Exam 4 GI Assessment Part 2

Question 1

Gastric outlet ____ onset may be ____ or ____

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Answer 1

obstruction
acute
slow

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Question 2

acute gastric outlet obstructions are caused by what?

Answer 2

edema & inflammation in pyloric channel at the beginning of duodenum

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Question 3

What are the symptoms of a pyloric obstruction? treatment?

Answer 3

recurrent vomiting, dehydration, and hyperchloremic alkalosis
Tx: NGT, IV hydration; normally resolves in 72hrs

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Question 4

Repetitive ulceration and scarring may lead to ____ & ____

Answer 4

Fixed-stenosis & Chronic obstruction

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Question 5

How many types of gastric ulcers are there? and what are they caused by?

Answer 5

5
Caused by NSAIDs, H. Pylori, and ETOH

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Question 6

what is the treatment for gastric ulcers?
What is the specific treatment for H. pylori?

Answer 6

antacids, H2 blockers, PPIs, prostaglandin analogues, cytoprotective agents
H Pylori ts: triple therapy (2 abx and PPI) X 14d

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Question 7

Classifications of gastric ulcers

Answer 7

Slide 27 picture

Question 8

Describe Zollinger Ellison syndrome

Answer 8

Non B cell islet tumor of the pancreas, causing gastrin hypersecretion
Gastrin stimulates gastric acid secretion. Gastric acid normally inhibits further gastrin release (neg feedback)
This feedback loop is absent in ZE syndrome

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Question 9

What are the symptoms associated with ZE syndrome?

Answer 9

peptic ulcer dz, erosive esophagitis, diarrhea
pts have increased gastric fluid vol, possible e-lytes imbalances, and endocrine abnormalities

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Question 10

What types of patients experience ZE syndrome?

Answer 10

0.1-1% of PUD pts
M>F; most commonly b/w ages 30-50
up to 50% of pts with gastrinomas are metastatic at time of diagonsis

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Question 11

Tx indicated for ZE syndrome

Answer 11

PPI and surgical resection of gastrinoma

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Question 12

Pre-operative considerations for ZE syndrome

Answer 12

Correct e-lytes, increased gastric pH w/meds, RSI

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Question 13

What is the function of the small intestines?

Answer 13

Small intestinal motility mixes the contents of the stomach w/ digestive enzymes, further reducing particle size and increasing solubility
The major function of the small intestine is to circulate the contents & expose them to the mucosal wall to maximize absorption of water, nutrients, and vitamins before entering the large intestine
The circular and longitudinal muscle layers coordinate to achieve segmentation
Segmentation: two nearby areas contract and thereby isolate a segment of intestine
Segmentation allows the contents to remain in the intestine long enough for the essential substances to be absorbed into the circulation
It is controlled mainly by the enteric nervous system with modulation of motility by the extrinsic nervous system

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Question 14

when considering sm bowel dysmotility, it is helpful to distinguish eteliogies based on what?

Answer 14

Reversible and nonreversible causes

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Question 15

What are the reversible causes of sm intestines?

Answer 15

mechanical obstruction such as hernias, malignancy, adhesions, and volvuluses
bacterial overgrowth leading to alterations in absorptive function
ileus, electrolyte abnormalities, and critical illness

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Question 16

How is nonreversible sm bowel dysmotillity classified?
What are they?

Answer 16

structural or neuropathic
Structural: scleroderma, connective tissue disorders, IBD
Neuropathic:pseudo-obstruction in which the intrinsic and extrinsic nervous systems are altered and the intestines can only produce weak, uncoordinated contractions
–>This leads to bloating, nausea, vomiting, and abdominal pain

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Question 17

How does the large intestine function?

Answer 17

Large intestine acts as reservoir for waste & indigestible material before elimination, & it extracts remaining electrolytes & water
Distention of the ileum will relax the ileocecal valve to allow intestinal contents to enter the colon
Subsequent cecal distention will contract the ileocecal valve
The colon also exhibits giant migrating complexes
Giant migrating complexes serve to produce mass movements across the large intestine
In the healthy state, these complexes occur approximately 6-10x a day

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Question 18

What 2 primary symptoms manifest with colonic dysmotility?

Answer 18

altered bowel habits and/or intermittent cramping

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Question 19

Most common diseases assd w/ colonic dysmotility

Answer 19

IBS and IBD

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Question 20

Rome II criteria define IBS as having what?

Answer 20

abdominal discomfort along with 2 of the following features:
-defecation relieves discomfort
-pain is assoc w/abnormal frequency (> 3x per day or < 3xper week)
-pain is associated with a change in the form of the stool

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Question 21

In ____ contractions are ____ d/t colonic wall ____ by the inflamed gastric mucosa, but the ____ remain

Answer 21

IBD
suppressed
compression
giant migrating complexes

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Question 22

If there is an increased frequency of giant migrating complexes, what happens?

Answer 22

their pressure-effect further compresses the inflamed mucosa, which can lead to hemorrhage, thick mucus secretion, and significant erosions

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Question 23

What are the common inflammatory bowel diseases?
What is their incidence?

Answer 23

IBD is the 2nd most common inflammatory disorder (RA is 1st)
UC
Chrones
18:100,000

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Question 24

what is ulcerative colitis?
what happens in severe cases?
Normal symptoms?

Answer 24

Mucosal dz of rectum and part or all of the colon
In severe cases, the mucosa is hemorrhagic, edematous, ulcerated
Sx: diarrhea, rectal bleeding, crampy abdominal pain, N/V, fever, weight loss

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Question 25

What labs might be seen in UC?

Answer 25

↑plts,↑erythrocyte sedimentation rate,↓H&H,↓albumin | Slide 33

Question 26

What warrants surgical colectomy with UC?

Answer 26

Hemorrhage requiring 6+ units blood in 24-48hrs | Slide 33

Question 27

Toxic megacolon is a complication of ____ triggered by ____ what percentage of cases resolve? require colectomy? what is the most dangerous complication of toxic megacolon?

Answer 27

UC, e-lyte distrubances 1/2 and 1/2 colon perforation: mortality rate 15% | Slide 33

Question 28

what is Crohn's disease? Where is the most common site?

Answer 28

Acute or chronic inflammatory process that may affect any/all of the bowel Most common site is the terminal ilium, usually presenting w/ileocolitis, RLQ pain & diarrhea | Slide 34

Question 29

What are the 2 patterns of disease seen in Crohn's disease?

Answer 29

penetrating-fistulous, or obstructing | Slide 34

Question 30

symptoms of Crohn's? how does it progress?

Answer 30

weight loss, fear of eating, anorexia, diarrhea Persistent inflammation gradually progresses to fibrous narrowing & stricture formation Diarrhea decreases and is replaced by chronic bowel obstruction | Slide 34

Question 31

Extensive inflammation in Chron's leads to what?

Answer 31

Loss of absorptive surfaces, resulting in malabsorption & steatorrhea | Slide 34

Question 32

Colonic disease may ____ in ____ causing ____

Answer 32

fistulize, stomach/duodenum, fecal vomitus | Slide 34

Question 33

1/3 of Chron's pts have additional symptoms such as

Answer 33

Arthritis, dermatitis, kidney stones | Slide 34

Question 34

What is the medical treatment for IBD?

Answer 34

5-Acetylsalicylic acid (5-ASA)- mainstay for IBD *antibacterial & anti-inflammatory PO/IV Glucorticoids during flares Antibiotics: Rifaximin, Flagyl, Cipro Purine analogues | Slide 35

Question 35

What is the surgical treatment for IBD

Answer 35

Last resort. Resected segment should be as conservative as possible. Small intestine resection should be limited to <1/2 length >2/3 SI resection leads to “short bowel syndrome", requiring TPN | Slide 35

Question 36

Most carcinoid tumors originate from ____ May occur where? What happens with carcinoid tumors?

Answer 36

GI tract any GI tissue/segment Secrete peptides & vasoactive substances: gastrin, insulin, somatostatin, motilin, neurotensin, tachykinins, glucagon, serotonin, other biological actives | Slide 36

Question 37

____% of pts with carcinoid tumors experience ____

Answer 37

ten carcinoid syndrome | Slide 36

Question 38

What is Carcinoid syndrome? symptoms?

Answer 38

Lg amts of serotonin & vasoactive substances reach systemic circulation Sx: flushing, diarrhea, HTN/HoTN, bronchoconstriction May acquire right heart endocardial fibrosis Left heart generally more protected as the lungs clear some of the vasoactive substances | Slide 36

Question 39

How are carcinoid tumors diagnosed? Treatment? pre-op considerations?

Answer 39

Dx: urinary or plasma serotonin levels, CT/MRI Tx: avoid serotonin-triggers, control diarrhea, serotonin antagonists & somatostatin analogues Preop: Octreotide before surgery and prior to tumor manipulation to attenuate volatile hemodynamic changes | Slide 36

Question 40

What are the secretory characterisitcs of carcinoid tumors? Location and presentation of carcinoid tumors? | this is a graph from the textbook

Answer 40

Question 41

What is acute pancreatitis? How mcuh has incidence increased and why? What does the pancreas contain?

Answer 41

inflammatory disorder of pancreas 10 fold, likely d/t increased alcoholism along w/ better diagnostics numerous digestive enzymes | Slide 39

Question 42

How is autodigestion of the pancreas normally prevented?

Answer 42

Proteases packaged in precursor form Protease inhibitors Low intra-pancreatic calcium, which decreases trypsin activity Failure of any of these mechanisms can trigger pancreatitis | Slide 39

Question 43

What are the most common causes of pancreatitis and how do they result in pancreatitis?

Answer 43

Gallstones and alcohol abuse are most common causes (60-80% cases) Gallstones obstruct ampulla of vater, causing pancreatic ductal HTN Pancreatitis is also seen in immunodeficiency syndrome, hyperparathyroidism/↑Ca² | Slide 39

Question 44

What are the symtpoms seen in acute pancreatitis? complications?

Answer 44

excruciating epigastric pain that radiates to back, N/V, abd distention, steatorrhea, ileus, fever, tachycardia, HoTN 25% experience serious complications s/a shock, ARDS, renal failure, necrotic pancreatic abscess | Slide 40

Question 45

Hallmark labs of acute pancreatitis? what imaging can be used to diagnose?

Answer 45

increased serum amylase & lipase contrast CT or MRI, endoscopic US (EUS) | Slide 40

Question 46

What is the treatment for pancreatitis? what is associated with greater risk of infectious complications?

Answer 46

Aggressive IVF, NPO to rest pancreas, enteral feeding (preferred over TPN), opioids TPN associated w/greater risk of infectious complications | Slide 40

Question 47

What is Endoscopic-retrograde cholangiopancreatography (ERCP)

Answer 47

Fluoroscopic examination of biliary & pancreatic ducts Interventions include stone removal, stent placement, sphincterotomy, hemostasis | Slide 40

Question 48

Are upper or lower GI bleeds more common?

Answer 48

upper

Question 49

in upper GI bleeds > ____% blood loss will cause ____ & ____

Answer 49

25% hypotension and tachycardia

Question 50

in upper GI blled, orthostatic hypotension normally indicates what hct?

Answer 50

<30% | Slide 41

Question 51

In GI bleed, melena indicates what?

Answer 51

bleed is above the cecume (Where Sm intestine meets colon | Slide 41

Question 52

What labs are seen in GI bleed? Why?

Answer 52

BUN >40mg/dL dt absorbed nitrogen into bloodstream | Slide 41

Question 53

What is the therapeutic procedure of choice for GI bleed? what are other choices? Last choice?

Answer 53

EGD is dx/therapeutic procedure of choice endoscopic ulcer ligation (perforation rx 0.5%) ligation of bleeding varices Mechanical balloon tamponade is last resort for uncontrolled variceal bleeding | Slide 41

Question 54

Lower GI bleed generally occurs in which population?

Answer 54

elderly | Slide 42

Question 55

Causes of Lower GI bleed

Answer 55

diverticulosis, tumors, colitis | Slide 42

Question 56

lower GI bleed treatments? persistent bleeding warrants what?

Answer 56

Unprepped sigmoidoscopy performed as soon as Hemodynamically stable Colonoscopy performed if pt can tolerate prep Persistent bleeding warrants angiography and embolic therapy | Slide 42

Question 57

what is an adynamic ileus?

Answer 57

Colonic ileus characterized by massive dilation of the colon without mechanical obstruction Loss of peristalsis leads to distention of the colon | Slide 43

Question 58

What are causes of adynamic ileus?

Answer 58

May be c/b e-lyte disorders, immobility, excessive narcotics, anticholinergics Also thought to be due to neural-input imbalance of excessive sympathetic stimulation along with inadequate parasympathetic input to the colon | Slide 43

Question 59

Tx for ileus? What happens if left untreated?

Answer 59

Restore e-lyte balance, hydrate, mobilize, NG suction, enemas Neostigmine 2-2.5mg over 5 min produces immediate results in 80-90% Cardiac monitoring required If left untreated, ischemia and perforation may occur | Slide 43

Question 60

what are the anesthesia effects on the GI system?

Answer 60

In the preop, pts are often nervous and sympathetically charged Inhibition of GI activity is directly proportional to the amount of norepinephrine secreted from SNS stimulation, so the higher anxiety = higher inhibition Volatile anesthetics depress the spontaneous, electrical, contractile, and propulsive activity in the stomach, small intestine, and colon | Slide 44

Question 61

How does the GI system recover from anesthesia? What inhibits GI function and motility?

Answer 61

The small intestine is the first part of the GI tract to recover, followed by the stomach in approximately 24 hours and then the colon 30 to 40 hours postoperatively Volatile agents, coupled with sympathetic nervous system hyperactivity associated with surgery can inhibit GI function and motility | Slide 44

Question 62

Nitrous oxide is ____X more soluble than nitrogen in the blood so it will ____ into ____-containingt cavities from the blood faster than ____ can diffuse out

Answer 62

30 diffuse gas nitrogen | Slide 45

Question 63

What is gut distention correlated with?

Answer 63

pre-existing amount of gas in the bowel, as well as the duration of nitrous oxide administration, and the concentration of nitrous oxide administered | Slide 45

Question 64

what medication should be avoided in lenghty abdominal surgeries or when the bowel is already distended?

Answer 64

Nitrous

Question 65

NMB only affect ____ muscle, so ____ remains intact

Answer 65

skeletal GI motility | Slide 45

Question 66

What medications will help wake the GI system up after anesthesia? How? which reversal agent does not have any effect on motility?

Answer 66

Neostigmine (AchE-I) will increase PNS activity and bowel peristalsis by increasing the frequency & intensity of contractions This cholinergic activity is partially offset by concurrent administration of the anticholinergic medications (glycopyrrolate or atropine) which counteract the bradycardia associated with neostigmine The alternate reversal agent, Sugammadex, does not appear to have any effect on motility | Slide 46

Question 67

What is a common medication known to cause reduced GI motility and constipation? Where do they work?

Answer 67

opioids Opioids exert their function on both central & peripheral mu, delta, and kappa receptors | Slide 47

Question 68

where in the GI tract has a high density of peripheral mu-opioid receptors?

Answer 68

myenteric and submucosal plexuses | Slide 47

Question 69

Activation of the mu-opioid receptors causes what? What other adverse events are assoicated with opioids?

Answer 69

delayed gastric emptying and slower transit through the intestine Other adverse events include nausea, anorexia, delayed digestion, abdominal pain, excessive straining during bowel movements, and incomplete evacuation | Slide 47

Question 70

____ and ____ movements are the two primary movements within and along the GI tract

Answer 70

Mixing and propulsive | Slide 49

Question 71

____, ____, ____ can induce ileus, inflammatory states, mesenteric ischemia, and partial or total disruption of myogenic continuity

Answer 71

hemodynamic changes, bowel manipulation, and open abdominal surgeries | Slide 49