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Flashcards in GI and Liver Deck (63)
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1

What to consider in ROS in regards to GI?

Does the patient have :

  • nutritional deficiency
  • nausea/vomiting
  • occult blood loss
  • overt GI bleeding
  • abdominal pain
  • abdominal distention
  • dysphagia
  • GERD
  • epigastric pain

2

NPO status?

Balance risk of fasting against pulmonary aspiration

  • In “healthy patients” liberal fasting guidelines can be followed
  • No chewing gum or candy after midnight
  • Clear liquids up to 2 hours before OR
  • Breast milk up to 4 hours before OR
  • Light meal, milk, formula up to 6 hours before OR
  • Fatty foods, fried foods, meats 8 hours or more
  • Sip of water or liquid pre-med up to 1 hour before OR

3

Who is considered an aspiration risk?

  • Age extremes <1 yr or >70 yr
  • Ascites (ESLD)
  • Collagen vascular disease ie Ehlers- Danlos
  • Eaten food
  • Hiatal Hernia/GERD/Esophageal disorder
  • Mechanical obstruction (pyloric stenosis, intestinal obstruction)
  • metabolic disorders (Diabetes obesity, ESRD, hypothyroid)
  • Morbid obesity
  • Neurologic diseases
  • Prematurity
  • Pregnancy
  • Severe pain/ anxiety

4

What is mendelson syndrome?

  • Chemical pneumonitis or aspiration pneumonitis
  • Characterized according to
    • pH
    • volume
    • gastric material aspirated
  • Risk factors for aspiration sequelae include
    • pH less than 2.5
    • Gastric volume of 0.4ml/kg (25ml/70kg)
  • Manifests as respiratory distress with
    • bronchospasm,
    • cyanosis,
    • tachycardia and
    • dyspnea from irritating action of hydrochloric acid and particulate material which are damaging to the lungs
  •  

5

What are H2 antagnoists role in aspiration prevention?

  • Cimetidine, Ranitidine and Famotidine (best result)
  • Acts as competitive antagonist of histamine binding to H2 receptors on gastric parietal cells
  • Reduces acid secretion
  • Best if given the night before and repeated 45-60 minutes before surgery

6

What is metoclopramide's role in aspiraiton prophylaxis?

  • Metoclopramide
  • Dopamine antagonist
  • Increases the pressure of the lower esophageal sphincter and enhances GI motility which speeds gastric emptying
  • Prevents or alleviates nausea and vomiting
  • Contraindicated in the presence of an obstruction

7

Should we give everyone aspiration prophylaxis?

No, ASA does not promote the routine use of these meds to decrease aspiration in pt with no apparent risk factors

8

What is sodium citrate?

 

  • Sodium Citrate - Bicitra
  • Non-particulate antacid
  • Customary dose of 30 ml po to raise gastric pH
  • Disadvantage: Increases gastric volume
  • Give 15 minutes before surgery and lasts 1-3 hours
    • repeat bicitra if sugery is delayed

9

Omeprazole admin for aspiration prophylaxis? 

  • Proton pump inhibitor
  • 80 mg po the night before and 40 mg repeated after the induction of anesthesia.

10

What is a hiatal hernia? s/s?

  • Protrusion of a portion of the stomach through the hiatus of the diaphragm upward into the thoracic cavity
  • Aspiration risk
  • Signs & Symptoms
    • Retro-sternal discomfort
    • Burning after meals
    • Reflux (+/-)

11

GERD dx? s/s, txmt?

  • Retrograde movement of gastric contents through the lower esophageal sphincter into esophagus
  • Aspiration risk
  • High incidence of bronchospasm

Signs

  • Heartburn
  • Noncardiac chest pain
  • Dysphagia
  • Pharyngitis, cough, asthma, hoarseness

Treatment:

  • Metoclopramide, H2 blockers, PPIs
  •  

 

12

What is barret's esophagus? s/s? treatment?

Metaplastic disorder of the esophagus secondary to reflux

  • Precursor to esophageal cancer

Signs & Symptoms

  • Dysphagia
  • Reflux esophagitis
  • Retrosternal pain or heartburn
  • Weight loss

Treatment

  • H2 Blockers
  • Proton Pump Inhibitors
  • Nissen fundoplication
  • will also do biopsies to evaluate and make sure it isn't progressing to higher stages

 

13

What is gastroparesis?

  • Partial paralysis of the stomach
    • Vagus nerve-stomach contraction-injury
    • Autonomic Neuropathy-Diabetes- most common cause
    • Connective tissue diseases-Scleroderma, Ehlers-Danlos
    • Opioids and anticholinergics
  • Leads to prolonged food retention
  • Aspiration risk

14

What is the schatzki ring?

  • A narrowing of the lower esophagus caused by a ring of mucosal tissue or muscular tissue
    • treatment= dilation of esophagus
  • produces dysphagia, food obstruction and vomiting
  • aspiration risk

15

What is peptic ulcer disease? Location? most commonly effected? causes? signs?

  • Ulcerations in the GI mucosa most commonly the duodenal bulb or antrum of stomach
  • Men and Women age 45-60 (Most commonly affected)
  • Causes: Chronic use of NSAIDS, ETOH, Steroids (also h pylori)
  • Signs:
    • Epigastric pain
    • Anorexia, wt. loss
    • Vomiting
    • Hematemesis or melena (this may be acute hemorrhage)
    • Abdominal tenderness and rigidity
    • Perforation (severe pain)

16

Gastric ulcer has pain when? wt loss? bleeding? causes? txmt?

  • Pain when: pain with food
  • weight loss: lose weight
  • bleeding= vomiting blood
  • causes= h pylori, nsaids, corticosteroids
  • txmt: PPI H2 block

17

What are duodenal ulcers?

pain, wt loss, bleedign, causes, treatment?

  • Pain- 3-4 hours after eating
  • Sometimes weight gain, but definitely no weight loss
  • bleeding= black, tarry stools
  • causes= h pylori (90% duodenal ulcer) nsaids
  • treatment= PPi, h2 blocker, sucralfate

18

What is crohn's disease?

 

  • Inflammation of the bowel wall w skip patterns involving the terminal ileum.  Rectal sparring
    • Deficiency in absorption of magnesium, calcium, etc
    • Protein loss, decreased plasma albumin
    • Anemia
  • Recurrent right lower quadrant pain, diarrhea, palpable mass, fever, anorexia/wt. loss

19

Ulcerative colitis?

inflammatory bowel disease

  • Inflammation and loss of colonic mucosa from rectum to distal colon; becomes hemorrhagic, edematous, ulcerated
    • usually starts low at rectum and advances up
  • diarrhea-blood, mucus
  • fever/ malaise
  • anorexia/wt. loss
  • abdominal  pain
  • associated with risk of colon cancer

20

What are carcinoid tumors? s/s?

  • Commonly found in the GI tract (appendix), metastasis
    • slowly develop tumor
  • Can produce carcinoid syndrome or crisis
    • normally hormones go to liver first and won't get bad side effects from release of hormones. however, if tumor outside of GI tract, can get big s/e from the hormones skipping the liver
    • treatment- try to release release of these substances (minimize adrenergic responses)
  • produced by the effects of hormones and substances secreted in the GI tract and systemic circulation
    • bradykinin
    • histamine
    • serotonin
    • dopamine
  • S&S Carcinoid Syndrome
    • cutaneous flushing
    • diarrhea
    • tachycardia, arrhythmias
    • dyspnea, wheezing, bronchospasm
    • hypotension
    • hypertension
    • orthostasis
    • fibrosis of pulmonary and tricuspid valves
    • right-sided valvular heart dz
  • Pre-op test are guided by physical findings

21

Do you palpate the abdomen of someone with carcinoid tumor? 

What labs test do you want?

No palpation! releases the hormones potentially

  • CBC
  • Electrolyte panel
  • LFTs
  • Blood glucose
  • ECG
  • Echo
  • Urine 5-HIAA level

22

What is periop malnutrition associated with? Indicators of severe nutritonal risk?

  • Malnutrition is associated with
    • prolonged hospital stay
    • wound infection
    • abscess
    • respiratory failure
    • death
  • Indicators of severe nutritional risk
    • Serum Albumin level of less than 3 g/dL
    • Wt loss > 10% in last 6 mo.
    • BMI < 18.5

23

GI physical exam?

  • General inspection
  • Weight, vital signs
  • Abdominal examination
  • Inspect
  • Auscultate
  • Palpate
    • Note guarding, pain, organomegaly
  • Percuss

important to do in order!!! inspect, auscultate before you manipulate the abdomen!

24

What are some things to look for on inspection of abdomen?

  • Pink-purple striae --> Cushing syndrome
  • Dilated veins (caput medusae) --> cirrhosis
  • Ecchymosis --> intra/retroperitoneal hemorrhage
  • Bulges --> hernias
  • Increased peristaltic waves --> intestinal obstruction

25

What are some things to listen for on ausculatation?

•Bruits --> vascular occlusive disease

•Altered bowel sound --> paralytic ileus, obstruction, etc

26

What are you asesesing for on percussion of abdomen?

  • Tympany --> normally what is heard in the GI tract (gas/air in the tract)
  • Dullness --> usually suggests masses, organs, fluid-filled cavities

27

What might palpation of an abdomen reveal?

•May reveal abdominal masses, tumors, AAA, gravid uterus

28

Lab values to consider for GI patient?

•Hematocrit

•Serum electrolytes

•BUN

•Serum albumin (prealb)

29

Preop concsideration in GI pt?

  • Aspiration risk
    • Prophylaxis and airway management considerations
  • Bleeding --> anemia
  • Nutritional deficits and/or electrolyte disturbances
  • Pain control
  • Medications:  stress-dose steroids?
  • If carcinoid, cardiac workup needed? Hemodynamically stable?

30

Pancreatitis s/s, txmt?

  • Cause is multifactorial
  • CV complications: pericardial effusions, s/s mimicking acute MI, cardiac depression
  • Pain: severe (Demerol might be preferred? Prob fentanyl)
  •           worse in supine position
  • S/S: N/V, fever, hypotension --> ARF might occur
    • cullen's sign (bruising around umbilicus)
    • grey turner sign (bruising around flank)
  • Treatment:  Pain management, FLUID Resus, e’lyte restoration
  • SX: cholecystectomy or endoscopic stone clearance