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Flashcards in Liver and GI Deck (39)
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1

What do you want to find out about regarding the GI history?

  • Nutritional deficiency- wt loss greater than 10%
  • N/V
  • occult blood loss
  • overt GI bleeding
  • abd. pain/distension/masses
  • dysphagia
  • gastric hyperactivity with or without reflux

2

Who is consdered an aspiration risk?

  • extreme ages
  • ascites
  • collagen vascular dx, metabolic disorders )DM, ESRD, hypothyroid)
  • hiatal hernia/GERD/esophageal surgery
  • mechanical obstruction
  • prematurity
  • pregnancy
  • neurologic diseases
  • morbid obesity
  • severe pain/anxiety
  • having eaten

3

What is the aspiration prophylaxis med plan?

  • H2 antagonists
  • sodium citrate (bicitra)
  • metoclopramide
  • omeprazole

4

What is Mendelson syndrome?

What are the risk factors?

How does it manifest?

  • Chemical pneumonitis or aspiration pneumonitis caused by aspiration during anesthesia
  • characterized by pH, volume, and gastric material aspirated
  • Risk factors for aspiration sequelae:
    • Gastric volume of 0.4 ml/kg
    • pH <2.5
  • Manifests as
    • resp distress w/bronchospasm, cyanosis, dyspnea
    • tachycardia

5

What is Barrett's esophagus?

signs/symptoms

treatment

  • metaplastic disorder of the esophagus secondary to reflux
    • precursor to esophageal cancer
  • S/S
    • dysphagia
    • reflux esophagitis
    • retrosternal pain or heartbrn
    • LES dystonia
    • wt loss
  • Treatment
    • H2 blockers
    • PPIs
    • Nissen fundoplication

6

What is Schatzki Ring?

  • a narrowing of the lower esophagus caused by a ring of mucosal tissue or muscular tissue
  • causes dysphagia, food obstruction, vomiting
  • aspiration risk

7

What is Gastroparesis?

What causes it?

  • Partial paralysis of the stomach
  • Causes:
    • Vagus nerve injury
    • autonomic neuropathy- diabetes (most common cause)
    • Connective tissue dx (sclerderma, Ehlers-Danlos)
    • Opioids, anticholinergics
  • Will have prolonged food retention and up to 1 liter of fluid
  • RSI!  Intubate if even for a minor procedure

8

9

What is a hiatal hernia?

  • stomach protrudes up into diaphragm
    • sliding- food enters stomach from esophagus and gets caught in the pouch above the diaphragm
  • symptoms:
    • Heart burn
    • regurgitation
    • **can cause barrets esophagus and then cancer
  • increases with age

10

What are peptic ulcers?

  • Chronic lesions that can be anywhere in GI tract but 98% are in proximal duodenum and stomach (4:1)
    • most commonly the duodenal bulb or antrum of stomach
    • H. pylori is involved in 70-90% of duodenal ulcer and 70% of gastric ulcers
  • Only 10-20% of ppl w/ H. Pylori get ulcers

13

What aggravates peptic ulcers?

  • Age 45-60
  • NSAIDS
  • smoking
  • alcohol
  • corticosteroids
  • high stress personality??
  • gastrinoma (zollinger-ellison syndrome)

14

What problems do peptic ulcers cause?

  • epigastric pain
  • nausea and vomiting
  • hemorrhage and perforation
  • generally do NOT progress to cancer
  • ** usually just impair quality of life rather than shorten it
    • 15,000 deaths/year attributed to complications of peptic ulcers

15

Carcinoid tumors:

most common site

What is Carcinoid syndrome?

Symptoms of Carcinoid syndrome?

  • GI tract- mostly common in appendix
  • Carcinoid syndrome is caused when substances secreted in the GI tract enter systemic circulation
    • bradykinin, histamine, serotonin, dopamine
  • S/S of carcinoid syndrome
    • cutaneous flushing
    • diarrhea
    • palpitations
    • dyspnea, wheezing, bronchospasm
    • hypotension
    • HTN
    • orthostasis
    • right sided valvular heart dx

16

What is malnutrition often associated with?

 

  • prolonged hospital stay
  • wound infection
  • abscess
  • respiratory failure
  • death
  • Serum albumin <3.5
    • <2.1 major predictor of morbidity in veterans undergoing non-cardiac surgery
  • wt loss >10% in last 6 months

17

What should you look for on the pts hands when assessing GI?

  • Koilonychia- brittle, thin nails that curve up
  • Leukonychia- nails that have big white spots
  • nail clubbing
  • palmar erythema
  • asterixis- can't hold hand steady
  • Dupuytren's Contracture- palmar fascia becomes thick, causing fingers to curl and limiting function

18

During a GI physical, how should you do the abdominal examination? (we don't really do this)

  • auscultate bowel sounds
  • palpate- note guarding and pain, note organomegaly
  • percuss

19

Besides hands and abdomen, what else do you want to look at during a GI physical?

  • Check sclera for jaundice or pallor
  • Examine chest for gynecomastia or spider nevi- signs of liver dx
  • skin color scratches, jaundice
  • skin turgor

20

What are some general pre-op considerations for GI patients?

  • Airway management and prevention of aspiration
  • fluid and electrolyte balance
  • Skin
  • peripheral circulation
  • HR, BP
  • UOP
  • kidney function
  • orthostasis

21

What labs and monitoring do you want for a GI patient?

  • Useful lab values:
    • hematocrit
    • serum electrolytes
    •  BUN
    • serum albumin
  • Monitoring
    • +/- CVP, PAP
    • +/- Art line

22

The liver does a lot of things.  What are some of them?

  • Reservoir of blood (10-15% total blood volume)
  • maintains normal clotting
  • mediates endocrine functions
  • bilirubin excretion
  • metabolism
  • synthesis of proteins
  • immunologic function
  • pharmacokinetics

23

What do you want to know about the history of a pt with liver problems?

  • easy bruising?
  • anorexia or wt changes
  • N/V or pain w/fatty meals
  • pruritis or fatigue
  • abdominal distension/ascites
  • GI bleed
  • scleral icterus, jaundice, or hx of it
  • hepatmegaly or splenomegaly
  • palmer erythema
  • gynecomastia
  • spider angiomata, petechiae, and ecchymosis
  • prior blood tx
  • recreational drugs/alcohol
  • travel history
  • occupational history

24

What medications can increase Liver enzyme levels (CYP450)

 

  • antibiotics
  • antiepileptic 
  • inhibitors of hydroxymethylglutaryl-coenzyme
  • NSAIDS
  • sulfonylureas for hyperflycemia
  • herbals
  • cocaine, ecstasy, angel dust, glues/solvents

25

How do you do a physical assessment of a liver pt?

Look at everything you would look at for a GI patient

26

What labs would be helpful with a liver pt?

  • albumin
  • CBC
  • coags
  • lytes and glucose levels
  • serum liver enzyme
  • serium ammonia levels
  • platelet counts >100,000
  • bilirubin
  • ABG

27

  • Normal lab Values
    • albumin
    • bilirubin
    • unconjugated bili
    • conjugated bili
    • aspartate aminotransferase (SGOT)
    • alanin aminotransferase (SGPT)
    • alk phos
    • prothrombin time

  • Albumin 3.5-5.5 g/dl
  • bili 0.3-1.1 mg/dL
  • unconjugated bili 0.2-0.7 mg/dl
  • conjugated bili 0.1-0.4 mg/dl
  • SGOT 10-40 U/mL
  • SGPT 5-35 U/mL
  • alk phos 10-30 U/mL
  • PT 12-14 sec

28

A currently non intoxicated alcoholic will require more/less anesthetic?

more

29

How do you determine if you should check LFTs?

(chart)

30

How do you determin what coags to look at?

(chart)

31

Would you get a pre-op EKG in a liver pt?

Why or why not?

  • Yes
  • incresed levels of endogenous vasodilators such as vasoactive intestinal peptide
  • high CO
  • decreased SVR
  • hyperdynamic circulatory state
  • arteriovenous shunting
  • portal hypertension

32

What does the Child-Pugh score use to calculate morbidity and mortality with liver insufficiency?

What are the scores?

  • encephalopathy
  • ascites
  • bilirubin
  • albumin
  • PT/INR
  • primary biliary cirrhosis
  • scored as A,B, and C- C being very severe