GI/Liver Flashcards by Ryan Fedewitz

When can liberal fasting guidelines be used?

In healthy patients

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How soon before surgery can a patient have a sip of water or oral liquid medication?

Up to 1 hour before surgery

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People who are aspiration risks

Age extremes (70)
Ascites
Collagen vascular diseases
Metabolic disorders (DM, hypothyroid, ESRD)
Mechanical obstruction
Prematurity
Pregnancy
Neurologic diseases

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People with greatest aspiration risk

Pregnant
Morbidy obese
Hiatal hernia
Pre-op anxiety

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Medications for aspiration prophylaxis

Anxiolytics
H2 receptor antagonists
Sodium citrate (Bicitra)– acts as a buffer
Metoclopramide (Reglan) - increase gastric motility and increases sphincter tone
Omeprazole (Prilosec)– will decrease acidity

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H2 Antagonist that gives the best result

Famotodine (Pepcid)

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Examples of H2 antagonists

Cimetidine (Tagamet)
Ranitidine (Zantac)
Famotodine (Pepcid)

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How do H2 antagonists work?

Reduce acid secretion by competitively binding to H2 receptors on parietal cells.

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When should H2 antagonists be given?

Night before surgery and repeated 45-60 minutes before surgery

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How does metoclopramide (Reglan) prevent aspiration?

By preventing and alleviating nausea

MOA: Dopamine antagonist which increases lower esophageal sphincter tone and increases gastric emptying

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When is metoclopramide (Reglan) contraindicated?

In a bowel obstruction

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When do we give meds like H2 blockers, reglan, and bicitra?

If the person has risk factors for aspiration**

We do not give these meds to patients routinely

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When before surgery to you give bicitra?

15 minutes before surgery, and it lasts 1-3 hours.

Increases gastric volume and can cause nausea.

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When would we do Sellick’s maneuver?

During RSI (for someone at high risk of aspiration and we can’t do an awake intubation)

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Complications of Sellick’s maneuver

Esophageal rupture and cricoid ring fracture

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How to perform Sellick’s maneuver

Apply light downward and cephalad pressure (10N) in the awake pressure, and increase pressure as the patient drifts to sleep (20-44N).

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Risk factors for aspiration pneumonitis (Mendelson Syndrome)

Gastric volume > .4mL/kg (about 25mL for a 70kg patient)

Gastric pH < 2.5

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Severity of aspiration pneumonitis depends on

pH
Volume
Contents of the gastric material aspirated

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S/S of aspiration pneumonitis

Resp distress with bronchospasm
Dyspnea
Cyanosis
Tachycardia

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Why does Barrett’s esophagus place a person at risk for aspiration?

Because the esophagus becomes less functional, causing dysphagia. Person also obviously has very bad GERD, as this is what caused the disease in the first place.

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S/S of hiatal hernia

Retro-sternal discomfort

Burning after meals

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Where does peptic ulcer disease most commonly occur?

Antrum of stomach
or
Duodenal bulb

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Causes/risk factors for peptic ulcers

Also s/s of peptic ulcers

H. Pylori
Age 45-60
Chronic NSAID use
Steroid use

S/S:
Epigastric pain
Vomiting
Hematemesis or melena in acute hemorrhage
Perforation
Abdominal tenderness/rigidity

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S/S of malabsorption syndromes

Unexplained weight loss****
Diarrhea
Steatorrhea
Vit. K deficiency
Bleeding dyscrasias
Anemia
Fatigue
Edema/ascites

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Differences between Crohn's and UC

Crohn's - Vit/mineral deficiencies (B12, mag, folic acid, zinc, iron, and potassium) - protein loss (decreased serum albumin) - anemia UC - Intermittent blood diarrhea (hooray!) - fever/malaise - Abd pain - Risk of colon CA

What is carcinoid syndrome?

Carcinoid tumors (which release hormones), arising from the appendix, pancreas, or bronchi, secrete substances into the GI tract and systemic circulation, causing an array of symptoms. ``` S/S: Flushing Diarrhea Bronchospasm Dyspnea Hypo/hypertenion Orthostatic hypotension) Palpitations ```

Substances released by carcinoid tumors in carcinoid syndrome

Bradykinin Histamine Serotonin Dopamine

Malnutrition is associated with these complications

Prolonged hospital stay Wound infection/abcess Resp failure Death

Albumin level less than ___ in the general surgical population is indicative of malnutrition

3.5 Also weight loss greater than 10% in 6 months is also indicative of malnutrition

Albumin level less than ___ is a major predictor of morbidity

2.1

The liver is a reservoir of blood representing ___-___% of total blood volume

10-15%

Two scoring methods of liver insufficiency

MELD Score | Child-Turcotte-Pugh Score

MELD Score

For ESLD Looks at Bilirubin, creat, INR, and if you're on dialysis)

Child-Turcotte-Pugh Score

``` Looks at: Bilirubin Encephalopathy Albumin Ascites PT/INR Primary biliary cirrhosis ```

5-nucleotidase

A lab more specific to the biliary tract

Which liver lab can individually test liver function?

None of them! They need to be looked at together and with the patient's condition in general

Why does cholestatic disease causing bleeding problems?

Bile salt must be secreted into the GI tract for vit K absorption. Lack of vitamin K causes a deficiency of clotting factors dependent on Vit K for synthesis.

How do you treat bleeding in someone with cholestatic disease?

Give Vit K | Give FFP if emergency surgery

Expected blood flow findings in cholestatic disease

Increased portal venous pressure and decreased flow Peripheral vasodilation Increased CO

This is the most common blood borne infection in the US

Hep C

Drug for Hep B

Interferon

Drugs for Hep C

Interferon | Ribavirin

Non-Alcoholic Fatty Liver Disease is defined as fat accumulation exceeding __% and can lead to ____

5% cirrhosis (the fat causes a degree of hapatocyte necrosis, accumulating inflammatory cells and causing cirrhosis)

Risk factors for non-alcoholic fatty liver disease

Obesity and NIDDM

Non-alcoholic fatty liver disease is asymptomatic but the person will have elevated ____

liver enzymes (AST/ALT)

What can reverse elevated liver enzymes in non-alcoholic fatty liver disease

Weight loss (even as much as only 5 pounds)

An alcoholic may become tremulous __-__ hours after their last drink

6-8 hours

Hallucinations and grand mal serizures may occur __ hours after ETOH withdrawal.

24 hours

How do you treat DTs?

Benzodiazepines | most of our anesthetics will abate most of the s/s of alcohol withdrawal

Cirrhosis is most commonly caused by

Alcoholism, Hep C, and fatty liver disease

CV changes with cirrhosis

Low SVR and high CO (sepsis-like) Pulmonary vessels dilate, but then become stiff, causing R heart failure

S/S of cirrhosis

``` Portal HTN Esophageal varices Ascites and edema Coagulation disorders Hepatic encephalopathy Endocrine disorders Intrapulmonary shunting and V:Q mismatch Hypoxemia due to intra-pulmonary vascular dilations ```

In liver disease, you have problems with these phases of clotting

Hemostasis Coagulation Fibrinolysis (all three stages!)

These clotting factors are reduced in liver failure

2, 5, 7, 9, 10 Abnormal fibrinogen present PT/INR are elevated Pts have thrombocytopenia

Why are platelets fucked up in liver disease?

Normally, the liver makes thrombopoietin, which results in the formation of megakaryocytes in the BM. Also, toxins build up in the bleed, messing with plt function. End result is decreased plts, fucked up plts, and increased bleeding time.

Vitamin K is needed for the synthesis of

Factors 2, 7, 9, & 10 | Proteins C&S

Who develops Vit K deficiency?

``` People with: TPN Biliary obstruction Pancreatic insufficiency Malabsorption GI obstruction Rapid GI transit ```

These coag levels will increase due to Vit K deficiency

PT/PTT

What are coumadin and heparin used for?

Coumadin - DVT, PE, A-fib, prosthetic valves, and MI Heparin - anti-coagulation for vascular cases and cardio-pulmonary bypass (CPD)

How does coumadin work?

It competes with binding sites for Vit K in the liver, resulting in the decrease of Vit-K dependent clotting factors (2,7,9,10)

How does heparin work?

Interacting with anti-thrombin III (Factor Xa) and Thrombin (factor IIa)

Normal prothrombin time (PT)

10-12 sec | Tests factors 1, 2, 5, 7, 10

Normal bleeding time

3-10 minutes (tests platelet function)

Normal PTT

25-35 seconds | Tests factors 1, 2, 5, 7, 9, 10, 11, 12

Treatments for Barrett's esophagus

H2 Blockers PPIs Nissen Fundoplication

Peptic ulcers and bleeding

80% stop on their own 10% will die Rebleeding will increase mortality 10x Accounts for 5% of ED admissions

Gastric ulcer and peptic ulcer s/s

Gastric: - Pain - Anorexia - Weight loss - Metabolic derangements Peptic: - Epigastric pain - Vomiting - Hematemesis or melena - Perforation - Abdominal tenderness/rigidity

Aspiration pneumonitis is also called

Mendelson Syndrome

We see a lot of malabsorption syndromes following this type of surgery

Gastric bypass

Autoimmune hepatitis is treated with

Corticosteroids and AZT

Left untreated, fatty liver disease can lead to

cirrhosis

Usually, a ___% increase in Creatinine indicates a corresponding decrease in GFR

50%

GI/Liver Flashcards

(72 cards)