GI - Exam 7 Flashcards
What is the principal function of the GI tract?
Provide the body with a supply of water, nutrients, and electrolytes.
Name the divisions of the GI tract
Esophagus, Stomach, small intestine, large intestine
What are the functions of the GI tract?
Passage, storage, digestion, and absorption of food.
What position is an EGD performed in usually?
Left Lateral Decubitus
What structures does the EGD involve?
Endoscope is placed into the esophagus, through the stomach and pylorus, and into the duodenum.
What complications are most common with EGD?
Cardiopulmonary complications in nature.
T/F: EGD cannot be performed without anesthesia or sedation
False, can be performed with or without. (not sure why anyone would do this to themselves…)
T/F: When deep sedation is chosen for an EGD, nasal intubation is preferred so the upper airway is clear for the Gastroenterologist.
False, the upper airway is shared and there is no consensus as to which airway technique is preferred.
What are the common respiratory complications of EGD?
Desaturation, airway obstruction, laryngospasm, and aspiration.
T/F:Because there is no consensus for best anestetic technique, the CRNA must understand both diagnostic and therapeutic EGD procedures.
True. Must take into account pt comorbidities to formulate anesthetic plan.
When is anesthesia typically involved in an EGD?
When a pt is not a good canidate for mild to moderate sedation or they have comorbidities that are too much for non - anesthetists.
When is an ETT indicated for an EGD?
Pts with difficult airways, risk of airway obstruction (OSA), prone position, and pts who are at risk for aspiration. This includes full stomach, gastroparesis, achalasia, and morbid obesity.
When does noxious stimuli need to be controlled with EGD?
Bile/pancreatic stent changes, dilations
What is a major concern relating to colonoscopy preparation?
Bowel preparation and its high risk of dehydration and required period of fasting.
How long should a patient be NPO for a colonoscopy?
6-8 hours
What method of bowel prep yields better results and tolerance in pts?
Split-dose bowel prep
T/F: gastric residual volume is higher in a traditional prep vs split-dose bowel prep
False, with 2 hours of fasting, the split-dose and traditional prep had the same levels of residual gastric volume.
What is an indication for use of high-resolution manometry?
If a motility disorder is suspected
What elements are used to create a esophageal pressure topography result?
3 dimensional display of time, distance, and pressure points along esophagus.
When is a barium contrast study indicated and what can it be used to diagnose?
pts who are poor candidates for endoscopy. Useful to dx esophageal reflux, hiatal hernias, ulcerations, erosions, and strictures.
What are the most common symptoms of esophageal disease?
Dysphagia, heart burn, and regurgitation
Define dysphagia and how do pts typically describe it?
Difficulty swallowing
-sensation of food getting stuck in the chest/throat
How can Dysphagia be classified?
Based on its anatomic origin (oropharyngeal or esophageal)
A parkinson/stroke pt is complaining of dysphagia. Where is the dysphagia taking place?
Oropharyngeal (seen in head and neck surgery pts as well)
How is esophageal dysphagia classified?
Based on its physiology (mechanical/structure or dysmotility)
You are assessing a pt for dysphagia, list the clinical information you would want from your pt.
Better/worse with solids or liquids, episodic, constant, or progressive in character.
T/F:Dysphagia for solid food only indicates a structural disorder
True!
Dysphagia for both liquid and solids suggests
a motility disorder
The most common cause of cholestasis is obstruction of the _ _ outside the _.
Biliary tract
Liver
About 90% of gallstones appear as radiologist structures composed of _ _ crystals.
Hydrophobic cholesterol crystals
-rest are calcium bilirubinate (seen in cirrhosis and hemolytic anemia)
Common causes of biliary tract obstruction/inflammation:
-stones
-strictures
-tumor
-infection
-ischemia
Biliary tracts is composed of which 6 components?
- Intrahepatic ducts
- R and L hepatic ducts(collection of intrahepatic ducts)
- Common hepatic duct (joins from L and R hepatic ducts in liver hilum)
- Gallbladder
- cystic duct
- Common bile duct
The cystic duct drains into the:
Common hepatic duct
The distal common bile duct joins the _ _ before entering the duodenum via the _ of _
Pancreatic duct
Ampulla of vater
Which structure maintains the sterility of the biliary tract?
Sphincter of oddi
The gallbladder’s arterial supply comes from
Cystic artery, which branches from the right hepatic artery
What are the indications for RSI r/t GI?
Bowel obstruction, appendectomy, full stomach, known hiatal hernia, GERD, 2nd trimester pregnancy, NGT, morbid obesity, diabetic (gastroparesis), ARF, emergency surgery, ASA 3, trauma
What are the steps for RSI?
preoxygenation, full dose IV induction med (2-3mg/kg prop, .2-.4mg/kg etomidate, .9-1.2mg/kg roc, 1mg/kg succ), sellick’s maneuver: cricoid pressure (10-20 awake; 30-40), NMBD intubate, inflate cuff, release cricoid
ERAS is important for GI procedures because it focuses on functional recovery of the pt. What are some
components of ERAS that should be on your radar for GI?
-Lap Cases
-Selective bowel preparation
-fluid balance
-goal directed therapy
What are symptoms of esophageal disease?
Dysphagia, heart burn, regurgitation, pain, odynophagia, globulus sensation
Heart burn is
burning/discomfort behind the sternum. Strong relationship between heartburn and GERD
Regurgitation is
effortless return of gastric contents into the pharynx w/o nausea/retching
Pain (r/t gi)
“chest pain” - cardiac vs esophageal etiology difficult to dx.
Description of heartburn plus chest pain may be result of GERD
Odynophagia is
pain w/ swallowing
Globulus sensation is
feeling of “a lump in the throat”
What are the 2 big causes of acute pancreatitis? Important lab values?
-Gallstone (triggered by obstruction of the duct)
-ETOH abuse
-trauma(post ERCP)
-meds (steroid/NSAIDS)
-autoimmune
-infections
-panc tumors
-metabolic (hypercalcemia, hypothermia, hyperTGL)
Lipase-high (>3 x normal), amylase (high), CRP (high >150=necrosis)
Explain the pathophys of acute pancreatitis
inappropriate activation of trypsin leads to activation of protease activated receptor 2 (PAR2) and activation of other pancreatic enzymes. Results in out of proportion inflammation of pancreas leading to a systemic inflammatory response syndrome (SIRS) - like response
What is the most common etiology of chronic pancreatitis?
Chronic ETOH use
What is the diagnostic triad for chronic pancreatitis?
Steatorrhea, pancreatic calcification, DM
When does steatorrhea occur? DM is the end result of loss of what function?
when 90% of pancreatic exocrine function is lost.
result of loss of endocrine function
What are the malignant strictures?
esophageal adenocarcinoma (Barretts)
squamous cell cancer (ETOH and NSAIDS)
extrinsic compression from malignant lymph nodes
What disease is there a loss of normal peristalsis in distal esophagus and failure of LES relaxation with swallowing? What is common with this disease process?
Achalasia. Pulmonary aspiration is common and leads to pneumonia
What medications are used to treat Achalasia?
Nitrates and calcium channel blockers. They relax the LES
-botox or pneumatic dilation with EGD
Distal/diffuse esophageal spasm
-patho
ANS dysfunction
-premature and rapidly propagated contractions in the distal esophagus
-premature rapid contractions associated with bolus retention
Esophageal motility disorders frequently present with what symptoms? What are the most common disorders?
Dysphagia, heartburn, or chest pain
Achalasia, diffuse esophageal spasm, and GERD
A 64-year-old patient presents for EGD with dilation for management of dysphagia. Past medical history is significant for hypertension, diabetes, adrenal insufficiency and achalasia. Patient reports no chest pain, no shortness of breath, no dysphagia with solids and occasional dysphagia with liquids. What is the most appropriate anesthetic plan of care?
A ) Monitored anesthesia care
B ) General anesthesia OETT; standard induction
C ) General anesthesia LMA
D ) General anesthesia OETT; RSI
D) GA OETT; RSI
Rapid-sequence induction/endotracheal intubation or awake intubation is required in all patients!!
Always FULL STOMACH PRECAUTIONS
Consider NGT to decompress the stomach
Large channel endoscope may be passed to evacuate esophageal contents
A 72-year-old patient presents for endoscopic myotomy for symptom relief from DES. Past medical history is significant for asthma, hyperlipidemia and DES. Medication management includes albuterol PRN, simvastatin, omeprazole and sildenafil. What is a concern in the perioperative period?
HYPOTENSION (this is the biggie)…in addition to headaches, flushing, angina.
For patients using PDEI type 5 drugs (sildenafil), the reduction in systemic vascular resistance may result and lead to hypotension, angina, and headaches, especially when taken in combination with other vasodilating medications- be aware!
Avoid other nitrate vasodilators, α adrenergic antagonists, during perioperative period due to risk of dangerously low BP
What is zollinger-ellison syndrome?
gastroduodenal and intestinal ulceration with gastric hyper secretion and non-beta islet cell tumors of the pancreas gastrinoma
Excess gastrin stimulates acid secretion and exerts trophic action on gastric epithelial cells; increased gastric acid output = PUD, erosive esophagitis, and diarrhea
A patient with esophageal diverticula may CO halitosis, gurgling in the throat, appearance of a mass in the neck, or regurgitation of food into the mouth. What should you be concerned with?
Aspiration and airway!
regurgitation of food increases risk of aspiration during anesthetic.
NO OGT, may perforate the diverticulum
Define GERD
Reflux that causes bothersome symptoms, mucosal injury in the esophagus or at extraesophageal sites, or combination of both
What is the body’s natural anti reflux mechanism?
LES, a high pressure system where esophagus meets stomach. Normal LES pressure is 30mmHg
What are the clinical manifestations of GERD?
Heartburn (pyrosis) and regurgitation (primary)
How is aspiration pneumonitis defined clinically? (Mendelson’s syndrome)
0.4mL/kg with pH below 2.5
What are the 3 different classes of medications to manage GERD?
proton pump inhibitors (Omeprazole, pantoprazole)
H2 receptor agonists (famotidine)
Antacids (can be over used resulting in large amount of calcium carbonate absorption)
PPIs work faster and are more efficient in reducing amount of gastric volume AND increasing pH (meaning it becomes more basic)
What is the difference between type 1 and type 2 hiatal hernias?
type 1 - GE junction and fundus of stomach slide upward above the diaphragm
type 2 - paraoesophageal = GE junction in normal place; pouch of stomach herniated next to junction
Patients with esophageal tumors have progressive dysphagia to solid food and weight loss. Treatment may include esophagectomy which means they are
an aspiration risk for life
With GERD, what increases the risk of aspiration?
Emergent surgery, full stomach, difficult airway, inadequate anesthesia, lithotomy, autonomic neuropathy, IDDM, gastroparesis, pregnancy, increased intraabdominal pressure, severe illness, morbid obesity, mucosal complications
As a means to increase gastric emptying, prokinetics (metoclopramide) is given to patients. In what situation would you not give this medication?
Parkinson disease, pheochromocytoma, **gastrointestinal obstruction, or in patients taking medications that may interact and cause extrapyramidal side effects
Metoclopramide is a dopamine antagonist that enhances LES tone, increases gastric emptying, and decreases gastric volume. What are its 2 uses?
Gut motility stimulator and antiemetic
In an emergency situation where you want to increase gastric pH above 2.5, what medication are you going to give that works the fastest?
Nonparticulate antacid - sodium citrate
What lowers LES tone?
Anticholinergic agents
Opioids
Thiopental
Benzo
Propofol
Inhaled anesthetics
Cricoid pressure
NG tube
Alkalinization
Protein feeding
Beta agonists
What increases LES tone?
Antiemetics
Succinylcholine
NMBD
Cholinergic agents
Antacids
What has no effect on LES tone?
Atracurium
Vecuronium
H2 antagonists
Sleep
The number 1 cause of peptic ulcer disease is
H. Pylori
chronic NSAID use is 2nd
Acute upper GI hemorrhage is a major complication of PUD. What would the pt present with?
Nausea, hematemesis, melena
What are the treatment options for peptic ulcer disease?
Antacids- symptomatic relief
H2-receptor antagonists (Famotidine/ranitidine/cimetidine (binds to CP450)- inhibit gastric acid secretion
PPI (omeprazole)- irreversibly inhibit hydrogen potassium ATPase/inhibits CP450/fastest and most potent acid inhibitor drugs!
Prostaglandin analogues (Misoprostol)- maintain mucosal integrity by enhancing bicarbonate secretion stimulating mucosal blood flow and decreasing mucosal turnover
Cytoprotective agents (Pepto)- coats ulcer
Surgical = vagotomy > stops vagus nerve from causing acid release but results in delayed gastric emptying
Chronic ingestion of large quantities of calcium containing antacids and milk for the treatment of peptic ulcer disease may lead to which of the following?
Alkalosis
Polydipsia
Seizures
Decreased blood urea nitrogen
A) Alkalosis
Large ingestion- calcium carbonate > hypercalcemia, alkalosis, acute/chronic renal injury > “milk-alkali syndrome”
What are the differences between ulcerative colitis and Crohn disease?
UC is a continuous distribution of disease, generally involves rectum, and is characterized by rectal bleeding, diarrhea, and abdominal pain mild/moderate
Crohns skips areas of involvement, affects distal ileum and proximal large colon. Characterized by diarrhea, moderate/sever abdominal pain, and diarrhea (with/without rectal bleeding), fatigue, and weight loss
Carcinoid syndrome is a result of
secretion of serotonin and vasoactive substances into systemic circulation in setting of neuroendocrine tumor
Primary = *serotonin, histamine, kallikrein
What medication is given to treat carcinoid syndrome?
Octreotide, a long acting synthetic analog of somatostatin
What are clinical manifestations of carcinoid crisis?
Severe flushing (cutaneous/facial)*
Dramatic changes in BP (hypotension)*
Cardiac arrhythmias (tachycardia)*
Bronchoconstriction (wheezing & dyspnea)*
Mental status changes
Diarrhea
Your patient is a 55-year-old undergoing appendectomy for carcinoid tumor of the appendix. What is an appropriate induction plan?
Lidocaine, fentanyl, ketamine, rocuronium
Lidocaine, fentanyl, propofol, succinylcholine
Lidocaine, fentanyl, propofol, rocuronium
Lidocaine, fentanyl, thiopental, atracurium
C) Lidocaine, fentanyl, Propofol, rocuronium
Avoid drugs that release histamine (morphine, meperidine, codeine, atracurium, vancomycin, hyperosmotic agents)
Avoid succinylcholine > increase in intraabdominal pressure and fasciculations may trigger mediator release
Propofol has profound effect suppressing the sympathetic response to intubation
Avoid sympathomimetics > ketamine
Balanced technique with GA OETT, PPV, inhalation agent, nondepolarizing muscle relaxation (rocuronium or vecuronium), opioid (fentanyl). N2O safe
What are preoperative considerations for patients with carcinoid tumor undergoing anesthesia?
Benzo to reduce anxiety
antihistamine to reduce histamine release
octreotide for symptomatic relief and prevention of perioperative hypotension
optimize fluid and electrolytes
Placement of invasive lines prior to induction (art and or pulm artery catheter with coexisting cardiac dysfunction)
she said 3 on the slide previous, then listed 5. Maybe a hint that this is a write in?
What are carcinoid tumors? 2 most common signs?
Well differentiated neuroendocrine tumors originating from GI tract*, lungs, kidneys, or ovaries.
Tumors composed of enterochromaffin cells (kulchitsky cells)
Modern > NET for tumors originating in GI tract or “neuroendocrine carcinoma”
2 most common signs are flushing with diarrhea w/ associated electrolyte abnormalities and dehydration
What is the role of glucagon in gallbladder surgery or ERCPs?
spasmolytic effect int he GI system and ability to relax the sphincter of oddi
Why is cricoid pressure controversial in the setting of esophageal diverticula?
If sac right behind CC, may push contents into pharynx and cause aspiration
ERAS considerations for GI cases
-preop
-ID pt
-educate
-screen for malnutrition
-smoking cessation
-SELECTIVE BOWEL PREP (THINK PT MAY BE MORE DRY, HD SWINGS)
-clear liq until 2 hr before case
-carb drink
ERAS considerations for GI cases
-intraop
-abx
-thrombophylaxis
-minimize invasive surgery
-multimodal anesthesia
-regional
-avoid salt and water overload (EUVOLEMIA)
-goal-directed fluid therapy
ERAS consideration for GI cases
-postop
-early feeding
-early mobilization
-early removal of pt tethers (foley, NGT, etc)
-optimize fluid regimen
-optimize analgesia
-stimulate gut motility
Benign esophageal strictures:
-peptic stricture (complication of GERD, found in EGJ)
-anastomotic stricture
-eosinophilic esophagitis (chronic, immune mediated stricture)
-postop fundoplication (anti-reflux procedure)
-radiation-induced stricture
-esophageal ring/web-Schatzki ring (distal esophagus from HH-mechanical issue swallowing food)
-post endoscopic mucosal resection
-extrinsic compression from vascular structures
-extrinsic compression from benign lymph nodes or large atrium
Motility disorders of the esophagus:
-GERD
-Achalasia
-HoTN peristalsis
-HTN peristalsis
-Distal/diffuse esophageal spasm
-functional obstruction
-pseudoachalasia
-chagas disease
-scleroderma
What is a tool to classify severity of esophageal motility disorders?
Chicago Classification
Describe the pain associated with esophageal diseases:
-chest pain behind sternum, may radiate to neck
-heartburn, plus chest pain may be GERD
During preoperative evaluation, the patient states they have difficulty swallowing. Upon further evaluation, the patient states they struggle with swallowing both liquids and solids. What is the most likely etiology?
A. GERD
B. Peptic stricture
C. Esophageal adenocarcinoma
D. Extrinsic compression
GERD-Dysphagia with solid and liquids = motility
Achalasia
Hypotensive peristalsis
Hypertensive peristalsis
Distal/diffuse esophageal spasm
Functional obstruction
Gastrointestinal reflux disease (GERD)
Other diseases: pseudoachalasia, Chagas disease, scleroderma
Which symptom of esophageal disease is described as a “lump in the throat”?
A.Odynophagia
B.Globulus
C.Regurgitation
D. Heartburn
B. Globulus sensation
During preoperative evaluation, the patient complains of return of gastric contents returning into the pharynx. Which esophageal symptoms describes this clinical manifestation?
A. Heartburn
B. MI
C. Odynophagia
D. Regurgitation
D. Regurgitation
Concerns with achalasia and anesthesia?
Airway, aspiration
Achalasia
-s/s
-main risk
s/s:
dysphagia (BOTH SOLIDS + LIQ)
regurgitation
heartburn
cp
main risk:
PULMONARY ASPIRATION -> PNA (COMMON)
-lifetime esophageal CA risk too
Achalasia
-dx
-tx
Dx: esophagram (barium XR), EGD to exclude structural issues
Tx: PALLIATIVE :(
-goal to relieve the LES obstruction but can’t fix peristaltic deficiency
-CCB and nitrates, botox
-best NON SURGICAL tx is pneumatic dilation via EGD
-best SURGICAL TX is myotomy
Achalasia
-patho
neuromuscular- degeneration of gangion cells in MYENTERIC PLEXUS in esophageal wall
-2 main issues
impaired ability of esophagus to move food into stomach (peristalsis) and LES to relax
Distal/Diffuse Esophageal spasm (DES)
-s/s
-dysphagia and cp
Distal/Diffuse Esophageal spasm (DES)
-diff dx
-Dx
Diff Dx:
-GERD
-stricture
-HH
-functional dysphagia
-opioid-induced hypomotility
DX: r/o other disorders with EGD/biopsy, use high resolution manometry to eval if motility disorder
Distal/Diffuse Esophageal spasm (DES)
-mgmt (this is important for anesthesia!!!!)
relieve s/s
-Primary PPI and or peppermint oil
-anticholinergics
-secondary antispasmotic agent (hyoscyamine, dicyclomine)
-short-acting nitrate (think low BP, low SVR)
-phosphodiesterase-5-enzyme inhibitor (think low BP, low SVR)
-CCB
-low dose TCA
-botox
-EGD dilation or surgical myotomy
-avoid further nitrates, alpha adrenergic drugs(precedex!), beta blockers, anything else that can lower BP
Most common locations for esophageal diverticula:
-pharyngoesophageal (Zenker diverticulum)-most common
-midesophageal
-epiphrenic (above diaphragm)
Zenker diverticulum is a sac-like outpouching of mucosa and submucosa thru _ _ , an area of muscle weakness between transverse fibers of the _ muscle and the oblique fibers of the lower inferior constrictor ( _ muscle)
Killian’s Triangle
cricopharyngeus m
thyropharyneus m
Bad breath (halitosis) from retained food globs in the throat from several days is related to which esophageal disorder?
Pharyngoesophageal (Zenker’s) diverticulum
T/F you can place an N/OGT in pts with esophageal diverticulum when you’re concerned with their likelihood of aspiration.
false, will perforate the diverticulum!
Esophageal Diverticulum
-Diff dx
-DX
Diff Dx:
-other causes of progressive dysphagia (peptic stricture or esophageal carcinoma)
DX: barium swallow eval
Esophageal Diverticula
-mgmt
surgical open or transoral rigid endoscope or flexible endoscope
Esophageal Diverticula
-anesthesia considerations
GA induced in the head-up position WITHOUT cricoid pressure
Empty pouch prior to anesthesia- patient applies external pressure (
NO OGT- perforate diverticulum
Careful with TEE
Hiatal Hernias T2,3,4 (paraesophageal)
-s/s
-complications
could be intermittent, vague or asymptomatic,
most common:
-epigastric or substernal pain
-post prandial fullness
-N/ retching
complications: vulvulus (surg emergency), bleeding ,dyspnea
Hiatal Hernias T1/ sliding
-s/s
asymptomatic
-GERD like s/s
most common:
-heartburn
-regurg
-dysphagia
Diff between a sliding T1 hernia and paraoesophageal (T2-4) hernias:
sliding: MORE COMMON, GE junction and fundus of stomach slide UP
paraesophageal: TRUE HERNIA, GE junction stay in place, stomach pouches out and herniates NEXT TO the junction
Hital Hernia
-Diff Dx
-DX
Diff DX: etiologies of epigastric or substernal pain, dysphagia, heartburn or regurgitation, and refractory gastroesophageal reflux disease (esophagitis, an esophageal motility disorder, functional dyspepsia, and coronary artery disease)
DX:suspected with symptoms or post dissection of history surgery, diagnosed with barium swallow, upper endoscopy, manometry, or imaging studies
Hiatal Hernia
-mgmt
- anesthesia considerations
mgmt: meds for GERD, surgical resection if symptomatic paraesophageal
A: AIRWAY- RISK OF ASP
Esophageal tumors
-tx
esophagectomy (curative or palliative doesn’t matter, asp risk for life!)
-will highly benefit from multimodal bc high incidence of pulmonary morbidity
-pts on chemo/radiation
-poor nutrition
GERD
-mechanism
Reflux that causes bothersome symptoms, mucosal injury in the esophagus or at extraesophageal sites, or combination of both
-natural antireflux mechs (LES and GE junction) not working
-Only lower 1/8th of esophageal mucosa tolerates stomach acid for prolonged period
Normal LES pressure:
30mmHg
GERD
-s/s
heartburn (pyrosis) and regurgitation (primary)
others: dysphagia, chest pain, water brash/hypersalivation, globus sensation, odynophagia, extraesophageal symptoms/laryngeal reflux (chronic cough, hoarseness, wheezing), and, infrequently, nausea (secondary)
GERD
-complications
Chronic peptic esophagitis
Heartburn
Esophagitis
Strictures
Ulcers
Barret metaplasia (adenocarcinoma)
Laryngopharyngeal reflux variant of GERD
-Gastric contents into pharynx, larynx, tracheobronchial tree > chronic cough, bronchoconstriction, pharyngitis, laryngitis, bronchitis, pneumonia
GERD
-diff dx
-dx
diff dx: Esophagitis, pill esophagitis, and eosinophilic esophagitis
Dysphagia
Esophageal rings/webs
Impaired peristalsis due to an esophageal motility disorder. Slowly progressive dysphagia for solids with episodic esophageal obstruction is suggestive of a
Stricture or an esophageal cancer (slowly progressive dysphagia for solids with episodic esophageal obstruction)
Odynophagia
DX: symptoms, upper GI endoscope, pH monitoring
classified as erosive or nonerosive
GERD
-tx
lifestyle mods
anesthesia considerations: PPI (faster/more efficient), H2 blockers and antacids, nonparticulate BIcitra, increases ph works asap, good in emergency
surgical tx: Nissen fundoplication
risk for asp
PPI
-MOA
inhibitors of gastric acid secretion by irreversibly binding to and inhibiting the hydrogen-potassium (H-K) ATPase pump
-less secretion, increase pH
H2 Receptor Agonist
-MOA
Decrease the secretion of acid by inhibiting the histamine 2 receptor on the gastric parietal cell
-less acid secretion, increases pH
Risk for aspiration/Mendelson syndrome:
-emergent surg
-full stomach
-difficult airway
-light anesthesia
-lithotomy
-autonomic neuropathy
-IDDM
-gastroparesis
-pregnancy
-increased intraabd pressure
-severe illness
-obesity
-mucosal issues
What is more critical to determining severity of aspiration, pH or volume of aspirated content?
pH
-pH <2.5 and 0.4mL/kg
Metoclopramide
-MOA
-prokinetic DOPAMINE ANTAGONIST (AVOID IN PD, PHEO, GI OBSTRUCTION-EPS meds)
- increases LES tone, increases motility, decrease volume
Which medications decreases volume of gastric contents and decrease acidity?
A. Prilosec
B. Reglan
C. Sodium Citrate
D. Famotidine
Prilosec AND Famotidiine
Which of the following decreases lower esophageal sphincter tone?
A. Neostigmine
B. Sux
C. Roc
D. Metoprolol
E. Atropine
E. Atropine
anticholinergics
PUD
-s/s
asymptomatic sometimes
-abd pain (upper abd/epigastric, radiates to back)
-2-5hr after meal or at night (for duodenal ulcers)
-dyspepsia
-bloating
-abd fullness
-N
-GERD
-anemia (bleeding)
-leukocytosis (perforation)
-abnormal CT (discontinued mucosa and luminal outpouch)
PUD
diff dx
dx
Diff DX: Other causes of dyspepsia such as drugs, biliary disease, gastric malignancy, chronic pancreatitis
Excluded by upper endoscopy
DX: direct visualization of ulcer via EGD
Most common cause of PUD:
H Pylori
PUD
-complications
-upper GIB
-hemorrhage (N/ hematemesis, melena)
-gastric outlet syndrome
-fistulation
-perf
PUD
-tx
Meds:
-antacids(first line for symptomatic disease)
-H2 blockers
-PPI
-prostaglandin analogs (misopristol)
-cytoprotective agents (Pepto)
Surgical:
-vagotomy (prevents vagus n from releasing acid but causes delayed emptying)
Prostaglandin analogues (Misopristol)
-MOA (GI)
maintain mucosal integrity by enhancing bicarbonate secretion stimulating mucosal blood flow and decreasing mucosal turnover
Differences between IBD variations (UC and Crohn’s):
UC
-relapsing/remitting episodes of inflammation -> CONTINUOUS mucosal lesions
-usually RECTUM; BLEEDING with BM
-diarrhea
-MILD/MOD abd pain (LLQ)
Crohn’s
-transmural SKIPPED lesions-> fibrotic strictures and obstructive abscesses
-usually in DISTAL ILEUM AND PROX LARGE COLON
-diarrhea
-MOD/SEVERE abd pain (RLQ-confused with appendicitis)
-fatigue/ wt loss
Carcinoid tumors originate from:
-GI tract
-lung
-kidney
-ovary
Carcinoid syndrome is caused from release of _ and vasoactive substances into systemic circulation in setting of the tumor.
serotonin (most common)
-also secretes histamine and kallikrein
Carcinoid syndrome s/s
-chronic severe (cutaneous/facial) flushing
-diarrhea
-marked HotN
-arrhythmias (tachy)
-bronchoconstriction(wheezing/dyspnea)
-AMS
-can happen (often) at induction or at any time
Carcinoid Syndrome
-tx
meds:
-pretreat with OCTREOTIDE or lanreotride 150-200mcg Q 4-6hr 24-48 hr preop continued thru surgery
-serotonin, H1/H2 blockers
-anxiolytics
-alpha agonists for HoTN (phenylephrine or vasopressin)
A:
-fluids/lytes
-monitor BG
-a line
surgery:
-complete excision of tumor with bowel resection and lymphadenectomy
Meds to AVOID in carcinoid tumor to prevent crisis:
-sympathomimetics (ketamine)
-histamine releasing agents (meperidine, atracurium, pancuronium, thiopental, hyperosmotic agents, morphine, codeine, vanco, etc)
-sux (fasciculations trigger release of mediators and increase intraabd pressure)
What is a safe anesthetic plan for a pt with carcinoid tumor?
Versed, antihistamine, and octreotide preop, place lines, give fluids
GA ETT, PPV, IA, NDMR (roc or vec), propofol (suppresses sympathetic response) opioid (fentanyl), N2O is ok too
Acute Pancreatitis
-s/s
-abd pain radiating to back
-N/V
-distention
-jaundice
-fever
-tachy/HoTN
-Cullen’s Sign (hemorrhagic discoloration of umbilicus)
-Grey-Turner’s sign (hemorrhagic discoloration of flanks)
Acute Pancreatitis
-complications
-shock’
-hypoxemia/ARDS
-DIC
-renal fail
-infection of necrotic panc tissue
-vomiting - > hyperchloremic alkalosis
Acute Pancreatitis
-tx
-aggressive fluids (bc fluid loss into peritoneum causes hemoconcentration and hypovolemia)
-lyte correction
-po fluids?
-TPN
-intubation for ARDS
Signs and symptoms that may be seen with acute pancreatitis include all of the following, except
A. altered cardiac rhythmicity
B. DIC
C. ARDS
D. Hyponatremia
E. Hemoconcentration
A altered heart rhythm
Which anesthetic technique would NOT be appropriate for a patient undergoing a colectomy?
A. volatile agent + prop infusion
B. N2O and narcotic
C. lumbar epidural and volatile agent
D. TIVA with prop, dex, and remi
E. spinal with sedation
B. N2O with narcotic
-nitrous oxide might be hazardous in venous or arterial air embolism, pneumothorax, acute intestinal obstruction with bowel distention, intracranial air (pneumocephalus following dural closure or pneumoencephalography), pulmonary air cysts, intraocular air bubbles, and tympanic membrane grafting
Which ventricle is frequently affected by carcinoid syndrome?
Right
Which kind of anesthesia technique is preferred in carcinoid syndrome?
GA
Carcinoid syndrome involves which kind of cells?
Enterochromaffin (Kulchitksy) cells
Appendicitis anesthesia techniques:
any
regional: T6-T8 blk
Major complications of appendicitis:
Perforation
Peritonitis
Abscess
Portal pylephlebitis
What does shifting abdominal pain mean when trying to differentiate between uterine and appendicitis pain?
It’s uterine (Adler’s sign)
Appendicitis
-patho
appendiceal lumen obstruction
Where is appendicitis pain felt?
McBurney’s point
-between iliac crest and umbilicus
-rebound tenderness
Which hormone inhibits gastric acid secretion?
Somatostatin
Which cells secrete intrinsic factor?
Parietal cells
What does gastrin do?
Stimulates acid and histamine release
Pepsinogen and gastrin are mediated by which CN?
CN X Vagus n
What is the main blood supply to the stomach?
Celiac artery
Which cranial nerves innervate the esophagus and LES?
CN IX, X, and XI
PUD with sudden epigastric pain?
Probably perf
Catastrophic complication of ulcerative colitis
Toxic megacolon (dilated transverse colon)
What lab test can evaluate the severity of pancreatitis/the necrosis?
CRP >150mg/L
What is the main anesthesia concern postoperatively for gastrectomy?
Epidural pain mgmt
What is the main concern intraoperatively gastrectomy?
hypovolemia
What is the main concern preoperatively gastrectomy?
malnourished
What gas should be avoided in gastrectomy?
N2O
What cellular changes occur with barrett’s esophagus?
Stratified squamous –> Columnar epithelium
Most effective supportive treatment for pancreatitis
fluids
Pancreas exocrine functions:
-keeps duodenum alkaline so enzymes can work
-secretes proteins and lytes
Pancreas endocrine functions:
-regulate energy via insulin + glucagon
Islet of Langerhaans:
-alpha
-beta
-delta
Sympathetic innervation of colon is from which vertebrae
T6-T10
What lab values are decreased in chronic pancreatitis?
-albumin
-Mag
-Calcium
-K+
-BSG
At what pancreatic functional level does steatorrhea occur in chronic pancreatitis?
when there is 10% function remaining
Which enzymes are primarily responsible for pancreatitis?
Trypsin
Enterokinase
Bile Acids
Three phases of pancreatitis:
- Premature activation of trypsin in acinar cells
- inflammatory response of pancreas
- systemic activation of immune response, remote organ dysfunction
Risk factors for gallstone pancreatitis:
-white
-woman
->60
-small gallstones
What sympathetic receptor stimulation causes decrease in insulin release?
alpha and beta 1
-cholinergic block
-beta 2 enhances insulin secretion
What does secretin do?
stim pancreas to produce bicarbonate, water and CCK
What gastric procedure may require an epidural?
partial or total gastrectomy for pain
What makes pain from gastric cancer different than ulcers?
pain is constant, nonradiating, UNRELIEVED by food
Most common gastric cancer
Adenocarcinoma
Underlying mechanism of PUD?
overabundance of HCl and pepsin
What neurotransmitter/hormones regulate gastric acid secretion? Principle neurotransmitter modulating acid secretion?
-ACh (main one)
-gastrin
-histamine
What stimulates release of bile?
CCK
Hormones overproduced by carcinoid tumor?
SEROTONIN
bradykinin
histamine
prostaglandin
KALLIKREIN
What causes the lab value of alkaline phosphatase to increase?
bile obstruction
Gastric pH in fasted patient
1.6-2.2
Five pathophysiologic or physiologic factors that decrease LES?
-secretin
-glucagon
-pregnancy
-obesity
-HH
What is a classic symptom of all esophageal disease?
dysphagia
What do cimetidine and ranitidine do to LES tone?
nothing
Who usually gets diffuse/distal esophageal spasm and what is it often related to?
elderly,
-ANS dysfunction
What will you see on esophagram in the case of diffuse esophageal spasm?
rosary beads or corkscrew esophagus
Does metoclopramide reduce PONV?
if given at end of case in high (10-20mg) doses, yes
What is the biggest anesthetic implication of a current or past esophagectomy?
high asp risk for life, high rates of poor outcomes with this surgery
What are the three main pathophysiologic mechanisms of GERD?
-LES relaxation after gastric distention
-LES HoTN
-anatomic distortion (HH)
What is a Nissen fundoplication?
wrapping proximal stomach around distal esophagus
Which H2 antagonist is most potent with fewest side effects?
Ranitidine
What is Mallory-Weiss syndrome? what does it lead to?
post-emesis/-retching tears in the gastric mucosa (near gastroesophageal junction)
Leads to upper GI bleeding, tx with vasopressin or embolization
What kind of pain is seen in peptic ulcer disease?
epigastric, worse when stomach empty, fixed by eating
3 things that serve as protection of the stomach and SI from ulceration?
-mucous bicarb layer
-surface epithelial cells
-prostaglandins
Which are more common, duodenal or gastric ulcers?
duodenal
How is H. Pylori typically treated?
2 abx + 1 PPI for 2 wks
Acute vs. Chronic pancreatitis: Causes
Acute: etoh/gallstons, abd. surgery, large volume of calcium intraop
Chronic: ETOH abuse most common!
Acute vs. Chronic pancreatitis: symptoms
Acute: mid-epigastric to periumbilical pain, n/v, fever, hypotension, EKG changes
Chronic: epigastric pain radiating to back after meals
Acute vs. Chronic pancreatitis: Treatment
acute: fluid resuscitation, bowel rest, ERCP
chronic: manage pain, malabsorption, diabetes
UC vs. Crohn’s: appearance
UC: thin colon wall, continuous
Crohn’s: thick colon wall, skipped
UC vs. Crohn’s: differentiating symptoms
UC: bloody diarrhea
Crohn’s: malabsorption, stomach ulcers, weight loss 10-20%
What postion will a patient be in for EGD?
LLD
What types of patients require anesthesa for EGD?
-difficult airway
-OSA
-poor candidates for conscious sedation
-asp risk
What can be used to slow motility for EGD?
Glucagon 0.5mg
An ERCP always requires the patient to be what?
prone + intubated
A patient undergoing a colonoscopy may have “split-dose bowel prep”…what does this mean? Why is it used?
Some is done the night before and some is done the morning of
It is better tolerated
What is a hallmark pain symptoms of acute pancreatitis?
midepigastric to periumbilical pain that worsens while supine
Alkaline reflux gastritis
Clinical triad?
stomach inflammation caused by reflux of bile and alkaline pancreatic secretions
- epigastric pain with n/v
- reflux of bile into stomach
- histologic evidence of gastritis
What anesthetic conditions should be avoided in carcinoid syndrome in order to avoid excess strain on the right ventricle
Hypercarbia
Hypoxemia
light anesthetic
What is a common problem with emergence related to carcinoid syndrome and why?
delayed awakening due to serotonin
What block may be helpful with post-op pain for pancreatic proceudres?
celiac plexus
What are the signs of gallstones obstructin the cystic duct?
RUQ pain (sudden)
Fever
Leukocytosis
What is murphy’s sign and what is it indicative of?
pain in RUQ with insp, gallbladder inflammation
What is Charcot’s triad? what is it diagnostic of
RUQ pain, fever, jaundice
Acute ductal obstruction
RUQ pain is associated with?
gallbladder
RLQ pain is associated with?
appendicitis
crohn’s
LLQ pain is associated with
UC
Which GI hormone stimulates the release of water and bicarb from pancreas, bile flow, and INHIBITS gastrin release?
secretin
What 3 conditions is ocreotide used for?
Dumping
Carcinoid Tumor
Zollinger-Ellison
What is a sign the appendix has ruptured?
Short-lived but abrupt improvement in pain
Tachycardia
Temp>39
The best initial intervention for acute pancreatitis is:
A.fluid and lyte resusc
B. morphine for spasms
C. FFP
D. vasodilators
E. correct acidosis
A. fluid and lyte resusc
During a right inguinal hernia repair under GA, the pt’s HR drops from 92 to 40. What is the correct first reaction?
A. give pnehylephrine
B. Give Epi
C. Give IV Ephedrine
D. Tell surgeon to release visceral traction
E. Decrease the VA
D. Tell surgeon to release traction
What are the correct manifestations of carcinoid syndrome?
A. severe HTN and bradycardia
B. Bronchospasm and bradycardia
C. Cutaneous flushing and HoTN
D. Laryngospasm and VT
C. Cutaneous flushing and HoTN
T/F Cut dose in half or avoid using H2 blockers in renal pts?
true
