GI Flashcards
What are some common causes of pancreatitis?
Biliary disease ETOH medications trauma hypertryglyceridemia infectious process
What are some biliary disease examples, these are things thatcan cause pancreatitis.
gallstones
biliary
bile duct obstruction8
What are some medications that can cause pancreatitis?
sulfas
flagyl
thiazide diuretics
ACE inhibitors
LOOK AT BOX 41-8
What are some common complications that come from pancreatitis?
Pancreatic necrosis pancreatic pseudocyst pancreatic abscess pulmonary: ARDS - leukocytes reach pulmonary microcirculation and migrate into the interstitial space which increases endothelial permeability and tissue edema which causes lung congestion and alveolar collapse cardiovascular complications renal failure DIC GI
What labs would be assed for diagnosis and treatment of pancreatitis?
SPECIFIC:
Amylase and lipase elevation in blood
Amylase increase in urine, pleural fluid, peritoneal paracentesis fluid
NONSPECIFIC:
CBC: leukocytosis - infection, stress, dehydration
CMP: hypoK - persistent vomiting, hypoCa - sign of necrosis, calcium binds to fatty acids in necrosis, hyperglycemia - decreased insulin release from beta cells and increased glucagon release as well as stress response
Hypertriglyceridemia - greater than 1,000 mg/dL
Liver: increases in AST, bilirubin, PT… threefold increase in ALT indicates biliary pancreatitis
Is ultrasound the preferred method of visualizing the pancreas and other structures for pancreatitis? Why?
No, often intestinal gas and adipose tissue make imaging difficult.
What is the preferred method of visualizing and diagnosing AP (acute pancreatitis)?
CT - allows visualization of size of pancreas, presence of peripancreatic fluid, pancreatic pseudocysts, and abscesses. Also used to guide needle for aspiration culture
Dynamic CT with contrast can identify areas of necrosis.
Can be sequentially used to monitor treatment progress or disease progression
What is the usefulness of MRCP (magnetic resonance cholangiopacreatography)?
Can detect bile duct stones, is said to have a high sensitivity for them.
CAN BE ISED FOR PREGNANT PATIENTS OR THOSE THAT ARE ALLERGIC TO CT CONTRAST OR PEOPLE WITH RENAL DISEASE
What is ERCP (endoscopic retrograde cholangiopancreatography) useful for?
Helps locate and remove stones in common bile duct if gallstone pancreatitis is present.
How much fluid may be necessary for replacement therapy in severe cases (think septic) of pancreatitis due to third spacing in the first 24 hours?
5-10 liters
What solutions may be used in the fluid resuscitation process for a patient suffering from AP?
crystalloid or colloid solutions
PRBCs may be necessary if acute hemorrhagic pancreatitis is present
How would fluid replacement be monitored with AP?
Daily weights
hemodynamic monitoring (PAOP or CVP) - usually used in severe cases
I/O - 30ml/h or 0.6ml/kg/h
If clients hypotension with associated with AP fails to respond to fluid resuscitation what is the next step?
Pressors
Why is pain such an important factor to control in patients with AP, besides the fact that it causes discomfort?
Pain increases pancreatic enzyme secretions and is directly related to the degree of pancreatic inflammation.
What is the preferred method of pain control for AP? Why? How should it be given? What if it doesnt work?
PCA meperidine (Demerol) - only opioid that doesnt carry the risk of a sphincter of Oddi spasm
Meperidine doesnt always work, and other opioids should not be held if this is the case, such as Fentanyl citrate (sublimaze) and hydromorphone (dilaudid)
What is the minimum interval that analgesia should be provided for a patient with pain associated with AP?
every 3-4 hours
If the client experiencing AP pain is continuing to vomit, has gastric distension or paralytic ileus, what is one way to help relieve this issue and help promote comfort as well?
NG tube hooked up to slow intermittent suction
ACID IN THE DUODENUM STIMULATES THE RELEASE OF SECRETIN, WHICH STIMULATES MORE SECRETIONS FROM THE PANCREAS
What is a very simple way of helping to relieve discomfort in a patient with AP?
POSITIONING
What dietary status will people suffering form AP initially be on?
NPO
How long will clients suffering from AP be NPO?
Until abdominal pain subsides and amylase levels return to normal. Also ensuring there is no presence of a paralytic ileus.
If prolonged NPO status is required due to any of the three listed reasons when experiencing AP (what are these three things again?), what should be started?
TPN
What is another way to give nutrition to a client suffering from AP on a prolonged NPO status, other than TPN?
Studies have shown that giving nutrition past the ligament of treitz in the distal duedenum or jejunum is safe and wont exacerbate or worsen AP.
What is one thing that needs to be avoided in diet during treatment and recovery of AP in order to keep the inflammation from worsening?
LIPIDS, to avoid excessive triglyceride levels.
In a client with mild AP, when can oral fluids typically be restarted?
What about solids?
Can TPN be supplemented if nutrition still isnt quite adequate?
after 3-7 days with solids being added as tolerated.
YES
Other than NPO, pain control, and fluid resuscitation, what is another important aspect during the treatment course of AP?
Tight glycemic control with close monitoring of blood glucose.
What does hematemesis mean?
Bright red bloody emesis
What does melena mean?
black tarry stool
What does hematochezia mean?
fresh blood in stool.
What does occult bleeding mean?
microscopic bleeding.
What are some common causes of upper GI bleeds(5 esophageal, 5 gastric, 4 duodenal)?
Esophageal - varices, esophagitis, ulcers, tumors, mallory-weiss tears
Gastric - peptic ulcers, gastritis, tumors, angiodysplasia, dieulafoys lesions
Duodenal - peptic ulcers, angiodysplasia, chrohns, meckels diverticulum
What the hell are mallory-weiss tears?
What causes them?
Lacerations in the distal esophagus either at the gastroesophageal junction or in the cardia of the stomach.
These are closely associated with heavy drinkers or recent binge drinking, also forceful vomiting or retching, as well as forceful coughing. Portal HTN is also associated with this.
What is angiodysplasia in relation to GI bleeds?
These are malformations of vasculature in the gut.
Also called AV malformations or angioma.
VERY WEAK
most commonly between 50-70 years
COMMON IN RENAL
venus or AV bleeding, less severe than diverticular disease, which is arterial
What the hell are dieulafoys lesions?
What can cause them?
These are unusually large submucosal vessels that form close to the surface of mucosa most commonly in the proximal stomach.
These are a common source of unknown recurrent GI bleeds and are hard to identify after the bleeding ceases due to the lack of an ulcer.
The book did not state a cause of these.
What are meckels diverticulum?
A diverticulum (bulge, outpouching) of the small intestine that is present from birth, CONGENITAL.
What are some of the most common causes of lower GI bleeds? 10
malignant tumors (erode)
polyps
ulcerative colitis
crohns
ischemic colitis
infectious colitis
angiodysplasia
diverticulosis VERY COMMON 30-50% of cases
hemorrhoids
massive upper GI hemorrhage
Describe stress-related erosive syndrome as it relates to upper GI bleeds.
critically ill or chronically ill patients have an increased risk for these, they differ from peptic ulcers in that they are more shallow and diffuse and higher in number. These can form within hours of causative injury.
These can erode deeper and cause a more massive hemorrhage.
The big idea is that a decrease in perfusion to the gastric mucosa causes this
What are risk factors for diverticular bleeding?
low-fiber diet
aspirin and NSAID use
elderly
constipation
What things are looked for upon taking a history that may indicate an upper GI bleed or the cause of one?
past GIBs
epigastric pain or dyspepsia
peptic ulcer disease
heavy alcohol use (varices)
tobacco use (duodenal ulcer)
renal failure (AV malformations)
coughing, vomiting, or retching before bleed occured (mallory-weiss
NSAID or aspirin use
What would be looked for upon physcial examination of a patient suffering from or having a suspected upper GI bleed?
Check hemodynamic stability!
vital signs (tachycardia or orthohypo)
Signs of volume loss
baseline ECG, especially in those with know CV disease because cardiac ischemia may occur
NEURO SYMPTOMS ASSOCIATED WITH BLOOD LOSS
abd tenderness, bowel sounds, guarding, rigidity, masses
rectal exam to assess for melena or hematochezia
What are some differential diagnoses based on abdominal assessment findings in someone with a suspected GI blees?
ddx:
splenomegaly, ascites, and caput medusae suggest LIVER DISEASE
tender, board-like abdomen suggest peritonitis, possibly due to BOWEL PERFORATION
What are some common lab abnormalities associated with acute GIB, and, therefore, what labs are important to assess for acute GIB?
decreased H&H - though may not be present initially due to even loss of plasma and RBCs initially.
mild leukocytosis and hyperglycemia (CBC & CMP)
increased BUN
hyperNa & hypoK (CMP)
PT & PTT (clotting studies)
thrombocytopenia (CBC)
hypoxemia
What access is preferred for fluid volume deficit management associated with acute GIB?
At least two large-bore IVs (14-16 gauge) or central access
After how much blood loss is fluids as well as blood replacement required?
1500 ml
What is one thing that should be done very early as soon as acute GIB has been recognized?
type & cross
What should be done while waiting for a type and cross to come back to restore volume in an acute GIB?
lactated ringers or NS should be started to prevent progression to hypovolemic shock
At what hemoglobin level should PRBCs be administered?
7 g/dl or less to help with oxygen carrying capacity of blood.
Why do you have to watch out for hypocalcemia related to large amounts of RBCs being replaced?
the citrate in these products binds to calcium
If overesuscitation related to cardiac or renal disease is an issue when replacing volume in an acute GIB, what type of monitoring should be done?
central venous catheter or pulmonary artery catheter
If coagulopathy is present, what medication is a form of vitamin K that can be given slowly IV or IM in an attempt to restore PT?
phytonadione (Aquamephyton)
In a client with coagulopathy. does this need to be corrected before an endoscopy is performed?
NO NO NO, it shouldnt be delayed
If fluid balance is low, whether or not it is being restored what drugs may be used to keep BP and perfusion up
vasoactive drugs such as:
dopamine, epinephrine, norepinephrine
How do you definitively diagnose and treat acute GIB?
endoscopy for upper
colonoscopy for lower
What is the use of vasopressin in an acute GI bleed? How should it be administered?
Vasopressin (pitressin) decreases portal HTN by constricting the splanchnic arteries which reduces the portal blood flow.
Through a central line!
Does the use of vasopressin come with some possible complications? What are these and what are they due to?
Vasopressin reduces coronary blood flow and constricts coronary vessels, it also causes an increase in blood pressure. All of this increases oxygen demand.
The coronary artery constriction and decreased flow can result in cardiac dysrhythmias.
Also, because vasopressin reduces the blood flow to the mesenteric circulation bowel ischemia can occur.
What is the use of somatostatin when it comes to an acute GIB?
This drug lowers the portal venous pressure through vasoconstriction of the splanchnic circulation.
What are the main differences between vasopressin and somatostatin and their use in an acute GIB?
Somatostatin is much more selective to the splanchnic circulation and has a shorter half-life so it is usually delivered via IV infusion.
What is octreotide and how does it differ from somatostatin in its use for acute GIBs?
This is a synthetic analog of somatostatin with a longer half-life of somatostatin, this is only available in the united states.
Not only does it cause splanchnic vasoconstriction, decreases intravariceal pressure, decreases secretions of gastric acid and pepsin, and stimulates mucous production.
What is the dosage for octreotide?
50-100 mcg IV bolus followed by 50 mcg/h for 3-5 days
How would you describe the effects of octreotide?
Vasopressin given with a nitroglycerin infusion
What clients are candidates for an angiography who is suffering from an acute GIB? Why is this?
Most cases of GIB resolve spontaneously or can be controlled through an endoscopy.
Clients that have persistent bleeding that doesnt resolve through endoscopy or by itself are candidates for an angiography.
What are two things that can be done through an angiography? Complicaitons for each?
intra-arterial vasopressin administration
embolization of bleeding vessel
Describe the process of intra-arterial vasopressin in an angiography to help a GIB.
after initial infusion a repeat angiography is performed and the dose can be titrated as needed. After initial control of the infusion, the infusion can be continued for 24-36 hours in the ICU.
TAPER INFUSION OVER 24 HOURS
What are some complications of intra-aortic vasopressin?
dysrhythmias
fluid retention
hyponatremia
if cardiac ischemic changes do develop, what can be done?
Nitro drip or patch
Describe the embolization of a bleeding vessel in an angiography for a GIB.
this is where the vessel is occluded with a temporary or permanent material
What are some complications of embolization for a GIB using an angiography?
bowel ischemia
secondary duodenal stenosis
gastric, hepatic, or splenic infarction
When is a balloon tamponade indicated in a GIB?
A client who needs temporary control of a bleed that wasnt controlled through an endoscopy.
How does a balloon tamponade work when treating a GIB?
A balloon inflates both the esophagus and the cardia of the stomach, compressing bleeding vessels.
How far is the tube inserted for a balloon tamponade, and how much air is initially inserted into the GASTRIC balloon?
50cm
250-300ml of air with gentle traction applied
Is permanent traction applied via a sponge or helmet device? What if chest pain occurs after?
YES
If chest pain occurs the gastric balloon should be deflated because it may mean the balloon moved into the esophagus
After the initial placement and inflation of the gastric balloon in a balloon tamponade, what happens if there is still bleeding?
The ESOPHAGEAL balloon should be inflated to 25-39 mmhg
Up to how long can the esophageal balloon be inflated in a balloon tamponade? Though it may need to be inflated longer, what are some complications?
12 up to 24 hours
edema, esophagitis, ulcerations, or perforation of esophagus. also gastric ischemia and necrosis.
Is there often rebleeds after deflation of the tamponade balloon?
YES
What is a TIPS (transjugular intrahepatic portosystemic shunt)?
This is a radiological procedure that creates a intrahepatic shunt in an attempt to decrease portal pressure. Considered if other management techniques of controlling bleeding have failed.
What are the main causes of a SBO (small bowel obstruction)?
ADHESIONS account for 50-75%
Hernias 10-15% of cases
tumors less than 5-10%
What are some risk factors for adhesions, hernias, and tumors associated with increasing the risk for SBO?
adhesions - colectomy, appendectomy, gynecological procedures, abdominal radiation, ischemia, infection, foreign bodies
Hernias - richters hernia (post laparotomy) or herniation without post-laparotomy
Tumors - compression of small bowel or local invasion by gastric, pancreatic, colonic, and gynelogical cancers. chrohns disease, radiation therapy, ischemia, drugs (EC potassium chloride or NSAIDS)
What are the signs and symptoms of a SBO?
hypovolemia, hypoK, hypoNA, vomiting, decreased peristalsis,
volume and electrolyte loss if through increased distention of proximal bowel causing increased permeability as well as vomiting
What are some of the main causes of a colonic obstruction?
Carcinoma 60-75%
diverticulitis 10%
Volvulus - loops of intestine twists around itself (commonly sigmoid or cecum). 10-15%
What are the s/s of a colonic obstruction?
abdominal pain, distention, progressive obstipation
SEVERE AND CONSTANT PAIN INDICATES GANGRENOUS BOWEL
vomiting occurs late in obstruction
volvulus tends to be sudden onset abdominal distention
cancerous tends to be more gradual, change in bowel habits or stool caliber
possible dyspnea if distention causes diaphragmatic excursion
most complain of constipation, but diarrhea may be present if watery stool leaks past obstruction.
What is the deal with the ileocecal valve as it relates to the bowel distention related to a colonic obstruction?
if it is competent the bowel will become more distended which increases the risk for ischemia and perforation, while an incompetent one allows for backflow.
If someone has a suspected bowel obstruction and has a high fever and tachycardia, what shouuld be done? What might be happening?
SURGICAL EVALUATION
There may be strangulation present
What are some s/s of a bowel perforation?
rebound tenderness of abdomen
ASSESS FOR SIGNS OF SHOCK
