Exam 4 - Gastrointestinal Flashcards
1
Q
What are the 5 functions of the GI system?
A
motility, digestion, absorption, excretion and circulation
GI tract is 5% of total body mass :)
3
2
Q
Name the layers of GI system from outer to inner
A
the serosa, longitudinal muscle, circular muscle, submucosa, mucosa
~Within mucosa is muscularis mucosae, lamina propia and epithelium
3
3
Q
How do the longitutional muscle and circular muscle layers propagate gut motility?
A
- longitudinal muscle shortens the length of the intestinal segment
- circular muscle layer decreases the diameter of the intestinal lumen
- They work together and propagate motility
4
4
Q
What does the celiac plexus innervate?
A
the GI organs up to the proximal transverse colon
5
5
Q
What does the inferior hypogastric plexus innervate?
A
the descending colon and distal GI tract
5
6
Q
What 4 ways can the celiac plexus be blocked?
A
Transcrural
Intraoperative
endoscopic ultrasound-guided
peritoneallavage
5
7
Q
Where does the submocosal plexus transmit information to?
What is the role of myenteric plexus?
A
submucosal plexus transmits information from the epithelium to the enteric & central nervous systems
-myenteric plexus lies btw smooth muscle layers and regulates smooth muscle
6
8
Q
The mucosa is made up of muscularis mucosa, lamina propia and epithelium. What are their functions?
A
- muscularis mucosa -thin layer; moves the villi
-
lamina propria -contains blood vessels & nerve endings
immune and inflammatory cells - epithelium- senses GI contects, secretes enzymes,absorbs nutrients, exretes waste
7
9
Q
The mucosa is made up of muscularis mucosa, lamina propia and epithelium. What are their functions?
A
- muscularis mucosa -thin layer; moves the villi
-
lamina propria -contains blood vessels & nerve endings
immune and inflammatory cells - epithelium- senses GI contects, secretes enzymes,absorbs nutrients, exretes waste
7
10
Q
GI innervated by ANS
The GI tract ANS consists of extrinsic nervous system and enteric nervous system.
What are their functions?
A
-
extrinsic nervous system (which has SNS and PNS components)
The extrinsic SNS -inhibitory ;decreases GI motility
extrinsic PNS - excitatory ; activates GI motility - enteric nervous system independent nervous system; controls motility, secretion, and blood flow
8
11
Q
The enteric system is comprised of myenteric plexus and submucosal plexus. What are the functions of these?
A
- myenteric plexus controls motility- carried out by enteric neurons,interstitial cells of Cajal, and smooth muscle cells
- submucosal plexus controls absorption, secretion, and mucosal blood flow
Both these respond to sympathetic and parasympathetic stimualtion
9
12
Q
Upper Gastrointestinal Endoscopy: may be diagnostic or therapeutic. Endoscope is placed into what 4 structures
A
- esophagus
- stomach
- pylorus
- duodenum
10
13
Q
T/F: An Upper Gastrointestinal Endoscopy can be done without anesthesia?
A
- True.
- Can be done w/ or without.
10
14
Q
Anesthesia challenges for and Upper Gastrointestinal Endoscopy include: __________ airway with the endoscpist, and the procdure is normally performed __________ the main OR.
A
- Sharing
- Outside
10
15
Q
Colonoscopy can be diagnostic or _______, with or with out anesthesia and include anesthesia challenges such as _________ d/t _______ _______ and NPO status.
A
- therapeutic
- dehydration
- bowel prep.
10
16
Q
____ _____ ____ _is a procedure when a catheter measures pressure along the entire esophageal length.
11
A
High Resolution Manometry (HRM)
11
17
Q
High Resolution Manometry is use to diagnose ______ disorder.
A
motility
12
18
Q
GI series with ingested barium is a _______ assessment of _______ function and GI transit.
A
- radiologic
- swallowing
12
19
Q
Gastric Emptying Study is when a patient _____ for atleast __ hours and consumes a meal with a ______. Continous or frequent _____ occurs for the next 1-2 hours.
A
- fasting
- 4
- radiotracer
- imaging
12
20
Q
Lower GI Series involves the administration of a _____ enema to a patient. The barium outines the ________ and it is visible on the radiograph. This allows for the detection of ______ and _____ anatomical abnormalities.
A
- barium enema
- intestines
- colon
- rectal
12
21
Q
Diseases of the esophagus are grouped in 3 classes:
A
- Anatomical
- Neurological
- mechanical
13
22
Q
Anatomical causes of Esophageal Disease include _______, ____ hernia, and changes associated with _____ acid reflux.
A
- diverticula
- Hiatal
- chronic
13
23
Q
Mechanical causes of Esophageal Disease include achalasia, _______ spasm and a ______ LES
A
- Esophageal
- Hypertensive
13
24
Q
Neurologic causes of Esophageal Disease may be stroke, ______ or hormone _________.
A
- vagotomy
- deficiencies
13
25
3 most common symptoms of esophageal disease include:
* Dysphagia
* GERD
* heartburn
## Footnote
14
26
Dysphagia is difficulty swallowing and may be _______ or ________.
* orpharyngeal
* esophageal
## Footnote
14
27
Oropharyngeal Dysphagia is most common after ______ and _______ surgeries.
* head
* neck
## Footnote
14
28
Esophageal Dysmotility occurs with _______ and ________.
* liquids
* Solids
## Footnote
14
29
Mechanical Esophageal Dysphasia occurs with _______.
Solids
## Footnote
14
30
Gastroesphageal Reflux Disease is the effortless return of _____ contents into ________.
* gastric
* pharynx
## Footnote
14
31
What are (3) Classic symptoms of GERD
* Heatburn
* Lump in throat
* nausea
## Footnote
14
32
Achalasia is a ________ disorder of the _________ consisting of outflow obstuction d/t an inadequate _____ tone and _____ hypomobile esophagus.
* neuromuscular
* esophagus
* LES
* dilated
## Footnote
15
33
Achalsia is caused by loss of _______ cells of the esophagus ______ plexus. Followed by an absence of ______ neurotransmitters of the LES. Causing unopposed _________ LES stimulation (LES can't RELAX)
* ganglionic
* myenteric
* inhibitory
* cholinergic
| This disease was referred to as a symptom of several GI disorders later
## Footnote
15
34
Achalasia causes Esophageal ____ with food ______ to pass to the stomach.
* dilation
* unable
## Footnote
15
35
Achalsia symptoms include _______, regurgitation, ________ and chest pain. Long-term can increase risk of ________ cancer.
* dysphagia
* heart burn
* esophageal
## Footnote
15
36
There are _____ classes of Achalasia.
3
## Footnote
15
37
Achalsia Type 1: __________ esophageal pressure, responds _______ to myotomy
* minimal
* well
## Footnote
15
38
Achalasia Type 2: _____ esophagus pressureized; responds well to treatment and has the ______ outcome.
* Entire
* Best
## Footnote
15
39
Achalasia Type 3: Esophageal ______ w/ premature contractions; has the ______ outcome.
* spasms
* worst
## Footnote
15
40
All treatments for Achalasia are __________.
* Palliative.
## Footnote
16
41
Medication treatments for Achalsia include nitrates and _____ to relax LES, and Endoscopic _____ injections.
* Calcium Channel Blockers (CCB)
* Botox
## Footnote
16
42
What is the most effective non surgical tx for achalasia?
Pneumatic dilation
## Footnote
16
43
What is the best surgical treatment for achalasia? *hint laparascopic*
* Laparascopic Hellar Myotomy
## Footnote
16
44
Surgical treatment for Achalasia can include Peri-oral Endoscopic Myotomy (POEM) which is the endoscopic division of the ____ muscle layers. 40% of the surgeries cause ________ or pneumoperitoneum.
* LES
* Pneumothroax
## Footnote
16
45
Esophagectomy for the treatment for Achalasia is only considered in the most _________ disease states.
* advanced.
| high aspiration risk! RSI or awake intubation
## Footnote
16
46
What are diffuse esophageal spasms? Why do they occur?
Spasms that usually occur in distal esophagus; likely d/t autonomic dysfunction
*Common in elderly
Tx: NTG, antidepressants, PD-I*
## Footnote
17
47
What is esophageal diverticula?
outpouchings in the wall of the esophagus
## Footnote
17
48
What are the (3) types of esophagela diverticula?
What are they all at risk of?
Pharyngoesophagelal (zenker diverticulum)
Midesophageal
Epiphrenic (supradiaphragmatic)
All are aspiration risks. Removal of particles and RSI indicated.
## Footnote
17
49
What are the signs of Pharyngoesophageal (Zenker diverticulum)?
bad breath d/t food retention
## Footnote
17
50
What are the causes of Midesophageal diverticula?
old adhesions or inflamed lymph nodes
## Footnote
17
51
What does the pain from diffuse esophageal spasms mimic? What is the treatment of diffuse esophagela spasms?
Pain mimics angina.
TX: NTG, antidepressants, PD-I's
## Footnote
17
52
What can Epiphrenic (supradiaphragmatic) pts experience?
achalasia
## Footnote
17
53
What is Hiatal Hernia? How does it occur? What is it associated with?
- **Herniation of stomach into thoracic cavity,** occurs through the esophageal hiatus in the diaphragm
- c/b weakening in anchors of gastroesophageal junction to the diaphragm
- May be asymptomatic; often **associated with GERD**
## Footnote
18
54
What type of cancer presents w/ progressive dysphagia and weight loss?
Esophageal cancer
5/100,000 ppl in US
| poor survival rate :(
## Footnote
18
55
What is the most common type of esophageal cancer?
What 3 conditions does it relate to?
Most are adenocarcinomas, located in lower esophagus
These are r/t **GERD, Barretts, Obesity**
*Squamous cell carcinoma accounts for the rest of esophageal cancers*
## Footnote
18
56
Why does esophageal cancer have poor survival rate?
B/c abundant lymphatics lead to lymph node metastasis
## Footnote
18
57
What is the surgical intervention for esophageal cancer?
How is it performed?
**Esophagectomy**: May be curative or palliative
May be performed transthoracic, transhiatal, or minimally invasive.
## Footnote
19
58
What are pts at risk of when undergoing esophagectomy?
Pts are often _____ in pre op and many months after!
If h/o of chemo and radiation, what 2 symptoms may occur?
High risk of **recurrent laryngeal nerve injury**; of which 40% resolve spontaneously.
Patients are often **malnourished** preop, and many months after.
If h/o chemo/radiation -**pancytopenia & dehydration** may present
## Footnote
19
59
What are all patients post- esophagectomy at risk of?
High aspiration risk for life!
## Footnote
19
60
# GERD
What do reflux contents include?
HCL, pepsin, pancreatic enzymes, bile
## Footnote
20
61
What is GERD? what are its s/s? How frequently does it occur in adults?
Incompetence of the gastro-esophageal junction, leading to reflux
Sx: heartburn, dysphagia & mucosal injury
Occurs in **15%** of adults.
## Footnote
20
62
What diseases is bile reflux associated with?
Barrett metaplasia & adenocarcinoma
## Footnote
20
63
What are 3 mechanisms of GE incompetence?
1. Transient LES relaxation, elicited by gastric distention
2. LES hypotension (normal LES pressure-29mmHg, avg GERD pressure-13 mmHg)
3. Autonomic dysfunction of GE junction
## Footnote
20
64
What is the treatment for GERD? (meds and surgery). What foods do you avoid?
* Meds: Antacids, H2 blockers, PPIs
* Surgery: Nissen Fundoplication, Toupet, LINX
* avoidance of trigger foods
## Footnote
21
65
What are the pre-op interventions for GERD patients?
- **Cimetidine, Ranitidine**-↓acid secretion & ↑pH
- PPI’s generally given night before and morning of surgery.
* **Sodium Citrate**- PO nonparticulate antacid
* **Metoclopramide**- gastrokinetic; often reserved for diabetics, obese, pregnant
*Aspirations precautions --> RSI*
## Footnote
21
66
What are the factors that increase intraop aspiration risk? (long list)
* Emergent surgery
* Full Stomach
* Difficult airway
* Inadequate anesthesia depth
* Lithotomy
* Autonomic Neuropathy
* Gastroparesis
* DM
* Pregnancy
* ↑ Intraabdominal pressure
* Severe Illness
* Morbid Obesity
## Footnote
22
67
The **stomach** is ____sac that serves as a ____ for large volumes of food, mixes and breaks down food to form ____, and slows emptying into the small intestine
J- shaped
reservoir
chyme
## Footnote
24
68
What does gastrin and motilin do?
What does gastric inhibitory peptide do ?
Gastrin & motilin increase the strength and frequency of contractions
Gastric inhibitory peptide inhibits contractions
| These are controlled by neurohormonal
## Footnote
24
69
What is the effect of PNS and SNS on the motility of the stomach?
**Parasympathetic** stimulation to the vagus nerve increases the number and force of contractions
**Sympathetic** stimulation inhibits these contractions via the splanchnic nerve
## Footnote
24
70
What does the intrinsic nervous system do for motility?
Provides coordination
## Footnote
24
71
What controls the motility of the stomach?
The motility of the stomach is controlled by **intrinsic** and **extrinsic** neural regulation
## Footnote
24
72
What size should solids be broken down to before entering duodenum?
1-2 mm particles
## Footnote
24
73
Peptic Ulcer Disease ::
* Most common cause of ____________________
* Prevalence= ___ women, ___ men
* ____ death per year
* may be associated with _______________
non-variceal upper GI bleeding
10% ,, 12%
15,000
Helicobacter Pylori
slide 25
74
Gastric Outlet Obstruction ::
* Onset may be ____ or ____
* 2 causes of acute obstructions
acute ,, slow
edema & inflammation in pyloric channel at beginning of duodenum
slide 26
75
Peptic Ulcer Disease ::
* Sx :: ______ epigastric pain exacerbated w/ ______ and improved w/ _______
* 10% risk of__________ in those who do not receive treatment
Mortality is d/t (2 things)
BURNING epigastric pain exacerbated w/ FASTING and improved w/ MEALS
perforation
shock or perforation >48h
slide 25
76
Perforation is sudden/severe ______ pain from _____ secretions into ________
sudden/severe EPIGASTRIC pain c/b ACIDIC secretions into PERITONEUM
slide 25
77
Gastric Outlet Obstruction Treatment (2)
Normally resolves in ___ hrs
Repetitive ______ & _____ may lead to fixed-stenosis and chronic obstruction
NGT + IV hydration
72 hrs
ulceration + scarring
slide 26
78
Gastric Ulcers ::
Treatment for H. Pylori
Tripple therapy
2 abx + PPI x 14 days
79
Pyloric obstruction :: 3 symptoms
Recurrent vomiting
dehydration
hyperchloremic alkalosis
Slide 26
80
What are 3 primary causes of gastric ulcers?
NSAIDs ,, alcohol ,, H. Pylori
## Footnote
27
81
What are the 5 types of gastric ulcers
Location -- acid hyper secretion?
1 = Lesser curvature close of incisura -- NO
2 = TWO ulcers : gastric body + duodenal - YES
3 = prepyloric - YES
4 = lesser curvature of gastroesophageal junction - NO
5 = anywhere - usually d/t NSAID use
## Footnote
27
82
Zollinger Ellison Syndrome ::
WHat are 2 treatments
Pts have ↑ gastric fluid_______, ________imbalances, &________ abnormalities
Preop :: Correct ______, ↑ gastric ____ w/meds
Induction technique?
PPIs and surgical resection of gastrinoma
volume ... electrolyte ... endocrine
electrolytes ... pH
RSI
## Footnote
28
83
Zollinger Ellison Syndrome ::
* 3 symptoms
* Occurs in ______ of PUD pts
* Gender affected?? Most commonly btw ages _____
Up to 50% of pts w/gastrinomas are______ at time of dx
peptic ulcer dz, erosive esophagitis, diarrhea
0.1-1%
Males > females agees 30-50
metastatic
## Footnote
28
84
Zollinger Ellison Syndrome ::
_________ tumor of the pancreas, causing ______ hypersecretion
Gastrin stimulates gastric acid ________.
Gastric acid normally ________ further gastrin release (neg feedback)
This feedback loop is ________ in ZE syndrome
Non B cell islet
gastrin
secretion
inhibits
absent
## Footnote
28
85
Small Intestine ::
* motility mixes contents of the stomach with _____ ________, further reducing particle___ and increasing _____
* Major function :: _____ the contents and expose them to the ______ _____ to maximize absorption of ____, ______, and _______ before entering the large intestine
digestive enzymes ... size .... solubility
circulate ... mucosal wall ...water, nutrients, vitamins
## Footnote
29
86
Small Intestine ::
The_____ and _________ muscle layers coordinate to achieve SEGMENTATION
Segmentation occurs when two areas _______ and thereby isolate a segment of intestine
Segmentation allows the contents to remain in the _______ long enough for the essential substances to be _______ into the circulation
It is controlled mainly by the ________ nervous system with modulation of motility by the extrinsic nervous system
circular ... longitudinal
contract
intestine .... absorbed
Enteric ....EXtrinisic
## Footnote
29
87
Small bowel Dysmotility
5 Reversible Causes
2 types Nonreversible causes
Mechanical Obstruction (hernias, adhesions)
bacterial overgrowth
ileus
electrolyte abnormalities
critical illness
Structural - scleroderma , IBD , connective tissue dx
neuropathic - intrinsic + extrinsic NS altered + produce weak contractions >>> n/v, bloating, abd pain
## Footnote
29
88
Large Intestine ::
The colon also exhibits giant _______ complexes
These serve to produce mass _______ across the large intestine
In the healthy state, these complexes occur approximately ______x a day
Migrating
movements
6-10
## Footnote
31
89
Large Intestine ::
* Acts as a reservoir for _____ and ______ material before elimination
* extracts remaining ______ and water
* _______ of the ileum will RELAX the _____ valve to allow intestinal contents to enter the colon
* Subsequent _____ distention will CONTRACT the ileocecal valve
waste .. indigestible
electrolytes
Distention ... ileocecal
cecal
## Footnote
31
90
What are the most common diseases associated with Colonic dysmotility?
## Footnote
Large Intestine
* **IBS** (Inflammatory Bowel Syndrome)
* **IBD** (Inflammatory Bowel Disease)
## Footnote
32
91
Rome II criteria defines IBS as having abdominal discomfort along with 2 of the following features?
| there are 3 features
* defecation relieves discomfort
* pain is assoc w/abnormal frequency (> 3x per day or < 3x per week)
* pain is associated with a change in the form of the stool
## Footnote
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92
In IBD, the contractions are suppressed due to colonic wall ____ by the inflamed mucosa, but the giant ____ complexes remain
In IBD, the contractions are suppressed due to colonic wall **compression** by the inflamed mucosa, but the giant **migrating** complexes remain
## Footnote
32
93
The ↑ frequency of the giant migrating complexes and their pressure effect = ↑ compression of inflamed mucosa which can lead to?
* hemorrhage
* thick mucus secretion
* significant erosions
## Footnote
S32
94
What is the 2nd most common inflammatory disorder (after RA)?
IBD
Incidence 18:100,000 ppl
## Footnote
33
95
What is a mucosal disease of rectum and part or all of the colon?
Ulcerative Colitis?
## Footnote
33
96
In severe cases of Ulcerative Colitis, what is the condition of the mucosa?
* hemorrhagic
* edematous
* ulcerated
## Footnote
S33
97
What are the s/s of Ulcerative Colitis?
* diarrhea
* rectal bleeding
* crampy abdominal pain
* N/V
* fever
* weight loss
## Footnote
33
98
What are the lab results of Ulcerative Colitis?
↑plts
↑erythrocyte sedimentation rate
↓H&H
↓albumin
## Footnote
33
99
What intervention to do after giving 6+ units of blood in 24-48 hours of hemorrhage of Ulcerative Colitis?
**surgical colectomy**
~ ½ cases resolve and ½ require colectomy
## Footnote
33
100
What are 2 primary symptoms that manifests with Colonic dysmotility?
**altered bowel habits**
and/or
**intermittent cramping**
## Footnote
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101
What is a complication of Ulcerative Colitis triggered by electrolyte disturbances?
Toxic megacolon
## Footnote
S33
102
What is a dangerous complication of toxic megacolon?
Colon perforation
## Footnote
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103
What is acute or chronic inflammatory process that may affect any/all of the bowel?
Crohn's Disease
## Footnote
S34
104
Where is the most common site of Cronh's disease?
Terminal ilium
## Footnote
34
105
What does presentation of Cronh's disease?
w/ ileocolitis
w/ RLQ pain
& diarrhea
## Footnote
S34
106
What are 2 patterns of Cronh's disease?
* penetrating-fistulous
* obstructing
## Footnote
S34
107
What are s/s of Cronh's disease?
* weight loss
* fear of eating
* anorexia
* diarrhea
## Footnote
34
108
What does *persistent inflammation* of Crohn's disease gradually progresses to?
* fibrous narrowing
* stricture formation
## Footnote
34
109
What replaces diarrhea with Cronh's disease progression?
Chronic bowel obstruction
## Footnote
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110
Colonic disease may ____ into stomach/duodenum, causing fecal ____
Colonic disease may **fistulize** into stomach/duodenum, causing fecal **vomitus**
## Footnote
S34
111
What are additional symptoms of 1/3 Cronh's patients?
* arthritis
* dermatitis
* kidney stones
## Footnote
S34
112
What are medical treatments of IBD?
* **5-Acetylsalicylic acid (5-ASA)** - for antibacterial & anti-inflammatory
* **PO/IV Glucorticoids** - during flares
* **Antibiotics** - Rifaximin, Flagyl, Cipro
* **Purine analogues**
## Footnote
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113
What intervention should be the last resort for IBD?
Resection surgery
## Footnote
S35
114
What length should small intestestine resection be limited to?
< 1/2 length
Resected segment should be as conservative as possible
## Footnote
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115
What does > 2/3 of small intestine resection leads to? And what does it require?
“short bowel syndrome"
requiring TPN
## Footnote
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116
Where do most carcinoid tumors originate from? Where can they occur?
GI tract
occur in any GI tissue/segment
## Footnote
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117
What kind of products are secreted by Carcinoid tumors?
peptides & vasoactive substances
(gastrin, insulin, somatostatin, motilin, neurotensin, tachykinins, glucagon, serotonin, other biological actives)
## Footnote
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118
What occurs to 10% of patients with Carcinoid tumors where large amounts of serotonin and vasoactive substances reach systemic circulation?
Carcinoid syndrome
## Footnote
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119
What are s/s of Carcinoid syndrome?
* flushing
* diarrhea
* HTN/HoTN
* bronchoconstriction
## Footnote
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120
Effects of Carcinoid sydrome on CV:
May acquire *right heart* endocardial ____
*Left heart* generally more ____ as the lungs clear some of the vasoactive substances
May acquire *right heart* endocardial **fibrosis**
*Left heart* generally more **protected** as the lungs clear some of the vasoactive substances
## Footnote
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121
How to diagnose Carcinoid syndrome?
* urinary or plasma serotonin levels
* CT/MRI
## Footnote
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122
What are the treatments for Carcinoid syndrome?
* avoid serotonin-triggers
* control diarrhea
* serotonin antagonists
* somatostatin analogues
## Footnote
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123
What medication to give before surgery and prior to tumor manipulation of Carcinoid syndrome and why?
Ocreotide
to attenuate volatile hemodynamic change
## Footnote
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124
What are the secretory characteristics in the Foregut of Carcinoid tumors?
**↓ Serotonin** secretion
secreted **ACTH, 5-HTP, GRF**
**Atypical** Carcinoid syndrome
## Footnote
S38 table
125
What are the secretory characteristics in the Midgut of Carcinoid tumors?
**↑ Serotonin** secretion
secreted **Tachykinins, rarely 5-HTP, ACTH**
**Typical** Carcinoid syndrome
## Footnote
S38 table
126
What are the secretory characteristics in the Hindgut of Carcinoid tumors?
**rare** Serotonin secretion
**rarely** 5-HTP, ACTH, other peptides
**rare** Carcinoid syndrome
## Footnote
S38 table
127
What are the presentations of Carcinoid Tumors at the Small Intestines?
* Abdominal pain
* Intestinal obstruction
* tumor
* GI bleeding
## Footnote
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128
What are the presentations of Carcinoid Tumors at the Rectum?
* Bleeding
* constipation
* diarrhea
## Footnote
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129
What is the presentation of Carcinoid Tumors at the Bronchus?
Asymptomatic
## Footnote
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130
What is the presentation of Carcinoid Tumors at the Thymus?
Anterior mediastinal mass
## Footnote
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131
What is the presentation of Carcinoid Tumors at the Ovary and Testicle?
Mass discovered on physical examination or ultrasound
## Footnote
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132
Where do Carcinoid Tumors metastasize to and what is the presentation?
in the Liver
presents as Hepatomegaly
## Footnote
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133
What is an inflammatory disorder of the pancreas?
Acute Pancreatitis
## Footnote
S39
134
How is autodigestion normally prevented to prevent trigger of Pancreatitis?
* Proteases packaged in precursor form
* Protease inhibitors
* Low intra-pancreatic calcium → decreases trypsin activity
## Footnote
S39
135
What are the most common causes of Pancreatitis?
1. **Gallstones** - obstruch ampula of vater → pancreatic ductal HTN
2. **Alcohol abuse**
## Footnote
S39
136
What other disorders is Pancreatitis also seen in?
immunodeficiency syndrome hyperparathyroidism (↑Ca++)
## Footnote
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137
What are s/s of Acute Pancreatitis?
* excruciating epigastric pain that radiates to back
* N/V
* abd distention
* steatorrhea
* ileus
* fever
* tachycardia
* HoTN
## Footnote
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138
What are the hallmark labs of Acute Pancreatitis?
↑serum amylase & lipase
## Footnote
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139
what are some imaging for acute pancreatitis?
contrast CT or MRI, endoscopic US (EUS)
## Footnote
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140
what are some complications of acute pancreatitis?
25% experience serious complications s/a shock, ARDS, renal failure, necrotic pancreatic abscess
## Footnote
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141
What are the treatments for Acute Pancreatitis?
* Aggressive IVF
* NPO (to rest pancreas)
* enteral feeding (preferred over TPN)
* opioids
| TPN associated w/greater risk of infectious complications
## Footnote
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142
what is an ERCP? and what does it help with?
Fluoroscopic examination of biliary & pancreatic ducts
Interventions include stone removal, stent placement, sphincterotomy, hemostasis
## Footnote
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143
which GI bleed is more common? (upper or lower?)
Upper GI bleed
## Footnote
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144
what vital sign changes will u see w/ >25% blood loss?
hypotension and tachycardia
## Footnote
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145
what does orthostatic hypotension normally indicate?
HCT < 30%
## Footnote
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146
what does melena indicate?
GI Bleed that is above the cecum!!
(Cecum is where small intestine meets colon)
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147
why does the BUN go up >40 mg/dL during a GI bleed?
because absorption of nitrogen into bloodstream
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148
what is the therapeutic procedure of choice and also diagnostic for GI bleeds?
EGD (Esophagogastroduodenoscopy)
for endoscopic ulcer ligation and ligation of bleeding varices
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149
what is the last resort for uncontrolled variceal bleeding?
Mechanical balloon tamponade
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150
who usually has lower GI bleeds and what are some causes?
elderly
causes - diverticulosis, tumors, colitis
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151
What procedure can be performed for Lower GI bleeding as soon as HD stabilizes?
Unprepped sigmoidoscopy
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152
What procedure can be done for Lower GI bleeding if pt can tolerate prep?
Colonoscopy
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153
What 2 interventions are warranted if persistent bleeding occurs with Lower Gi bleed?
angiography and embolic therapy
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154
what is an adynamic ileus?
Colonic ileus characterized by massive dilation of the colon without mechanical obstruction
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155
what leads to distention of colon?
loss of peristalsis
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156
what is an adynamic ileus caused by?
electrolyte disorders, immobility, excessive narcotics, anticholinergics
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157
what could be the neural reason for adynamic ileus?
thought to be due to neural-input imbalance of excessive sympathetic stimulation along with inadequate parasympathetic input to the colon
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158
whats the tx for adynamic ileus?
* Restore e-lyte balance
* hydrate
* mobilize
* NG suction
* enemas
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159
what med and dose will u give for adynamic ileus?
and what do monitoring do u need if u give it?
neostigmine 2-2.5 mg over 5 min
- produces immediate results 80-90%
- CARDIAC MONITORING REQUIRED
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what happens if u leave an adynamic ileus untreated?
ischemia and perforation!
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s43
161
what is inhibition GI activity directly proportional to?
amount of norepinephrine secreted from SNS stimulation, so the **higher anxiety = higher inhibition**
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162
what do volatiles do to the GI system?
**depress the spontaneous, electrical, contractile, and propulsive activity** in the stomach, small intestine, and colon
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163
whats the process of recovery of GI system?
1. small intestine --> **first part of GI tract to recover**
2. followed by stomach in approx 24 hrs
3. then, colon 30-40 hours post-op
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what is important about nitrous oxide and gas containing cavities?
* N2O is 30x more soluble than nitrogen in blood
* will d**iffuse into gas-containing cavities from the blood faster than the nitrogen can diffuse out**
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165
do NMBs affect GI motility?
No, NMBs only affect skeletal muscle, so GI motility remains intact
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166
when should N2O be avoided?
in lengthy abdominal surgeries or when the bowel is already distended
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167
what does gut distention correlate to?
* pre-existing amount of gas in the bowel
* **duration** of nitrous oxide administration
* **concentration** of nitrous oxide administered
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168
what will neostigmine (AChE-I) cause w/ GI system?
what will offsets the cholinergic activity of neostigmine?
increase PNS activity and bowel peristalsis by increasing the frequency & intensity of contractions
- concurrent admin of anticholinergics (glycopyrrolate or atropine)
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169
What is sugammadex's effects on motility?
NONE, Sugammadex does not appear to have any effect on motility
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170
What is known to cause reduced GI motility and constipation?
How?
Opioids
by exerting their function on **both** central & peripheral mu, delta, and kappa receptors
* and there's a high density of peripheral mu-opioid receptors in the myenteric and submucosal plexuses!!!
* **Activation of the mu-receptors causes delayed gastric emptying and slower transit through the intestine**!!!
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171
what are some adverse events w/ opioids and the GI system?
* nausea
* anorexia
* delayed digestion
* abdominal pain
* excessive straining during bowel movements
* incomplete evacuation
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172
what are the 5 main functions of the GI tract?
* motility
* digestion
* absorption
* excretion
* circulation
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173
name the layers of GI tract wall from outermost to innermost
outermost to innermost
1. serosa
2. longitudinal muscle
3. circular muscle
4. submucosa
5. mucosa
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174
name the layers of the mucosa from **outer to inner**
1. muscularis mucosae
2. lamina propria
3. epithelium
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175
how do the SNS and PNS act on the GI motility?
The extrinsic nervous system consists of:
SNS --> primarily inhibitory
PNS --> primarily excitatory on GI tract motility
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176
what does the enteric nervous system control?
motility, secretion, and blood flow
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177
what are the 2 primary movements w/in and along the GI tract?
mixing and propulsive movements
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178
What can hemodynamic changes, bowel manipulation and open abdominal surgeries induce?
ileus, inflammatory states, mesenteric ischemia, and partial or total disruption of myogenic continuity
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