Exam 4 Gastrointestinal Diseases Flashcards
What symptoms are presented with esophageal disease?
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
What is Achalasia?
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.
What is the normal resting tone of the LES?
29 mmHg
LES hypertension is greater than 29 mmHg
LES hypotension is less than 29 mmHg
Signs and Symptoms ofAchalasia.
Dysphagia (both solids/liquids)
Regurgitation (high risk of aspiration, sleep upright)
Heartburn
Chest pain
Prolonged achalasia is correlated to high incidences of _____ cancer.
Esophageal
What are treatments for achalasia to relieve obstruction (drugs and procedures)?
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)
Anesthesia concerns for achalasia
Aspiration➔ RSI or awake intubation
POEM – NPO up to 48 hours
What does a Distal Esophageal Spasm mimic?
Mimics anginal pain - patients often think they are having a heart attack
What is used to dx distal esophageal spasm?
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.
What are treatments for esophageal spasms?
Nitroglycerin (0.4 mg)
Trazodone (25-50 mg)
Imipramine (antidepressants)
Sildenafil (Phosphodiesterase Inhibitors)
What is an esophageal diverticula?
What 3 regions of the esophagus can have a diverticulum?
Esophageal wall outpouching.
- Pharyngoesophageal (Zenker’s diverticulum)-picture below.
- Mid-esophageal
- Epiphrenic (supradiaphragmatic diverticulum)
What are the signs and symptoms of esophageal diverticula?
What is the treatment for esophageal diverticula?
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)
Anesthesia considerations for esophageal diverticula.
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.
What is a hiatal hernia?
What are the two different types of hiatal hernias?
A condition where part of the stomach enters the thoracic cavity through the esophageal hiatus (diaphragm).
- Sliding hiatal hernia
- Gastroesophageal (GE) junction and fundus
slideupward - Paraesophageal hernia
- GE junction doesn’t move
- Pouch of the stomach herniates next to the GE junction through esophageal hiatus
How are hiatal hernias repaired?
Hiatal hernias are not generally repaired.
Most patients are asymptomatic.
What kind of cells make up esophageal tumors?
What are the signs and symptoms of esophageal tumors?
Treatment for esophageal tumors?
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)
What is GERD?
Reflux causes esophageal mucosal injury or at extraesophageal sites (pharynx or larynx).
How does our body prevent reflux?
LES
LES pressure (29 mmHg) - patients with significant GERD have an LES pressure of 13 mmHg
Crural diaphragm
GE junction
What causes GE junction/LES incompetence?
Transient LES relaxation
LES hypotension ( <29 mmHg)
Anatomic distortion of GE junction - hernia
S/S of Gerd.
Complications of GERD.
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
GERD treatment:
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.
Anesthesia concerns for GERD.
Aspiration Risk
Perform RSI w/ cricoid pressure
What can be given to mitigate aspiration risk for GERD?
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.
What is peptic ulcer disease (PUD)?
What do a lot of patients complain of?
Ulcers in the mucosal lining ofthe stomach or duodenum.
A lot of patients complain of burning epigastric pain. Exacerbated when the patient is fasting.
What is the number one cause of peptic ulcer disease?
Helicobacter Pylori (H. Pylori) - reduce the duodenal mucosa’s production of bicarbonate.
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
What are peptic ulcer disease risk factors for death?
Peritonitis - from perforation
Perforation
Sepsis
Dehydration
Bleeding
What is the mortality rate of patients with PUD if there are complications with bleeding?
Mortality 10% to 20%
What is the percent risk of perforation with untreated duodenal ulceration?
10%
If there is perforation there will be sudden and severe epigastric pain.
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)
PUDTreatment
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
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.
What is Dumping Syndrome?
Emptying hyperosmolar gastric contents into the proximal small bowel from the release of vasoactive GI hormones (histamine, bradykinin, NO).
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
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.
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
Complications of UC.
Treatment for UC.
Massive hemorrhage
Toxic megacolon - transverse colon is dilated (picture)
Obstruction
Perforation
Treatment: Total Proctocolectomy, removing colon and rectum.
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.
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
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
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
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)
Which gut will have high serotonin secretion?
Midgut
Likelihood of carcinoid syndrome in the
Foregut:
Midgut:
Hindgut:
Carcinoid Syndrome
Foregut: Atypical
Midgut: Typical
Hindgut: Rare
How are carcinoid tumors without carcinoid syndromes usually found?
Found accidentally during an appendectomy. .
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.
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
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.
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
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.
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
What are three protective mechanisms that prevent autodigestion of the pancreas?
- Packaging of proteases in precursor form
- Synthesis of protease inhibitors
- The low intra-pancreatic concentration of calcium
What are the causes of pancreatitis?
Gallstones and ETOH abuse account for 60 to 80% of pancreatitis
AIDS
Hyperparathyroidism
Trauma
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
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:
Metabolicacidosis 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%
Metabolicacidosis with a base deficit: > 4 mmol/L
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
Complications of Acute Pancreatitis.
Shock will be the major risk factor for death
Acute Pancreatitis Treatment
Aggressive IVF administration
Colloid replacement
NPO - prevent pancreas stimulation
Enteral/TPN
NGT suction
Pain management
Removal of gallstones
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
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
What is the top cause of upper GIB?
Esophageal Varices
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”
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
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
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
