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Physical & Health Assessment (Spring '24) - 1 > Exam 2 Gastrointestinal Diseases > Flashcards

Exam 2 Gastrointestinal Diseases Flashcards

1
Q

What symptoms are presented with esophageal disease?

A

Dysphagia

Heartburn

Regurgitation - the effortless movement of gastric content up to the pharynx, not necessarily vomiting

Chest pain

Odynophagia- pain with swallowing

Globus sensation- lump in the throat

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2
Q

What is Achalasia?

A

Motility disorder where the esophageal outflow obstruction d/t inadequate relaxation of the lower esophageal sphincter (LES).

Essentially, the distal end of the esophagus is dilated and food accumulates there and drains into the LES very slowly.

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3
Q

What is the normal resting tone of the LES?

A

29 mmHg

LES hypertension is greater than 29 mmHg
LES hypotension is less than 29 mmHg

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4
Q

Signs and Symptoms ofAchalasia.

A

Dysphagia (both solids/liquids)
Regurgitation (high risk of aspiration, sleep upright)
Heartburn
Chest pain

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5
Q

Prolonged achalasia is correlated to high incidences of _____ cancer.

A

Esophageal

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6
Q

What are treatments for achalasia to relieve obstruction (drugs and procedures)?

A

Relieves obstruction… not peristalsis

Nitrates, CCB - LOW doses

Botox - Relax LES

Pneumatic (balloon) dilation

Heller myotomy - cutting smooth muscle at the distal portion of the esophagus and the top portion of the fundus, laparoscopic procedure.

Per oral endoscopic myotomy (POEM)

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7
Q

Anesthesia concerns for achalasia

A

Aspiration➔ RSI or awake intubation

POEM – NPO up to 48 hours

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8
Q

What does a Distal Esophageal Spasm mimic?

A

Mimics anginal pain - patients often think they are having a heart attack

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9
Q

What is used to dx distal esophageal spasm?

A

Esophagram- a series of x-ray pictures of the esophagus taken after a patient drinks a liquid containing barium sulfate.

A distal esophageal spasm x-ray will show a corkscrew-like or rosary bead-like appearance.

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10
Q

What are treatments for esophageal spasms?

A

Nitroglycerin (0.4 mg)
Trazodone (25-50 mg)
Imipramine (antidepressants)
Sildenafil (Phosphodiesterase Inhibitors)

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11
Q

What is an esophageal diverticula?

What 3 regions of the esophagus can have a diverticulum?

A

Esophageal wall outpouching.

  1. Pharyngoesophageal (Zenker’s diverticulum)-picture below.
  2. Mid-esophageal
  3. Epiphrenic (supradiaphragmatic diverticulum)
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12
Q

What are the signs and symptoms of esophageal diverticula?

What is the treatment for esophageal diverticula?

A

Bad Breath
Dysphagia - the bigger the diverticulum, the more compression on the esophagus, and the worse the dysphagia.

Diverticula removal
(or drink a beer- won’t be on the test)

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13
Q

Anesthesia considerations for esophageal diverticula.

A

Aspiration risk

No cricoid pressure - increase the risk of displacing contents in the diverticulum.

Intubate w/ head elevated

Avoid NGT - increase the risk of perforating the diverticulum.

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14
Q

What is a hiatal hernia?

What are the two different types of hiatal hernias?

A

A condition where part of the stomach enters the thoracic cavity through the esophageal hiatus (diaphragm).

  1. Sliding hiatal hernia
    - Gastroesophageal (GE) junction and fundus
    slideupward
  2. Paraesophageal hernia
    - GE junction doesn’t move
    - Pouch of the stomach herniates next to the GE junction through esophageal hiatus
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15
Q

How are hiatal hernias repaired?

A

Hiatal hernias are not generally repaired.
Most patients are asymptomatic.

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16
Q

What kind of cells make up esophageal tumors?

What are the signs and symptoms of esophageal tumors?

Treatment for esophageal tumors?

A

Squamous cells (mid esophagus) or adenocarcinomas (distal esophagus)

S/S:
Progressive dysphagia - tumor causing compression
Malnourishment
Dehydration
Significant weight loss
Pancytopenia
Lung injury (post-chemo and radiation)

Treatment: Esophagectomy, chemotherapy, or radiation(cut, poison, and burn)

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17
Q

What is GERD?

A

Reflux causes esophageal mucosal injury or at extraesophageal sites (pharynx or larynx).

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18
Q

How does our body prevent reflux?

A

LES

LES pressure (29 mmHg) - patients with significant GERD have an LES pressure of 13 mmHg

Crural diaphragm

GE junction

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19
Q

What causes GE junction/LES incompetence?

A

Transient LES relaxation
LES hypotension ( <29 mmHg)
Anatomic distortion of GE junction - hernia

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20
Q

S/S of Gerd.

Complications of GERD.

A

S/S:
Heartburn
Regurgitation
Dysphagia
Chest pain - the bigger the hernia, the bigger the chest pain

Complications:
Esophagitis
Laryngopharyngeal reflux variant- can lead to a chronic cough
Recurrent pulmonary aspiration

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21
Q

GERD treatment:

A

Lifestyle Modification - Avoid fried food, acidic food, EtOH, and peppermint. Reduce LES tone

PPIs > H2 antagonists

Nissen Fundoplication - Surgery where the top of the stomach is wrapped around the lower esophagus. This reinforces the LES, making it less likely that acid will back up in the esophagus.

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22
Q

Anesthesia concerns for GERD.

A

Aspiration Risk
Perform RSI w/ cricoid pressure

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23
Q

What can be given to mitigate aspiration risk for GERD?

A

Cimetidine and Ranitidine
Famotidine > Cimetidine

PPIs - given during the day of surgery

Sodium citrate + metoclopramide - raise the pH of stomach acid (pH 2.5). This will be given to DM, morbidly obese, and pregnant pts d/t decreased emptying.

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24
Q

What is peptic ulcer disease (PUD)?

What do a lot of patients complain of?

A

Ulcers in the mucosal lining ofthe stomach or duodenum.

A lot of patients complain of burning epigastric pain. Exacerbated when the patient is fasting.

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25
What is the number one cause of peptic ulcer disease?
Helicobacter Pylori (H. Pylori) - reduce the duodenal mucosa's production of bicarbonate.
26
What is a Gastric Ulcer? What is it caused by?
Form of Peptic Ulcer Disease, where the ulcer is the stomach. NSAIDs (most common) H. pylori + NSAIDs use
27
What are peptic ulcer disease risk factors for death?
Peritonitis - from perforation Perforation Sepsis Dehydration Bleeding
28
What is the mortality rate of patients with PUD if there are complications with bleeding?
Mortality 10% to 20%
29
What is the percent risk of perforation with untreated duodenal ulceration?
10% *If there is perforation there will be sudden and severe epigastric pain.*
30
What is a gastric outlet obstruction (GOO)? Signs and Symptoms. Anesthesia considerations.
A clinical syndrome characterized by epigastric abdominal pain and postprandial vomiting due to mechanical obstruction. Acute or slow development. S/S: vomiting, dehydration, and  hypochloremic alkalosis. Anesthesia Consideration: GOO is considered as a full stomach, NGT suction, IV  antisecretory drugs (ex: PPIs)
31
PUD Treatment
**Antacids** OTC for symptomatic relief of dyspepsia/indigestion Aluminum/magnesium hydroxide  (TUMS) Calcium carbonate **H2 Receptor Antagonists** Inhibits basal and stimulated HCL secretion Cimetidine, **ranitidine, famotidine, and nizatidine**  4-6 weeks **PPIs** Inhibits all phases of gastric acid secretion Omeprazole, pantoprazole **Prostaglandin Analogues** Misoprostol will Maintain mucosal integrity   **Cytoprotective agents** Sucralfate or Peptobismol will create a physicochemical barrier to protect the mucosa
32
Treatment of H. Pylori.
Triple combination therapy - 14 days PPI + 2 ABX (Clarithromycin and amoxicillin or metronidazole) Surgery will correct the immediate problem such as hemorrhage, perforation, and obstruction.
33
What is Dumping Syndrome?
Emptying hyperosmolar gastric contents into the proximal small bowel from the release of vasoactive GI hormones (histamine, bradykinin, NO).
34
When can Dumping Syndrome occur?
Early – 15-30 mins post-prandial Crampy abdominal pain, syncope, palpitations, epigastric discomfort, nausea, tachycardia, dizziness, diaphoresis, and diarrhea. *C SPENT DDD* Late – 1-3 hours post-prandial Vasomotor symptoms secondary to **hypoglycemia** d/t excessive insulin release 
35
What are treatments for Dumping Syndrome?
Dietary modification Octreotide therapy- works by reducing the secretion of hormones that cause rapid movement of food through the digestive system.
36
What is Ulcerative Colitis (UC)? Signs and Symptoms.
A mucosal disease where there is continuous inflammation of the colon to the rectum. Diarrhea Rectal bleeding Anorexia Fever **Tenesmus** - a continual urge to have a BM. Passage of mucous Crampy abdominal pain N/V Weight loss *DRAFT Pick Cam NeWton*
37
Complications of UC. Treatment for UC.
Massive hemorrhage Toxic megacolon - transverse colon is dilated (picture) Obstruction Perforation  Treatment: Total Proctocolectomy, removing colon and rectum.
38
What is Crohn's disease?
Acute or chronic bowel inflammation. (*Terminal ileum/ cecal value is the area where there will be a presentation of Chron's disease.*) In Crohn's disease, there are healthy parts of the intestine mixed in between inflamed areas. Whereas in UC, there is continuous inflammation.
39
What are the signs and symptoms of Crohn's disease?
Weight  loss Inflammatory  mass **Malnutrition** Postprandial  pain - pain after eating **Steatorrhea** - increases fat excretion in stool **Stricture formation** - a type of abnormal narrowing in a passage in the body. Bowel  spasm WIMPSSB
40
Complications of Crohn's disease. Surgical Treatment.  
Complications: **Stricture**, obstruction, abscess, or fistula Surgical Treatments: **Small bowel resection** d/t fistula or obstruction Total proctocolectomy w/ end ileostomy
41
Inflammatory Bowel Disease medical treatment.
Purine Analogs: Azathioprine and 6-mercaptopurine, 3-4 weeks to reach efficacy Immunosuppressive: Methotrexate (inhibit DNA synthesis of UC/Crohn's) and Cyclosporine (inhibit T-cell mediated responses). Glucocorticoids to treat both UC and Crohn's Anti-inflammatory: 5-Acetylsalicylic acid (5-ASA) ABX – Ciprofloxacin or metronidazole
42
Where can carcinoid tumors originate from? What can these tumors secrete?
Originate from the GI tract: Foregut, midgut, and hindgut  <25% of carcinoid tumors originate in lung tissue  (foregut) Secrete GI peptides and/or vasoactive substances (**insulin, histamine, serotonin**)
43
Which gut will have high serotonin secretion?
Midgut
44
Likelihood of carcinoid syndrome in the Foregut: Midgut: Hindgut:
Carcinoid Syndrome **Foregut: Atypical** **Midgut: Typical** **Hindgut: Rare**
45
How are carcinoid tumors without carcinoid syndromes usually found?
Found accidentally during an appendectomy. .
46
Carcinoid tumors w/ systemic symptoms are d/t what secreted products?
GI peptides and /or vasoactive substances (**insulin, histamine, serotonin**) *Midgut carcinoids are more likely to produce mediators than foregut carcinoids.* *Non-producing tumors can present as a mass or bowel obstruction.*
47
What common presentation will be present if there are carcinoid tumors in these locations? Small Intestine: Rectum: Bronchus: Thymus:
Small Intestine: Abdominal pain (51%) and Intestinal obstruction (31%) Rectum: Bleeding (39%) and constipation (17%) Bronchus: Asymptomatic Thymus: Anterior Mediastinal Mass
48
Patients with carcinoid syndrome will release _________ and _______ (vasoactive substances) into the systemic circulation. What will be the signs of symptoms of Carcinoid Syndrome?
Patients with carcinoid syndrome will release **Serotonin** and **Histamine** (vasoactive substances) into the systemic circulation. Flushing, diarrhea, hypotension,  HTN, bronchoconstriction, wheezing.
49
What are the signs and symptoms of a carcinoid crisis?
Intense flushing, diarrhea, abdominal pain, tachycardia, HTN or hypotension. *Carcinoid Crisis may be fatal w/o treatment*
50
What can cause a carcinoid crisis? What drugs may provoke mediator release? What drugs do not provoke mediator release?
Spontaneous or provoked by stress, chemotherapy, biopsy, or drugs. Succinylcholine, Atracurium, Epi, NE, Dop, Isoproterenol, Thiopental. Propofol, Etomidate, Vecuronium, Cisatracurium, Fentanyl, Inhalation Anesthetics.
51
Carcinoid Tumors medical treatment.
Serotonin blockers 5HT1 or 5HT2 - treat diarrhea 5HT3 (ondansetron) – diarrhea and nausea;  occasionally relieve the flushing  Histamine blockers- treat flushing  **Somatostatin analogs (works great on 80% of patients)** Prevents crisis development **Lanreotide** most commonly used, Subq for 4 weeks. **Octreotide-start 24-48 hours before surgery** Octreotide, histamine blockers, and ipratropium- treat or prevent Bronchoconstriction
52
What are three protective mechanisms that prevent autodigestion of the pancreas?
1. Packaging of proteases in precursor form 2. Synthesis of protease inhibitors  3. The low intra-pancreatic concentration of calcium 
53
What are the causes of pancreatitis?
**Gallstones and ETOH abuse account for 60 to 80% of pancreatitis** AIDS Hyperparathyroidism Trauma
54
Signs and Symptoms of Pancreatitis.
Mid-epigastric pain,  N/V, abd distention (ileus) Dyspnea, low-grade  fever, tachycardia, hypotension Shock d/t hypovolemia **Increased serum amylase and lipase** 
55
Name the components of the Ranson Criteria for Acute Pancreatitis. Age: WBC count: BUN: AST: Arterial PaO2: Fluid deficit: Blood glucose: Lactate dehydrogenase: Corrected [Calcium]:   Fall in Hct: Metabolic acidosis with a base deficit:
Age: **> 55 years** WBC count: **> 16,000 cells/mm3** BUN: **>16 mmol/L** AST: **> 250 units/L** Arterial PaO2: **< 60 mmHg** Fluid deficit: **> 6 L** Blood glucose: **> 200 mg/dL w/o  a  history  of DM** Lactate dehydrogenase: **> 350 IU/L** Corrected [Calcium]: **< 8 mg/dL**  Fall in Hct: **>10%** Metabolic acidosis with a base deficit: **> 4 mmol/L**
56
Mortality r/t number of Ranson criteria present in acute pancreatitis 0-2 criteria: 3-4 criteria: 5-6 criteria: 7-8 criteria:
0-2 criteria **<5% mortality**  3-4 criteria **20% mortality** 5-6 criteria **40% mortality** 7-8 criteria **100% mortality**
57
Complications of Acute Pancreatitis.
*Shock will be the major risk factor for death*
58
Acute Pancreatitis Treatment
Aggressive IVF administration Colloid replacement NPO - prevent pancreas stimulation Enteral/TPN  NGT suction  Pain management  Removal of gallstones
59
What is Chronic Pancreatitis? What is this caused by?
Persistent inflammation w/ irreversible damage. There will be a loss of exocrine and endocrine function. Caused by Chronic ETOH abuse, CF, and hyperparathyroidism
60
Signs of and symptoms of chronic pancreatitis. Treatment.
Signs and symptoms Post-prandial, epigastric pain **Thin, emaciated,** steatorrhea DM - end result of chronic pancreatitis Treatment Management of pain,  manage diabetes and treat malabsorption
61
What is the top cause of upper GIB?
Esophageal Varices
62
What is the top cause of upper GIB, outside of esophageal varices? What can cause lower GIB?
PUD (Duodenal 36% or Gastric Ulcer 24%) Diverticulosis or tumors (10-20%) Colonic Diverticulosis (42%) Older Patients *"Focus on the big numbers"*
63
Signs and symptoms of upper GIB
Acute GIB will present with Hypotension and tachycardia w/ blood loss >25% of total blood volume Hct will initially appear normal. Anemia after fluid resuscitation. Orthostatic hypotension when Hct <30% BUN >40 mg/dL Esophageal variceal bleeding, malignancy
64
Treatment for upper GIB. Anesthetic consideration.
Treatment Upper endoscopy to dx Active bleeding with maintained airway use endoscopic coagulation or clipping Anesthetic Considerations Aspiration risk – ETT w/ **RSI**
65
What is Lower GIB? Causes of Lower GIB. Treatment of Lower GIB.
Abrupt passage of bright red blood and clots via the rectum Caused by diverticulosis, tumors, ischemic colitis, and infectious colitis caused by C diff. Treatment Sigmoidoscopy/colonoscopy to find the source of bleeding. Angiography and embolic therapy Surgery

Physical & Health Assessment (Spring '24) - 1 (27 decks)

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