them to reasonable amounts. Animal fats, processed meat, dairy products not made with non-rat milk, egg yolks, salty snacks, cakes, cookies, fried foods and similar high-calorie choices are forbidden.
The Plan also calls for at least 45 minutes of moderate exercise daily such as walking. People who check into the Longevity Center receive a personalized exercise program after a physician gives them an examination. This doctor follows their progress while at the center and makes a written report at the end of their stay that they can take home to their personal physician. People who do not visit the Longevity Center can receive support and inspiration through the Plan’s extensive Web site. Pritikin has also developed a Family Plan aimed at families with obese children.
Function
Unlike many diets, the Pritikin Plan never claims that a person will lose a certain amount of weight within a certain length of time. People who follow the Plan, which is a low calorie diet, do lose weight and keep it off so long as they stay on the plan. However, the Plan is primarily intended to cause changes in lifestyle that will promote heart health for a lifetime.
Benefits
Pritikin Diet emphasizes the following health benefits:
• lowered total cholesterol and LDL or “bad” cholesterol
• lowered blood pressure, so that people with high blood pressure may no longer need pressure-lowering drugs
• better control of insulin levels, so that people with type 2 diabetes can often control their disease through diet and without drugs
• decrease in the circulating levels of compounds that increases the risk of heart disease and blood vessel damage
• a substantially reduced risk of heart disease, hypertension, type 2 diabetes, and breast, colon, and prostate cancers.
• lifetime freedom from obesity and all of its associated health risks and lifestyle-limiting conditions
Precautions
As with any diet, people should discuss with their physician the pros and cons of the Pritikin Plan based on their individual circumstances. This diet may not be right for actively growing children.
Risks
The greatest risk to this diet is that it is too rigorous for many people, and that they will lose weight on the diet and then gain it back, causing weight cycling (yo-yo dieting) and the potential health problems that repeated weight gain and loss cause.
Research and general acceptance
Unlike many diets, the Pritikin Plan has the respect of much of the medical community and has a thirty-year history of delivering on most of its health promises. Supporters of the diet point to many studies done by both Longevity Center doctors and outside investigators and published in highly respected journals such as the Journal of the American Medical Associationand the New England Journal of Medicine. People do lose weight and keep it off, along with decreasing the risk of heart disease when following the plan.
Dietitians and nutritionists also like the fact that the diet teaches people how to eat well using ordinary foods rather than special pre-packaged foods. This keeps the cost of following the Plan low, especially since the Plan calls for dieters to eat only small quantities of meat. In addition, the Plan is designed to provide a balance of vitamins and minerals from food and does not rely on dietary supplements.
The biggest criticism of the Pritikin Plan is that it requires rigorous self-discipline to stay on for a lifetime. People who do well on the Pritikin Plan tend to be highly motivated and zealous about following the diet. Many healthcare professionals feel long-term success for most people is more likely to occur if the dieter follows a well-balanced but less rigorous diet.
Some nutritionists also take issue with whether the low fat component of the diet allows people to get enough beneficial fats such as omega-3 fatty acids and whether absorption of the fat-soluble vitamins A, D, E, and K is impaired. To date these criticisms have not been supported by research findings. However, critics were handed more ammunition by a long-term study of 49,000 American women ages 50–79 that found that a low-fat diet had no effect on the risk of developing heart disease or cancer. The study was published in February 2006 in the Journal of the American Medical Association. The findings are controversial, and go against much current medical thinking. This study will certainly stimulate additional research on low-fat diets.
http://www.diet.com/g/pritikin-diet
The Pritikin diet is a heart-healthy high-carbohydrate, low-fat, moderate-exercise lifestyle diet developed in the 1960s.
Origins
Nathan Pritikin, the originator of the Pritikin Diet, was diagnosed with heart disease at the age of 42. In the late 1950s when Pritikin was diagnosed, about 40% of calories in the average American diet came from fats. Pritikin was given little medical guidance on how lifestyle changes might slow his heart disease. Although educated as an engineer, Pritikin devised his own heart-healthy diet, which he followed rigorously. Based on his experience, he opened the Pritikin Longevity Center in Florida in 1975. Here people could come and immerse themselves for one or more weeks in the Pritikin Eating Plan.
Nathan Pritikin developed cancer and committed suicide in 1985 at the age of 69. At his autopsy, doctors discovered no signs of heart disease, a fact they attributed to his rigorous life-long adherence to his diet. Robert Pritikin, Nathan’s son, took over the Longevity Center enterprises after Nathan’s death. While maintaining the core of the original diet, Robert updated some of the concepts in his book The Pritikin Principle: The Calorie Density Solution. published in 2000.
Description
The Pritikin Plan is a diet that is high in whole grains and dietary fiber, low in cholesterol, and very low in fats. Fewer than 10% of calories come from fats. This is much lower than the average twenty-first century American diet, in which about 35% of calories come from fats. It is about half the amount of fats recommended in the federal Dietary Guidelines for Americans 2005. The diet is also lower in protein than suggested in the federal guidelines. However, in general, the Pritikin Plan reflects many recommendations in the Dietary Guidelines for Americans 2005. It results in low calorie, nutritionally balanced meals. In addition, the Pritikin plan calls for 45 minutes daily of moderate exercise such as walking, another recommendation in line with mainstream medical advice.
The newest version of the Pritikin Plan calls for avoiding foods that are calorie dense. These are foods that pack a lot of calories into a small volume of food (e.g. oils, cookies, cream cheese). Instead, Plan followers are encouraged to choose low-calorie foods that provide a lot of bulk (e.g. broccoli, carrots, dried beans). This way, dieters can eat a lot of food and feel full without taking in a lot of calories. The plan does not limit the amount of healthy fruits and vegetables a dieter can eat, and it suggests that dieters divide their food among five or six smaller meals during the day.
The Pritikin Plan is based on eating a particular number of servings of each group of foods as follows:
• at least five ½-cup servings of whole grains such as wheat, oats, and brown rice or starch vegetables such as potatoes, and dried beans and peas. Refined grain products (white flour, regular pasta, white rice) are limited to two servings daily, with complete elimination of refined grain products considered optimal.
• at least four 1-cup servings of raw vegetables or ½-cup servings of cooked vegetables. Dark green, leafy, and orange or yellow vegetables are preferred.
• at least three servings of fruit, one of which can be fruit juice.
• two servings of calcium-rich foods such as nonfat milk, nonfat yogurt or fortified and enriched soymilk.
• no more than one 3.5 cooked serving of animal protein. Fish and shellfish are preferred. Lean poultry should optimally be limited to once a week and lean beef to once a month. This diet is easily adapted to vegetarians by replacing animal protein with protein from soy products, beans, or lentils.
• no more than one caffeinated drinks daily. Instead drink water, low-sodium vegetable juices, grain-based coffee substitutes (e.g. Postum) or caffeine-free teas.
• no more than four alcoholic drinks per week for women and no more than seven for men, with red wine preferred over beer or distilled spirits.
• no more than seven egg whites per week
• no more than 2 ounces (about 1/4 cup) of nuts daily
Other foods such as unsaturated oils, refined sweeteners (e.g. concentrated fruit juice, corn syrup), high-sodium condiments (e.g. soy sauce), and artificial sweeteners (e.g. Splenda) are “caution” foods. They are not recommended, but if they are used, the Plan gives guidance in how to limit them to reasonable amounts. Animal fats, processed meat, dairy products not made with non-rat milk, egg yolks, salty snacks, cakes, cookies, fried foods and similar high-calorie choices are forbidden.
The Plan also calls for at least 45 minutes of moderate exercise daily such as walking. People who check into the Longevity Center receive a personalized exercise program after a physician gives them an examination. This doctor follows their progress while at the center and makes a written report at the end of their stay that they can take home to their personal physician. People who do not visit the Longevity Center can receive support and inspiration through the Plan’s extensive Web site. Pritikin has also developed a Family Plan aimed at families with obese children.
Function
Unlike many diets, the Pritikin Plan never claims that a person will lose a certain amount of weight within a certain length of time. People who follow the Plan, which is a low calorie diet, do lose weight and keep it off so long as they stay on the plan. However, the Plan is primarily intended to cause changes in lifestyle that will promote heart health for a lifetime.
Benefits
Pritikin Diet emphasizes the following health benefits:
• lowered total cholesterol and LDL or “bad” cholesterol
• lowered blood pressure, so that people with high blood pressure may no longer need pressure-lowering drugs
• better control of insulin levels, so that people with type 2 diabetes can often control their disease through diet and without drugs
• decrease in the circulating levels of compounds that increases the risk of heart disease and blood vessel damage
• a substantially reduced risk of heart disease, hypertension, type 2 diabetes, and breast, colon, and prostate cancers.
• lifetime freedom from obesity and all of its associated health risks and lifestyle-limiting conditions
Precautions
As with any diet, people should discuss with their physician the pros and cons of the Pritikin Plan based on their individual circumstances. This diet may not be right for actively growing children.
Risks
The greatest risk to this diet is that it is too rigorous for many people, and that they will lose weight on the diet and then gain it back, causing weight cycling (yo-yo dieting) and the potential health problems that repeated weight gain and loss cause.
Research and general acceptance
Unlike many diets, the Pritikin Plan has the respect of much of the medical community and has a thirty-year history of delivering on most of its health promises. Supporters of the diet point to many studies done by both Longevity Center doctors and outside investigators and published in highly respected journals such as the Journal of the American Medical Associationand the New England Journal of Medicine. People do lose weight and keep it off, along with decreasing the risk of heart disease when following the plan.
Dietitians and nutritionists also like the fact that the diet teaches people how to eat well using ordinary foods rather than special pre-packaged foods. This keeps the cost of following the Plan low, especially since the Plan calls for dieters to eat only small quantities of meat. In addition, the Plan is designed to provide a balance of vitamins and minerals from food and does not rely on dietary supplements.
The biggest criticism of the Pritikin Plan is that it requires rigorous self-discipline to stay on for a lifetime. People who do well on the Pritikin Plan tend to be highly motivated and zealous about following the diet. Many healthcare professionals feel long-term success for most people is more likely to occur if the dieter follows a well-balanced but less rigorous diet.
Some nutritionists also take issue with whether the low fat component of the diet allows people to get enough beneficial fats such as omega-3 fatty acids and whether absorption of the fat-soluble vitamins A, D, E, and K is impaired. To date these criticisms have not been supported by research findings. However, critics were handed more ammunition by a long-term study of 49,000 American women ages 50–79 that found that a low-fat diet had no effect on the risk of developing heart disease or cancer. The study was published in February 2006 in the Journal of the American Medical Association. The findings are controversial, and go against much current medical thinking. This study will certainly stimulate additional research on low-fat diets.
http://www.diet.com/g/pritikin-diet
Weight Watchers
A simplified version can be found here! http://www.aboutww.com/weight-watchers-points.htm
Healthy weight loss
First, any approach developed by Weight Watchers must provide healthy weight loss, which means:
Fits into your life
Second, any Weight Watchers approach must be realistic, practical and livable. It must also be flexible enough so that people can apply the approaches that work well for them. That means encouraging the achievement of realistic goals. For example, we do not recommend that a person with a lot of weight to lose begin with a weight-loss goal that defines "ultimate success." Rather, we start with our "5% or 10% goal" or losing 5% or 10% of body weight (e.g., a 5% goal for someone who is 200 pounds is 10 pounds and a 10% goal would be 20 pounds). A weight loss of 5% to 10% translates into significant health benefits. Likewise, pacing weight loss and following a system that encourages food and activity choices that are livable and sustainable in the real world is key. Weight Watchers is designed on the premise that weight management
needs to fit into your life, not be your life.
Informed choices
Third, Weight Watchers believes in imparting knowledge. At Weight Watchers, people learn not only what to do, but why. This knowledge brings understanding and with understanding comes the confidence needed to make informed choices and live by them.
A holistic view
Finally, the Weight Watchers approach must be comprehensive. Sustained weight loss comes from taking a holistic view of all its components – food, exercise, behavior and a supportive atmosphere.
Momentum Plan
The Momentum plan is based on Weight Watchers patented POINTS® Food System that helps you evaluate the weight-loss impact of foods. Every food has a POINTS value – a small, easy to remember number (e.g, 1, 2, 3). The number is based on the calories, grams of total fat and grams of dietary fiber of a specific portion of the food. The system does not require exact weighing and measuring, but instead encourages people to focus on the bigger picture by building awareness of the food choices they make and eating reasonable portions.
The POINTS formula gently guides food choices by encouraging selection of healthy foods with a lower energy density because that's where you get the most food for a given POINTS value. Based on a person's current weight, height, gender, age and level of daily activity, a POINTS Target is established, that is the total of POINTS values for the day. Choosing foods to meet the Target ensures a healthful rate of weight loss. On the Momentum plan, we teach you how to be stay aware of your food choices by tracking what you eat – a proven method to enhance weight-loss success.
This plan also encourages the selection of Filling Foods to help keep you satisfied longer. The Filling Foods are a list of foods comprised from all the food groups: fruits and vegetables; grains and starches; lean meats, fish and poultry: eggs, and dairy products. We pre-selected these foods because they provide eating satisfaction and fill you up without the empty calories. They are low in energy density and have a low potential for overeating based on our research.
Healthy weight loss
First, any approach developed by Weight Watchers must provide healthy weight loss, which means:
- Produce a rate of weight loss of up to two pounds per week (after the first 3 weeks, during which losses may be greater due to water loss).
- Guide food choices that not only reduce calories, but meet current scientific recommendations for nutritional completeness and reduced disease risk.
- Construct an activity plan that provides the full range of weight- and health-related benefits that exercise offers.
- Be sustainable. Healthy weight loss is weight loss that lasts, so it is necessary to look beyond losing the excess weight and address keeping it off.
Fits into your life
Second, any Weight Watchers approach must be realistic, practical and livable. It must also be flexible enough so that people can apply the approaches that work well for them. That means encouraging the achievement of realistic goals. For example, we do not recommend that a person with a lot of weight to lose begin with a weight-loss goal that defines "ultimate success." Rather, we start with our "5% or 10% goal" or losing 5% or 10% of body weight (e.g., a 5% goal for someone who is 200 pounds is 10 pounds and a 10% goal would be 20 pounds). A weight loss of 5% to 10% translates into significant health benefits. Likewise, pacing weight loss and following a system that encourages food and activity choices that are livable and sustainable in the real world is key. Weight Watchers is designed on the premise that weight management
needs to fit into your life, not be your life.
Informed choices
Third, Weight Watchers believes in imparting knowledge. At Weight Watchers, people learn not only what to do, but why. This knowledge brings understanding and with understanding comes the confidence needed to make informed choices and live by them.
A holistic view
Finally, the Weight Watchers approach must be comprehensive. Sustained weight loss comes from taking a holistic view of all its components – food, exercise, behavior and a supportive atmosphere.
Momentum Plan
The Momentum plan is based on Weight Watchers patented POINTS® Food System that helps you evaluate the weight-loss impact of foods. Every food has a POINTS value – a small, easy to remember number (e.g, 1, 2, 3). The number is based on the calories, grams of total fat and grams of dietary fiber of a specific portion of the food. The system does not require exact weighing and measuring, but instead encourages people to focus on the bigger picture by building awareness of the food choices they make and eating reasonable portions.
The POINTS formula gently guides food choices by encouraging selection of healthy foods with a lower energy density because that's where you get the most food for a given POINTS value. Based on a person's current weight, height, gender, age and level of daily activity, a POINTS Target is established, that is the total of POINTS values for the day. Choosing foods to meet the Target ensures a healthful rate of weight loss. On the Momentum plan, we teach you how to be stay aware of your food choices by tracking what you eat – a proven method to enhance weight-loss success.
This plan also encourages the selection of Filling Foods to help keep you satisfied longer. The Filling Foods are a list of foods comprised from all the food groups: fruits and vegetables; grains and starches; lean meats, fish and poultry: eggs, and dairy products. We pre-selected these foods because they provide eating satisfaction and fill you up without the empty calories. They are low in energy density and have a low potential for overeating based on our research.
Tuesday, July 20, 2010
Atkins Diet
· Designed by Dr Atkins in the year 1972 that suggests a high protein, high fat and low carbohydrate diet.
· Aims to:
o Reduce weight
o Reduce hunger
o Healthier lifestyle (great increase in energy)
· Theory behind the low carbohydrate and high fat and protein diet.
o Weight loss
§ By eating a low carbohydrate diet, the body switches its primary fuel source to fat instead. Therefore, your body will be burning fat and there can be weight reduction.
§ Normally, glucose, broken down from carbohydrates, will be the primary fuel source. When carbohydrate is broken down into glucose and enters the blood stream, a rise in the blood glucose level triggers the release of insulin which converts glucose into glycogen.
§ After a heavy carb meal the body will stop burning fat as insulin level rises to deal with the elevated blood glucose level. Fat calories are always pushed to the back as a back-up fuel source. Hence, insulin is called the “fat hormone” according to Dr Atkins.
o Reduce hunger
§ By eating foods primarily consisting of protein, fat and fibre, the body produces far less insulin. Therefore it prevents unnecessary spikes in the blood sugar level. Hence the blood sugar level is steady with the energy level. The body doesn’t crave for a fast fix energy booster in the form of sugary and starchy food
· Consists of four phases
o In phase one (Atkins Diet Induction Phase), carbohydrate consumption is restricted to 20 grams per day. Most carbohydrate can be obtained from salad and other non-starchy vegetables.
o In Atkins Diet phase two (Ongoing Weight Loss) you add carbohydrate, in the form of nutrient-dense and fibre-rich foods, by increasing to 25 grams daily the first week, 30 grams daily the next week and so on until your weight loss stops. Then subtract 5 grams of carbohydrate from your daily intake so that you continue sustained, moderate weight loss.
o Atkins Diet Phase three's (Pre-Maintenance) objective is to make the transition from weight loss to weight maintenance by increasing the daily carbohydrate intake in 10-gram increments each week so long as very gradual weight loss is maintained.
o And the Atkins Diet final phase (Lifetime Maintenance) is the foundation for a lifetime of better health. In this phase you can select from a wide variety of foods while controlling carbohydrate intake to ensure weight maintenance and a sense of well-being.
· Types of low carb food
o Meats
Bacon , Beef , Calf Liver , Chicken , Cornish Game Hen , Duck , Goose , Ham , Kielbasa , Lamb , Pork , Quail , Sausage ,Steak , Turkey , Veal Steak.
Bacon , Beef , Calf Liver , Chicken , Cornish Game Hen , Duck , Goose , Ham , Kielbasa , Lamb , Pork , Quail , Sausage ,Steak , Turkey , Veal Steak.
o Fish
Anchovies in Oil , Bluefish , Catfish , Cod , Flounder , Halibut , Herring , Mackerel , Mahi-mahi , Salmon , Sardine , Scrod , Snapper , Trout , Tuna.
Anchovies in Oil , Bluefish , Catfish , Cod , Flounder , Halibut , Herring , Mackerel , Mahi-mahi , Salmon , Sardine , Scrod , Snapper , Trout , Tuna.
o Shellfish
Clams , Crab , Lobster , Mussel , Oysters , Scallops , Shrimp , Squid.
Clams , Crab , Lobster , Mussel , Oysters , Scallops , Shrimp , Squid.
o Daily
Butter , Cheese , Cream , Coffee , All Egg , Mineral Water , Mayonnaise , Tea ,Water.
Butter , Cheese , Cream , Coffee , All Egg , Mineral Water , Mayonnaise , Tea ,Water.
o Salad Vegetables
Alfalfa Sprouts , Arugula , Bok Choy , Boston Lettuce , Celery , Chicory , Chives , Cucumber , Endive , Escarole , Fennel , Jicama , Mache , Morels , Mushrooms , Olives , Parsley , Peppers , Posse Pied , Radiccio , Radishes , Romaine , Sorrel.
Alfalfa Sprouts , Arugula , Bok Choy , Boston Lettuce , Celery , Chicory , Chives , Cucumber , Endive , Escarole , Fennel , Jicama , Mache , Morels , Mushrooms , Olives , Parsley , Peppers , Posse Pied , Radiccio , Radishes , Romaine , Sorrel.
o Vegetable
Asparagus , Avocado , Bamboo Shoots , Bean Sprouts , Beet Greens , Broccoli , Brussel Sprouts , Cabbage , Cauliflower , Celery Root , Chard , Christophene , Collard Creens , Dandelion Greens , Eggplant , Hearts of Palm , Kale , Kohlrabi , Leeks , Okra , Onion , Pumpkin , Rhubarb , Sauerkraut , Scallions , Snow Pea Pods , Spagheti Squash , Spinach , String or Wax Beans , Summer Squash , Tomato , Turnips , Water Chestnuts , Zucchini
Asparagus , Avocado , Bamboo Shoots , Bean Sprouts , Beet Greens , Broccoli , Brussel Sprouts , Cabbage , Cauliflower , Celery Root , Chard , Christophene , Collard Creens , Dandelion Greens , Eggplant , Hearts of Palm , Kale , Kohlrabi , Leeks , Okra , Onion , Pumpkin , Rhubarb , Sauerkraut , Scallions , Snow Pea Pods , Spagheti Squash , Spinach , String or Wax Beans , Summer Squash , Tomato , Turnips , Water Chestnuts , Zucchini
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