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Health Assessment Test 2 > GI and Liver > Flashcards

GI and Liver Flashcards

1
Q

What to consider in ROS in regards to GI?

A

Does the patient have :

  • nutritional deficiency
  • nausea/vomiting
  • occult blood loss
  • overt GI bleeding
  • abdominal pain
  • abdominal distention
  • dysphagia
  • GERD
  • epigastric pain
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2
Q

NPO status?

A

Balance risk of fasting against pulmonary aspiration

  • In “healthy patients” liberal fasting guidelines can be followed
  • No chewing gum or candy after midnight
  • Clear liquids up to 2 hours before OR
  • Breast milk up to 4 hours before OR
  • Light meal, milk, formula up to 6 hours before OR
  • Fatty foods, fried foods, meats 8 hours or more
  • Sip of water or liquid pre-med up to 1 hour before OR
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3
Q

Who is considered an aspiration risk?

A
  • Age extremes <1 yr or >70 yr
  • Ascites (ESLD)
  • Collagen vascular disease ie Ehlers- Danlos
  • Eaten food
  • Hiatal Hernia/GERD/Esophageal disorder
  • Mechanical obstruction (pyloric stenosis, intestinal obstruction)
  • metabolic disorders (Diabetes obesity, ESRD, hypothyroid)
  • Morbid obesity
  • Neurologic diseases
  • Prematurity
  • Pregnancy
  • Severe pain/ anxiety
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4
Q

What is mendelson syndrome?

A
  • Chemical pneumonitis or aspiration pneumonitis
  • Characterized according to
    • pH
    • volume
    • gastric material aspirated
  • Risk factors for aspiration sequelae include
    • pH less than 2.5
    • Gastric volume of 0.4ml/kg (25ml/70kg)
  • Manifests as respiratory distress with
    • bronchospasm,
    • cyanosis,
    • tachycardia and
    • dyspnea from irritating action of hydrochloric acid and particulate material which are damaging to the lungs
      *
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5
Q

What are H2 antagnoists role in aspiration prevention?

A
  • Cimetidine, Ranitidine and Famotidine (best result)
  • Acts as competitive antagonist of histamine binding to H2 receptors on gastric parietal cells
  • Reduces acid secretion
  • Best if given the night before and repeated 45-60 minutes before surgery
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6
Q

What is metoclopramide’s role in aspiraiton prophylaxis?

A
  • Metoclopramide
  • Dopamine antagonist
  • Increases the pressure of the lower esophageal sphincter and enhances GI motility which speeds gastric emptying
  • Prevents or alleviates nausea and vomiting
  • Contraindicated in the presence of an obstruction
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7
Q

Should we give everyone aspiration prophylaxis?

A

No, ASA does not promote the routine use of these meds to decrease aspiration in pt with no apparent risk factors

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8
Q

What is sodium citrate?

A
  • Sodium Citrate - Bicitra
  • Non-particulate antacid
  • Customary dose of 30 ml po to raise gastric pH
  • Disadvantage: Increases gastric volume
  • Give 15 minutes before surgery and lasts 1-3 hours
    • repeat bicitra if sugery is delayed
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9
Q

Omeprazole admin for aspiration prophylaxis?

A
  • Proton pump inhibitor
  • 80 mg po the night before and 40 mg repeated after the induction of anesthesia.
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10
Q

What is a hiatal hernia? s/s?

A
  • Protrusion of a portion of the stomach through the hiatus of the diaphragm upward into the thoracic cavity
  • Aspiration risk
  • Signs & Symptoms
    • Retro-sternal discomfort
    • Burning after meals
    • Reflux (+/-)
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11
Q

GERD dx? s/s, txmt?

A
  • Retrograde movement of gastric contents through the lower esophageal sphincter into esophagus
  • Aspiration risk
  • High incidence of bronchospasm

Signs

  • Heartburn
  • Noncardiac chest pain
  • Dysphagia
  • Pharyngitis, cough, asthma, hoarseness

Treatment:

  • Metoclopramide, H2 blockers, PPIs
    *
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12
Q

What is barret’s esophagus? s/s? treatment?

A

Metaplastic disorder of the esophagus secondary to reflux

  • Precursor to esophageal cancer

Signs & Symptoms

  • Dysphagia
  • Reflux esophagitis
  • Retrosternal pain or heartburn
  • Weight loss

Treatment

  • H2 Blockers
  • Proton Pump Inhibitors
  • Nissen fundoplication
  • will also do biopsies to evaluate and make sure it isn’t progressing to higher stages
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13
Q

What is gastroparesis?

A
  • Partial paralysis of the stomach
    • Vagus nerve-stomach contraction-injury
    • Autonomic Neuropathy-Diabetes- most common cause
    • Connective tissue diseases-Scleroderma, Ehlers-Danlos
    • Opioids and anticholinergics
  • Leads to prolonged food retention
  • Aspiration risk
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14
Q

What is the schatzki ring?

A
  • A narrowing of the lower esophagus caused by a ring of mucosal tissue or muscular tissue
    • treatment= dilation of esophagus
  • produces dysphagia, food obstruction and vomiting
  • aspiration risk
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15
Q

What is peptic ulcer disease? Location? most commonly effected? causes? signs?

A
  • Ulcerations in the GI mucosa most commonly the duodenal bulb or antrum of stomach
  • Men and Women age 45-60 (Most commonly affected)
  • Causes: Chronic use of NSAIDS, ETOH, Steroids (also h pylori)
  • Signs:
    • Epigastric pain
    • Anorexia, wt. loss
    • Vomiting
    • Hematemesis or melena (this may be acute hemorrhage)
    • Abdominal tenderness and rigidity
    • Perforation (severe pain)
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16
Q

Gastric ulcer has pain when? wt loss? bleeding? causes? txmt?

A
  • Pain when: pain with food
  • weight loss: lose weight
  • bleeding= vomiting blood
  • causes= h pylori, nsaids, corticosteroids
  • txmt: PPI H2 block
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17
Q

What are duodenal ulcers?

pain, wt loss, bleedign, causes, treatment?

A
  • Pain- 3-4 hours after eating
  • Sometimes weight gain, but definitely no weight loss
  • bleeding= black, tarry stools
  • causes= h pylori (90% duodenal ulcer) nsaids
  • treatment= PPi, h2 blocker, sucralfate
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18
Q

What is crohn’s disease?

A
  • Inflammation of the bowel wall w skip patterns involving the terminal ileum. Rectal sparring
    • Deficiency in absorption of magnesium, calcium, etc
    • Protein loss, decreased plasma albumin
    • Anemia
  • Recurrent right lower quadrant pain, diarrhea, palpable mass, fever, anorexia/wt. loss
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19
Q

Ulcerative colitis?

A

inflammatory bowel disease

  • Inflammation and loss of colonic mucosa from rectum to distal colon; becomes hemorrhagic, edematous, ulcerated
    • usually starts low at rectum and advances up
  • diarrhea-blood, mucus
  • fever/ malaise
  • anorexia/wt. loss
  • abdominal pain
  • associated with risk of colon cancer
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20
Q

What are carcinoid tumors? s/s?

A
  • Commonly found in the GI tract (appendix), metastasis
    • slowly develop tumor
  • Can produce carcinoid syndrome or crisis
    • normally hormones go to liver first and won’t get bad side effects from release of hormones. however, if tumor outside of GI tract, can get big s/e from the hormones skipping the liver
    • treatment- try to release release of these substances (minimize adrenergic responses)
  • produced by the effects of hormones and substances secreted in the GI tract and systemic circulation
    • bradykinin
    • histamine
    • serotonin
    • dopamine
  • S&S Carcinoid Syndrome
    • cutaneous flushing
    • diarrhea
    • tachycardia, arrhythmias
    • dyspnea, wheezing, bronchospasm
    • hypotension
    • hypertension
    • orthostasis
    • fibrosis of pulmonary and tricuspid valves
    • right-sided valvular heart dz
  • Pre-op test are guided by physical findings
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21
Q

Do you palpate the abdomen of someone with carcinoid tumor?

What labs test do you want?

A

No palpation! releases the hormones potentially

  • CBC
  • Electrolyte panel
  • LFTs
  • Blood glucose
  • ECG
  • Echo
  • Urine 5-HIAA level<– serotonin metabolite and would signify carcinoid tumor
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22
Q

What is periop malnutrition associated with? Indicators of severe nutritonal risk?

A
  • Malnutrition is associated with
    • prolonged hospital stay
    • wound infection
    • abscess
    • respiratory failure
    • death
  • Indicators of severe nutritional risk
    • Serum Albumin level of less than 3 g/dL
    • Wt loss > 10% in last 6 mo.
    • BMI < 18.5
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23
Q

GI physical exam?

A
  • General inspection
  • Weight, vital signs
  • Abdominal examination
  • Inspect
  • Auscultate
  • Palpate
    • Note guarding, pain, organomegaly
  • Percuss

important to do in order!!! inspect, auscultate before you manipulate the abdomen!

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24
Q

What are some things to look for on inspection of abdomen?

A
  • Pink-purple striae –> Cushing syndrome
  • Dilated veins (caput medusae) –> cirrhosis
  • Ecchymosis –> intra/retroperitoneal hemorrhage
  • Bulges –> hernias
  • Increased peristaltic waves –> intestinal obstruction
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25
Q

What are some things to listen for on ausculatation?

A
  • Bruits –> vascular occlusive disease
  • Altered bowel sound –> paralytic ileus, obstruction, etc
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26
Q

What are you asesesing for on percussion of abdomen?

A
  • Tympany –> normally what is heard in the GI tract (gas/air in the tract)
  • Dullness –> usually suggests masses, organs, fluid-filled cavities
27
Q

What might palpation of an abdomen reveal?

A

•May reveal abdominal masses, tumors, AAA, gravid uterus

28
Q

Lab values to consider for GI patient?

A
  • Hematocrit
  • Serum electrolytes
  • BUN
  • Serum albumin (prealb)
29
Q

Preop concsideration in GI pt?

A
  • Aspiration risk
    • Prophylaxis and airway management considerations
  • Bleeding –> anemia
  • Nutritional deficits and/or electrolyte disturbances
  • Pain control
  • Medications: stress-dose steroids?
  • If carcinoid, cardiac workup needed? Hemodynamically stable?
30
Q

Pancreatitis s/s, txmt?

A
  • Cause is multifactorial
  • CV complications: pericardial effusions, s/s mimicking acute MI, cardiac depression
  • Pain: severe (Demerol might be preferred? Prob fentanyl)
  • worse in supine position
  • S/S: N/V, fever, hypotension –> ARF might occur
    • cullen’s sign (bruising around umbilicus)
    • grey turner sign (bruising around flank)
  • Treatment: Pain management, FLUID Resus, e’lyte restoration
  • SX: cholecystectomy or endoscopic stone clearance
31
Q

What are some pancreatic enzymes?

A
  • Proteolytic- trypsinogen,chymorpsinogen, procarboxypeptidase A, procarboxypeptidase B, proaminopeptidase, prolelastase
  • Amylolytic- alpha amylase
  • Lipolytic- lipase, prophospholipas A 2, carboxylesterase liapse, procolipase
  • Nuceolytic- deoxyribonuclease, riboneculease
  • other- trypsin inhibitor

I don’t think we need to know all of these. definitely know amylase and lipase

32
Q

Purpose of the liver?

A
  • •Liver is responsible for an enormous number of complex and interrelated functions.
    • Reservoir of blood (10-15% total blood volume)
    • Maintains normal clotting
    • Mediator of endocrine functions
    • Bilirubin excretion
    • Metabolism
    • Synthesis of proteins
    • Immunologic Function
    • Pharmacokinetics
  • Liver has large functional reserve
33
Q

Liver History?

A
  • anorexia or weight changes
  • scleral icterus, jaundice
  • gynecomastia
  • N&V or pain with fatty meals
  • abdominal distention/ascites
  • hepatomegaly or splenomegaly
  • GI Bleeding
  • pruritus or fatigue
  • palmer erythema
  • easy bruising?
  • spider angiomata, petechiae, and ecchymosis
  • dark urine
  • history of jaundice
  • prior blood transfusions
  • recreational drugs/Alcohol
  • current medications including herbals
  • family history of jaundice and liver disease
  • travel history
  • cccupational history

pic found online…

34
Q

What are some hepatotoxic meds?

A
  • acetaminophen, PCN, Bactrim, tetracyclines, erythromycins
  • anticancer drugs
  • antiepileptic drugs-Dilantin
  • nonsteroidal anti-inflammatory drugs-ASA, ibuprofen
  • methotrexate
  • sulfonylureas
  • amiodarone
  • herbals
  • cocaine, ecstasy, angel dust, glues/solvents
35
Q

What are some parenchymal liver diseases?

obstructive?

A
  • Parenchymal
    • Acute: viral or toxic
    • Chronic: chronic hepatitis and cirrhosis
  • Obstructive: common bile or hepatic ducts
    • tumors, gallstones
36
Q

What happens in prehepatic liver disease? intrahepatic? post? causes for each?

A
  • Prehepatic –> bilirubin overload
    • hemolysis/whole blood transfusion
  • Intrahepatic –> hepatocellular damage
    • viruses, drugs, sepsis, cirrhosis
  • Posthepatic –>cholestatic dysfunction
    • gallstones, tumors
37
Q

What to look for on physical to indiate liver dfx?

A

General inspection (wt., vital signs, mental status)

  • Exam patient’s hands, looking for:
    • Koilonychia “spoon nails”–> anemia
    • Leukonychia- white spots on nails
    • Palmar erythema-reddening of palms –> portal HTN
    • Asterixis-profound hand tremor –> hepatic encephalopathy
    • Dupuytren’s contracture–> risk is increased by alcoholic cirrhosis
  • Check sclera for jaundice or pallor
  • Exam chest for gynecomastia
  • Skin color (jaundice), scratches (itching)
  • Dependent edema
38
Q

Lab assessment for liver?

A
  • Albumin (normal 3.5-5.0 g/dl) or prealbumin
  • Complete CBC
  • Coagulation studies (esp PT)
  • Serum electrolytes and glucose levels
  • Serum BUN/ Cr
  • Serum liver enzymes (LFTs)
  • Serum ammonia levels
  • Platelet count >100,000
  • Bilirubin
  • ABG
  • CXR
39
Q

Whta is normal PT and meaning?

A
  • 12-14 seconds
  • very sensitive for acute injury (V and VII t1/2 is <24 hours)
  • prolonged by vit K deficiency
40
Q

Albumin normal values and meaning?

A
  • Normal 3.5-5 g/dL
  • Not sensitive for acute injury t1.2 is 21 days
  • poor specificity for liver disease
  • decreased by impaired synthesis or increased consumption/loss
  • conditions that reduce albumin include: infection, nephrotic syndrome, malnutrition, malignnayc and burns
41
Q

Normal AST/ ALT? Meaning?

A

AST 10-40 units/L

ALT 10-55 units/L

  • Marked elevation of both suggests hepatitis
  • AST/ALT ratio >2 suggests cirrhosis or alcoholic liver disease
  • aka transaminases
42
Q

Normal bilirubin? Meaning?

A
  • Normal 0-11 units/L
  • confounding factors: hemolysis or hematoma reabsorption
43
Q

What is normal alk phos? meaning?

A

45-115 units/L

  • AP is not very specific for biliary tract obstruction (it’s also in bone, placenta and tumors)
44
Q

GGT normal (gamma-glutamyl transpeptidase)? meaning?

A
  • 0-30 units/L
  • GGTP is more sensitive than AP for biliary tract obstructions (it’s not present in bone)
45
Q

Normal 5’ nucleotidase? meaning?

A
  • 0-11 units/L
  • most sensitive indicator of biliary duct obstruction
  • when there is bile duct obstruciton, these enzymes spill into systemic circulation
46
Q

what lab tests show liver synthetic function?

A

PT

Albumin

47
Q

What lab tests show hepatocellular injury?

A

AST

ALT

48
Q

What tests show hepatic clearance?

A

bilirubin

49
Q

What tests show biliary duct obstruction?

A

AP

GGT

5’NT

50
Q

ALT indicates what damage?

AST indicates what damage?

Most sensitive in detection of liver disease?

Which is used to evaluate liver and heart dx?

Which is most sensitive for detecting alcholic liver dz?

A
  • ALT (aminotransferase, ALT) = SGPT
  • Location: primarily large [] in liver
  • AST (aminotransferase, AST) = SGOT
  • Location: Several places (“S” – several)
    • Places that are highly metabolic: liver, heart, kidney, skeletal muscle, pancreas
    • AST/ALT AKA → transaminases
  • Which is most sensitive in the detection of liver disease? ALT
  • Which is used to evaluate liver and heart dz? AST
  • Which is most sensitive for detecting alcoholic liver dz? AST → for alcohol … (‘S’ means scotch)
    • Ex: AST elevated more when dealing with alcoholic liver (looking at ratio)
      • Ex: Someone complaining of chest pain? → AST
51
Q

What might happen to coagulation in liver d/o?

A
  • Disorders of coagulation rapidly develop in patients with severe liver failure
  • Factors II, V, VII, IX, X all reduced in liver failure
  • PT and INR elevated
  • Thrombocytopenia
  • Abnormal fibrinogen
52
Q

What are platelets?

What might you find in abnormal liver disease?

A
  • Platelets are derived from the megakaryocytes in the bone marrow in response to thrombopoietin which is synthesized in the liver.
    • Liver failure = decreases thrombopoietin → plts low

This process is abnormal in liver disease and you may find:

  • Abnormal platelet function
  • Decreased platelet function
  • Increased bleeding time
53
Q

What is vitamin K?

What happens in vitamin K deficiency?

A
  • Vitamin K is fat soluble and requires bile salts for the absorption into the jejunum
  • Vitamin K is necessary for the hepatic synthesis of Factors II, VII, IX, X, and Protein S and Protein C
    • Just know: Vitamin K deficiency → goes w/ liver fx
  • Vitamin K deficiency develops in patients on parenteral nutrition, biliary obstruction, pancreatic insuff, malabsorption, GI obstruction
  • Effects of Vitamin K deficiency include prolonged PT, PTT
54
Q

What is the Child-Pugh Classification?

A

for severity of cirrhosis

  • Looks at encephalopathy, ascites, bilirubin, albumin, PT time
  • Class A (5-6 points)= 10% mortality
  • Class B (7-9 pts)= 30%
  • Class C= 10-15 points= 80% mortality
55
Q

What is the MELD score?

A
  • looks at bilirubin, INR, serum creatinine
  • score used to predict 90 day mortality
    • used for tx recipients and surgeries
  • Score
    • >40= 71%
    • 30-39= 52% mortaility
    • 20-29= 19% mortality
    • 10-19= 6% motality
    • <9= 1.9% mortality
56
Q

What is hepatitis?

A
  • Group of liver disorders of varying etiologies that result in hepatic inflammation and necrosis for >6 months
  • Includes etiologies such as HBV HDV, HCV auto-immune, drugs, alcohol
  • Liver is graded based on degree of inflammation, necrosis, progression of disease and degree of fibrosis
  • Treatment may include Interferon, Ribavirin, corticosteroids, AZT
57
Q

Mode of transmission, prevention and course of hepatitis A?

A
  • Mode- fecal- oral
  • Prevention= Hep A vaccine, IgG
  • Course- does not progress to chronic unless pt alreayd has hep C
58
Q

Mode of transmission, prevention and course of hep B?

A
  • Mode= percutaneous and sexual contact
  • Prevention- hep B vaccine
  • Course- chronic disease in 1-5 %
    • prognosis worse if complicated with Hep D
59
Q

Mode transmission, prevention, course of Hep C?

A
  • Mode= transfusion, percutaeneous and sexual contact
  • Prevention= unknown
  • Course= chronic dx in 85%,
    • leading cause of liver transplant
    • Increased risk of cirrhosis
    • 15-20 fold increase of developing hepatocellular carcinoma
  • Population to be concerned about:
  • 1992 started screening→ baby boomers
  • CAN BE CURED
60
Q

What is non-alcoholic fatty liver disease?

A
  • Most common cause of chronic liver disease
  • Fat accumulation in the liver exceeding 5%
  • Risk factors:
    • NIDDM, obesity, HTN, dyslipidemia
  • Asymptomatic but elevated liver enzymes (AST & ALT) found on physical exam
  • Produces some degree of hepatocyte necrosis which promotes the accumulation of inflammatory cells in liver
  • Leads to cirrhosis → can get fibrosis scan
    • Weight loss (even 5 lbs) can reverse the elevated liver enzymes
61
Q

What is alcoholic liver disease? S/S?

A
  • Liver damage → results from chronic heavy ETOH use
  • Clinical features do not distinguish from the 3 types
  • Liver biopsy is necessary to give definitive diagnosis: GOLD STANDARD
  • Nonalcoholic steatohepatitis (NASH) – a type of NA fatty liver dz
  • Alcoholic hepatitis (precursor Cirrhosis)
  • Cirrhosis

S&S

  • malaise
  • nausea
  • anorexia
  • weakness
  • abdominal discomfort
  • hepatomegaly jaundice
62
Q

What are some signs of early alcohol withrawl? Later signs? txmt?

A

Alcohol withdrawal (early)—most pronounced 3-6 hours post withdrawal

  • S/S: tremors, hallucinations, tachycardia (A_NS hyperactivity_), N/V
    • 6-8 hours may become tremulous
    • 6-24 hours hallucinations and seizures
      • → seizures actually end up killing them
  • TX: Benzodiazepines and beta antagonists

Alcohol withdrawal/delirium tremens—most common 2-4 days post withdrawal

  • S/S: hallucinations, combativeness, hyperthermia, tachycardia, hypertension, hypotension, and grand mal sz (bolded= diff from alcohol withdrawal)
  • TX:
    • Diazepam 5-10 mg IV
    • Beta-antagonists (BB) → (for tachycardia/dysrhythmias)
    • correct e’lyte abn (Mg, K), thiamine, lidocaine for dysrhythmias
63
Q

What is cirrhosis?

A
  • Cirrhosis: Greek word “yellowish”
  • Regenerative nodules surrounding surrounded by fibrous bands in response to chronic liver injury à portal HTN and ESLD
    • BF wont go, shunts around liver
  • Commonly due to hepatitis C and alcoholism
  • Picture:
    • esophageal varices
    • ascites and edema
    • coagulation disorders w/ bleeding
    • encephalopathy
    • portal hypertension
    • splenomegaly
    • caput medusae
    • hemorrhoids

Health Assessment Test 2 (5 decks)

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