Exam 4 GI Assessment Part 1 Flashcards
The GI tract constitutes approximately ____% of the total human body mass
5%
slide 3
what are the main functions of the GI system?
- motility
- digestion
- absorption
- excretion
- circulation
slide 3
what are the layers of the GI tract from outer most to inner most?
the serosa, longitudinal muscle layer, circular muscle layer, submucosa, and mucosa
slide 3
within the mucose (outermost to innermost) is what 3 things?
- muscularis mucosae
- lamina propria
- epithelium
slide 3
The ____ is a smooth membrane of thin connective tissue and cells that secrete serous fluid to enclose the cavity and reduce friction between muscle movements
serosa
slide 3
The ____ muscle layer contracts to shorten the length of the intestinal segment
longitudinal
slide 4
The ____ muscle layer contracts to decrease the diameter of the intestinal lumen
circular
slide 4
what 2 layers work together to propagate gut motlility?
longitudinal muscle layer and circular muscle layer
slide 4
Innervation of the GI organs up to the proximal transverse colon is supplied bythe ____.
celiacplexus
slide 5
Innervation of the descending colon and distal GI tract comes from the inferior____.
hypogastricplexus
slide 5
what different approaches can be used to block the celiac plexus?
- Transcrural
- Intraoperative
- endoscopic ultrasound-guided
- peritoneallavage
slide 5
The____lies btwthe smooth muscle layers and regulatesthesmoothmuscle
myenteric plexus
slide 6
The____ transmits information from the epithelium to the entericand central nervoussystems
submucosal plexus
slide 6
what is the mucosa composed of?
- muscularis mucosa
- lamina propria
- immune and inflammatory cells
- epithelium
slide 7
what is the muscularis mucosa and what does it do?
a thin layer of smooth muscle which functions to move the vili
slide 7
what does the lamina propria contain?
blood vessels and nerve endings
slide 7
what happens in the epithelium?
- Gi contents are sensed
- enzymes are secreted
- nutrients are absorbed
- waste is excreted
slide 7
what is the GI tract innervated by?
autonomic nervous system
slide 8
what does the GI ANS consist of?
- extrinisic nervous system
- enteric nervous system
slide 8
what are the components of the GI ANS extrinsic nervous system and how do they effect GI motility?
- has SNS and PNS components)
- The extrinsic SNS is primarily inhibitory anddecreases GI motility
- The extrinsic PNS is primarily excitatory and activates GI motility
slide 8
____ is the independent nervous system, which controls motility, secretion, and blood flow
enteric nervous system
slide 8
what is the enteric system comprised of?
myenteric plexus and submucosal plexus
slide 9
how does the myenteric plexus control motility?
carried out by enteric neurons,interstitial cells of Cajal (aka ICC cells, GI pacemakers), andsmooth musclecells
slide 9
the myenteric plexus and submucosal plexus respont to what kind of stimulation?
sympathetic and parasympatheticstimulation
slide 9
- This procedure may be diagnostic or therapeutic.
- It is performed by endoscope placed into esophagus, stomach, pylorus, and duodenum
- May be done with or w/o anesthesia but has anesthesia challenges of sharing airway with endoscopist and/or procedure performed outside of the main OR
Upper Gastrointestinal Endoscopy:
slide 10
- This procedure may be diagnostic or therapeutic/interventional
- May be done with or w/o anesthesia and has anesthesia challenges of pt dehydration d/t bowel prep & NPO status
Colonoscopy:
slide 10
this procedure is wherea pressure cathetermeasures pressuresalong entire esophageal length and is generally used to dx motility disorders
High Resolution Manometry (HRM)
slide 11
what procedure uses radiologic assessment of swallowing function and GI transit
GI series with ingested barium
slide 11
What procedure haspatient fasts for at least 4 hours, then consumes a meal with a radiotracer. Continuous or frequent imaging occurs for the next 1-2 hrs
Gastric emptying study
slide 11
- This procedure uses acatheter to measure contraction pressures andmotility of the small intestine
- evaluatescontractions during three periods: fasting, during a meal, and post-prandial.
- Normally the recording time consists of 4 hrs fasting, followed by ingestion of a meal, and 2 hrs post-meal
- Abnormalresults are grouped into myopathic and/or neuropathic causes
Small intestine manometry
slide 12
This procedure involves the administration of a barium enema to a patient. The barium outlines the intestines and it is visible on radiograph. This allows for detection of colon and rectal anatomical abnormalities
lower GI series
slide 12
diseases of the esophagus are grouped into:
- Anatomical
- Mechanical
- Neurologic
although many disease states overlap
slide 13
Anatomical causes of esophageal disease include:
- diverticula
- hiatal hernia
- change assoc w/ chronic acid reflux.
These abnormalities interrupt the normal pathway of food,which changes the pressure zones of the esophagus
slide 13
mechanical causes of esophageal disease include:
- achalasia
- esophageal spasms
- hypertensive LES
slide 13
neurologic causes of esophageal disease include:
caused by neurologic disorders such as:
* stroke
* vagotomy
* hormone deficiencies
slide 13
what are the most common symptoms of esophageal disease?
- dysphagia
- heartburn
- GERD
slide 14
what is dysphagia and what are the differnt types?
- difficulty swallowing
- orpharyngeal or esophageal
slide 14
when is oropharryngeal dysphagia commonly seen?
after head and neck surgeries
slide 14
what are the 2 different types of esophageal dysphasia?
Classified based on physiology
* Esophageal dysmotility: sx occur w/ both liquids & solids
* Mechanical esophageal dysphasia: sx only occur w/solid food
slide 14
what is gastroesophageal reflux disease (GERD), and what is normal s/s?
- effortless return of gastric contents into pharynx d/t Incompetence of the gastro-esophageal junction, leading to reflux
- S/S: Heartburn, nausea, “lump in throat”, dysphagia, and mucosal injury
slide 14/20
what is achalasia?
neuromuscular disorder of the esophagus consisting of an outflow obstruction d/t inadequate LES tone and a dilated hypomobile esophagus
slide 15
what are the causes of achalasia?
- Theoretically c/b loss of ganglionic cells of the esophageal myenteric plexus
- Followed by absence of inhibitory neurotransmitters of the LES
- Unopposed cholinergic LES stimulation (LES can’t relax)
- Esophageal dilation with food unable to pass into stomach
slide 15
s/s of achalasia?
- dysphagia
- regurgitation
- heartburn
- chest pain
Long term increased rx of esophageal cancer
slide 15
how is achalasia diagnosed?
w/esophageal manometry and/or esophagram
slide 15
what are the 3 classes of achalasia?
- Type 1: minimal esophageal pressure, responds well to myotomy
- Type 2: entire esophagus pressurized; responds well to treatment, has best outcomes
- Type 3: esophageal spasms w/premature contractions; has worst outcomes
slide 15
what is the treatment for achalasia?
- all treatments are palliative
- Medications
- Endoscopic botox injections
- Pneumatic dilation
- Laparoscopic Hellar Myotomy
- Peri-oral endoscopic myotomy (POEM)
- Esophagectomy
slide 16
why would we do RSI or awake intubation with pts who have achlasia?
increased risk for aspiration
slide 16
what medications can be used for achalasia?
nitrates & CCBs to relax LES
slide 16
whats the most effective nonsurgical treatment for achalasia?
Pneumatic dilation
slide 16
what is the best surgical treatment for achalasia?
Laparoscopic Hellar Myotomy
slide 16
- What is peri-oral endoscopic myotomy (POEM)?
- how many pt develop pneumothorax or pneumoperitoneum?
- endoscopic division of LES muscle layers
- 40% develop pneumothorax or pneumoperitoneum
slide 16
when is esophagectomy considered for achalasia?
only considered in the most advanced dz states
slide 16
- what is diffuse esophageal spasms?
- most common in?
- diagnosed with?
- pain mimics ____.
- treatment?
- Spasms that usually occur in distal esophagus; likely d/t autonomic dysfunction
- More common in elderly
- Dx on esophagram
- Pain mimics angina
- Tx: NTG, antidepressants, PD-I’s
slide 17
what is esophageal diverticula?
outpouchings in the wall of the esophagus
slide 17
what type of esophageal diverticula has bad breath d/t food retention
Pharyngoesophageal (Zenker diverticulum)
slide 17
what type of esophageal diverticula may be caused by old adhesions or inflamed lymph nodes
Midesophageal:
slide 17
what type of esophageal diverticula have pts that may experience achalasia
Epiphrenic (supradiaphragmatic)
slide 17
for esophageal diverticula all are aspiration risk so what should we do?
removal of particles and RSI indicated
slide 17
- What is hital hernia?
- What is it caused by?
- may be ____
- often associated with ____
- Herniation of stomach into thoracic cavity, occurs through the esophageal hiatus in the diaphragm
- c/b weakening in anchors of GE junction to the diaphragm
- May be asymptomatic
- often associated with GERD
slide 18
this happens in 4-5 out of 100,000 people in US
esophageal cancer
slide 18
Esophageal Cancer
- Presents w/
- Poor survival rate bc
- Most are adenocarcinomas, located in ____.
- ____ accounts for the rest of esophageal cancers
- progressive dysphagia and weight loss
- abundant lymphatics leads to lymph node metastasis
- lower esophagus
- Squamous cell carcinoma
slide 18
- These are r/t GERD, Barretts, Obesity
adenocarcinomas located in the lower esophagus
slide 18
what can be curative or palliative for esophageal cancer?
- esophagectomy and may be performed transthoracic, transhiatal, or minimally invasive
slide 19
____ has a high risk of recurrent laryngeal nerve injury; of which ____% resolve spontaneously.
- esophagectomy
- 40%
slide 19
things to keep in mind for pts recieving esophgectomies for cancer
- Pts often malnourished preop, and many months after
- If h/o chemo/radiation -pancytopenia & dehydration may present
- Post-esophagectomy pts are very high aspiration risk for life
slide 19
GERD occurs in ____% of adults.
15
slide 20
in GERD reflux contents include
- HCL
- pepsin
- pancreatic enzymes
- bile
slide 20
bile reflux in GERD is associated with ____ and ____.
Barrett metaplasia & adenocarcinoma
slide 20
3 mechanisms of GE incompetence
- Transient LES relaxation, elicited by gastric distention
- LES hypotension
- Autonomic dysfunction of GE junction
slide 20
- normal LES pressure:
- avg GERD pressure:
- 29 mmhg
- 13 mmhg
slide 20
treatment for GERD
- avoidance of trigger foods
- Meds: Antacids, H2 blockers, PPIs
- Surgery: Nissen Fundoplication, Toupet, LINX
slide 21
Preop interventions for GERD
- Cimetidine & Ranitidine-↓acid secretion & ↑pH
- PPI’s generally given night before and morning of
- Sodium Citrate- PO nonparticulate antacid
- Metoclopramide- gastrokinetic; often reserved for diabetics, obese, pregnant
- Aspiration precautions!
- RSI indicated. Cricoid pressure has become controversial
slide 21
what factors increase intraoperative risk of aspiration?
- Emergent surgery
- Full Stomach
- Difficult airway
- Inadequate anesthesia depth
- Lithotomy
- Autonomic Neuropathy
- Gastroparesis
- DM
- Pregnancy
- ↑ Intraabdominal pressure
- Severe Illness
- Morbid Obesity
slide 22
the stomach is a____ sac that serves as a reservoir for large volumes of food, mixes and breaks down food to form ____, and slows emptying into the ____.
- J-shaped
- chyme
- small intestine
slide 24
Solids must be broken down into ____ particles before entering the duodenum
1-2 mm
slide 24
The motility of the stomach is controlled by?
intrinsic and extrinsic neural regulation
slide 24
- ____ stimulation to the vagus nerve increases the number and force of contractions
- ____ stimulation inhibits these contractions via the splanchnic nerve
- The ____ nervous system provides coordination for motility
- Parasympathetic
- Sympathetic
- intrinsic
slide 24
Neurohormonal control also occurs with:
* gastrin & motilin which does ….?
* and gastric inhibitory peptide does…?
- increase the strength and frequency of contractions
- inhibits contractions
slide 24
What disease is this?
- Most common cause of non-variceal upper GI bleeding
- Lifetime prevalence= 10% women, 12% men
- 15,000 death per year
- may be associated with Helicobacter Pylori
peptic ulcer disease
slide 25
s/s of peptic ulcer disease
burning epigastric pain exacerbated w/fasting and improved w/meals
slide 25
Peptic Ulcer Disease
- ____% risk of perforation in those who do not receive treatment
- Perforation s/s?
- Mortalityis d/t shock or perforation >____h
- 10%
- sudden/severe epigastric pain c/b acidic secretions into peritoneum
- 48H
slide 25
The submucosal plexus controls what?
- absorption
- secretion
- mucosal bloodflow
slide 9
