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Flashcards in GI/Liver Deck (72):
1

When can liberal fasting guidelines be used?

In healthy patients

2

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

Up to 1 hour before surgery

3

People who are aspiration risks

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

4

People with greatest aspiration risk

Pregnant
Morbidy obese
Hiatal hernia
Pre-op anxiety

5

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

6

H2 Antagonist that gives the best result

Famotodine (Pepcid)

7

Examples of H2 antagonists

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

8

How do H2 antagonists work?

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

9

When should H2 antagonists be given?

Night before surgery and repeated 45-60 minutes before surgery

10

How does metoclopramide (Reglan) prevent aspiration?

By preventing and alleviating nausea

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

11

When is metoclopramide (Reglan) contraindicated?

In a bowel obstruction

12

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

13

When before surgery to you give bicitra?

15 minutes before surgery, and it lasts 1-3 hours.
Increases gastric volume and can cause nausea.

14

When would we do Sellick's maneuver?

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

15

Complications of Sellick's maneuver

Esophageal rupture and cricoid ring fracture

16

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).

17

Risk factors for aspiration pneumonitis (Mendelson Syndrome)

Gastric volume > .4mL/kg (about 25mL for a 70kg patient)
Gastric pH < 2.5

18

Severity of aspiration pneumonitis depends on

pH
Volume
Contents of the gastric material aspirated

19

S/S of aspiration pneumonitis

Resp distress with bronchospasm
Dyspnea
Cyanosis
Tachycardia

20

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.

21

S/S of hiatal hernia

Retro-sternal discomfort
Burning after meals

22

Where does peptic ulcer disease most commonly occur?

Antrum of stomach
or
Duodenal bulb

23

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

24

S/S of malabsorption syndromes

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

25

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

26

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

27

Substances released by carcinoid tumors in carcinoid syndrome

Bradykinin
Histamine
Serotonin
Dopamine

28

Malnutrition is associated with these complications

Prolonged hospital stay
Wound infection/abcess
Resp failure
Death

29

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

30

Albumin level less than ___ is a major predictor of morbidity

2.1

31

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

10-15%

32

Two scoring methods of liver insufficiency

MELD Score
Child-Turcotte-Pugh Score

33

MELD Score

For ESLD

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

34

Child-Turcotte-Pugh Score

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

35

5-nucleotidase

A lab more specific to the biliary tract

36

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

37

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.

38

How do you treat bleeding in someone with cholestatic disease?

Give Vit K
Give FFP if emergency surgery

39

Expected blood flow findings in cholestatic disease

Increased portal venous pressure and decreased flow
Peripheral vasodilation
Increased CO

40

This is the most common blood borne infection in the US

Hep C

41

Drug for Hep B

Interferon

42

Drugs for Hep C

Interferon
Ribavirin

43

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)

44

Risk factors for non-alcoholic fatty liver disease

Obesity and NIDDM

45

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

liver enzymes (AST/ALT)

46

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

Weight loss (even as much as only 5 pounds)

47

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

6-8 hours

48

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

24 hours

49

How do you treat DTs?

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

50

Cirrhosis is most commonly caused by

Alcoholism, Hep C, and fatty liver disease

51

CV changes with cirrhosis

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

52

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

53

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

Hemostasis
Coagulation
Fibrinolysis
(all three stages!)

54

These clotting factors are reduced in liver failure

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

55

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.

56

Vitamin K is needed for the synthesis of

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

57

Who develops Vit K deficiency?

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

58

These coag levels will increase due to Vit K deficiency

PT/PTT

59

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)

60

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)

61

How does heparin work?

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

62

Normal prothrombin time (PT)

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

63

Normal bleeding time

3-10 minutes (tests platelet function)

64

Normal PTT

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

65

Treatments for Barrett's esophagus

H2 Blockers
PPIs
Nissen Fundoplication

66

Peptic ulcers and bleeding

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

67

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

68

Aspiration pneumonitis is also called

Mendelson Syndrome

69

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

Gastric bypass

70

Autoimmune hepatitis is treated with

Corticosteroids and AZT

71

Left untreated, fatty liver disease can lead to

cirrhosis

72

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

50%