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Health Assessment Exam 2 > GI/Liver > Flashcards

GI/Liver Flashcards

1
Q

What are some things to look for in the pre-op evaluation of the GI/liver patient?

A
  • Nutritional deficiency
  • Weight loss greater than 10% in last 6 months
  • Nausea/Vomiting or pain with fatty meals
  • Occult Blood loss
  • Overt GI Bleed
  • Abdominal Pain/Abdominal Distention/ascites
  • Abdominal masses
  • Dysphagia
  • Gastric hyperacidity with or without Reflux
  • Jaundice
  • List of medications
  • Pruritis or fatigue
  • Scleral icterus
  • Hepatamegaly or splenomegaly
  • Palmar erythema
  • Gynecomastia
  • Spider aniomata, petechiae, and ecchymosis
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2
Q

What fasting guidelines should be followed for liver/GI patients?

A
  • 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
  • Sip of water or liquid pre-med up to 1 hour before OR
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3
Q

What patients with GI/liver disease are considered an aspiration risk?

A
  • Age extremes 70 yr
  • Ascites (ESLD)
  • Collagen vascular disease, metabolic disorders (Diabetes obesity, ESRD, hypothryoid)
  • Hiatal Hernia/GERD/Esophageal surgery
  • Mechanical obstruction (pyloric stenosis, intestinal obstru)
  • Prematurity
  • Pregnancy
  • Neurologic diseases
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4
Q

What patients are considered the greatest aspiration risk?

A
  • Pregnant
  • Morbidly obese
  • Hiatal hernia patients
  • Pre-operative anxiety
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5
Q

What medications can be used for patients at risk for aspiration?

A
  • H2 receptor antagonists
  • Sodium citrate (bicitra)
  • Metoclopramide
  • Omeprazole
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6
Q

What are some H2 receptor antagonists and how do they work?

A
  • Cimetidine Zantac and Famotodine (best result)
  • Act as competitive antagonists 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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7
Q

What is the mechanism of action of Metoclopramide?

A
  • Dopamine antagonist that increases the pressure of the lower esophageal sphincter to speed gastric emptying
  • Prevents of alleviates nausea and vomiting
  • Contraindicated in the presence of an obstruction
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8
Q

Describe Sodium Citrate (Bicitra)

A

-Non-particulate antacid
-Customary dose of 30 mls to raise gastric ph
Increases gastric volume
-Give 15 minutes before surgery and lasts 1-3 hours

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9
Q

How is Aspiration Pneumonitis/Mendelson Syndrome characterized?

A
  • pH
  • Volume
  • Gastric material aspirated
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10
Q

What are the 2 main risk factors for aspiration?

A
  • Gastric volume of 0.4ml/kg (25 ml/70kg)

- pH less than 2.5

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11
Q

How does aspiration pneumonitis/mendelson syndrom manifest?

A

As respiratory distress with bronchospasm cyanosis, tachycardia and dyspnea from the irritation action of hydrochloric acid and particulate material damaging the lungs

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12
Q

What is Barrett’s esophagus?

A
  • Metaplastic disorder of the esophagus secondary to reflux

- Precursor to esophageal cancer

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13
Q

What is the medical treatment for Barrett’s esophagus?

A
  • H2 blockers
  • Proton pump inhibitors
  • Nissen fundoplication
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14
Q

What are the signs and symptoms of Barrett’s esophagus?

A
  • Dysphagia
  • Reflux esophagitis
  • Retrosternal pain or heartburn
  • LES dystonia
  • Weight loss
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15
Q

What is a hiatal hernia?

A

-Protrusion of a portion of the stomach through the hiatus of the diaphragm upward into the thoracic cavity.

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16
Q

What are the signs and symptoms of a hiatal hernia?

A
  • Retro-sternal discomfort

- Burning after meals

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17
Q

What is peptic ulcer disease?

A
  • Ulcerations in the GI mucosa
  • Most commonly the duodenal bulb or antrum of the stomach
  • Caused by H. Pylori
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18
Q

What is the treatment for peptic ulcer disease?

A
  • H2 antagonists
  • Proton pump inhibitors
  • Antimicrobial therapy
  • Antacids
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19
Q

What are the risk factors/signs of peptic ulcer disease?

A
  • Men and women age 45-60
  • Chronic use of NSAIDS
  • ETOH
  • Steroids
  • Epigastric pain
  • Vomiting
  • Hematemesis or melena
  • Abdominal tenderness and regidity
  • Perforation
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20
Q

What are the signs and symptoms of a gastric ulcer?

A
  • Pain
  • Anorexia
  • Weight loss
  • Metabolic derangements
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21
Q

What are malabsorption syndromes?

A
  • Clinically significance deficits in mineral, vitamins and electrolytes
  • Small Bowel perforation or obstruction
  • Small Intestine
  • Celiac Sprue
  • Fat Malabsorption
  • Protein Malabsorption
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22
Q

What are the signs and symptoms of malabsorption syndromes?

A
  • Unexplained weight loss
  • Steatorrhea
  • Diarrhea
  • Anemia
  • Fatigue
  • Deficiency in vitamin K
  • Bleeding dyscrasia
  • Edema/ascites
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23
Q

What part of the large intestine does Chron’s disease effect and what are the signs/symptoms?

A
  • Distal ileum and large colon
  • Deficiency in magnesium, B12, phosphorous, folic acid, zinc, iron, potassium
  • Protein loss: decreased plasma albumin
  • Anemia
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24
Q

What part of the large intestine dose Ulcerative Colitis effect and what are the signs/symptoms?

A
  • Distal colon and rectum
  • Intermittent bloody diarrhea
  • Fever/malaise
  • Anorexia/weight loss
  • Abdominal pain
  • Associated with risk of colon cancer
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25
Q

What is carcinoid syndrome?

A
  • Site of origin is in the GI tract (appendix, pancreas or bronchi)
  • Most symptoms are produced by the effects of hormones and substances secreted in the GI tract and systemic circulation:
  • Bradykinin
  • Histamine
  • Serotonin
  • Dopamine
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26
Q

What are the signs and symptoms of carcinoid syndrome?

A
  • Cutaneous flushing
  • Diarrhea
  • Palpitations
  • Bronchospasm
  • Dyspnea
  • Hypotension
  • Hypertension
  • Orthostasis
  • Pre-op test are guided by physical findings
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27
Q

What are some general pre-operative considerations for the GI patient?

A
  • Airway management and prevention of aspiration
  • Fluid and electrolyte balance
  • Skin
  • Peripheral circulation
  • Heart rate
  • Blood pressure
  • Urine output
  • Kidney function
  • Orthostasis
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28
Q

What are some useful lab values to get on the GI patient?

A
  • Hematocrit
  • Serum electrolytes
  • BUN
  • Serum albumin
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29
Q

What monitoring is needed for GI patients?

A
  • Maybe they need invasive lines like CVP or PAP monitorime

- A-line

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30
Q

What are some negative consequences of malnutrition?

A
  • Prolonged hospital stay
  • Wound infection
  • Abscess
  • Respiratory failure
  • Death
31
Q

How can malnutrition be predicted?

A
  • A serum albumin level of less than 3.5 in the general surgical population is an accurate predictor of malnutrition
  • A serum albumin of less than 2.1 is a major predictor of morbitity in veterans undergoing non-cardiac surgery
  • Weight loss of greater than 10% in the last 6 months
32
Q

What are some functions of the liver?

A
  • Reservoir of 10-15% of total blood volume
  • Maintains normal clotting
  • Mediator of endocrine functions
  • Bilirubin excretion
  • Metabolism
  • Synthesis of proteins
  • Immunologic function
  • Pharmacokinetics
33
Q

What are risk factors and symptoms associated with chronic liver disease?

A
  • History of jaundice
  • Prior blood transfusions
  • Recreational drugs/alcohol
  • Current medications including herbals
  • Family history of jaundice and liver disease
  • Travel history
  • Occupational history
34
Q

What physical exam findings are indicative of liver disease?

A
  • Easy bruising
  • Anorexia
  • Weight loss or gain
  • Nausea and vomiting
  • Pain
  • Pruritis
  • GI bleeding
35
Q

What are two ways to grade liver dysfunction to predict surgical morbidity and mortality? What factors do these look at?

A

-MELD Score
-Child-Turcotte-Pugh Score
Look at:
-Encephalopathy
-Ascites
-Bilirubin
-Albumin
-PT (INR)
-Primary biliary cirrhosis

36
Q

What are some lab tests that can be used to assess liver function?

A
  • AST and ALT
  • Alkaline phosphatase
  • 5’ Nucleotidase
  • GGT
  • Serum bilirubin
  • Prothrombin time, coagulation studies
  • Albumin (normal 3.5-5 g/dl)
  • Serum ammonia levels
  • Platelet count >100,000
  • Complete CBC
  • Consider a toxicology screen
  • Blood alcohol levels
37
Q

What are you looking for in the preoperative physical assessment of a liver patient?

A
  • Jaundice
  • Ascites
  • Hepatitis
  • Blood transfusion
  • Dependent edema
  • Asterixis (hand tremor)
38
Q

What are some cardiovascular findings you may see in the liver patient?

A
  • Increased levels of endogenous vasodilators such as vasoactive intestinal peptide
  • High cardiac output
  • Decreased systemic vascular resistance
  • Hyperdynamic circulatory state
  • Arteriovenous shunting
  • Portal hypertension
  • Pre-operative ECG is warrented
39
Q

What are some respiratory findings you may see in the liver patient?

A
  • Ascites impairs the movement of the diaphragm resulting in decreased FRC
  • Right to left shunting secondary to arteriovenous shunting
40
Q

What are some considerations regarding fluid status for the liver patient?

A
  • Ascites and edema offer evidence of derangement in fluid status
  • Correction of volume status with attention to centralfilling pressures
41
Q

What are some considerations regarding the CNS for the liver patient?

A

-Encephalopathy is the most dramatic manifestation of CNS involvement during hepatic failure

42
Q

What are some examples of liver diseases?

A
  • Cholestatic disease
  • Chronic hepatitis
  • Acute hepatitis
  • Non-alcoholic fatty liver disease
  • Alcoholic liver disease
  • Cirrhosis
43
Q

What are the characteristics of cholestatic disease?

A
  • Predisposes towards vitamin k deficiency
  • Biliary obstruction coagulopathy results from a deficiency of factors dependent on Vitamin K (II,VII, IX, X)
  • Absorption of Vitamin K depends on Bile Salt excretion into GI tract
  • Long term biliary obstruction can cause liver dysfunction interfering with protein synthesis
44
Q

What is the treatments for cholestatic disease?

A
  • Treatment is to correct with parental Vitamin K

- FFP is necessary if emergent surgery or presence of hepatic injury

45
Q

What are some expected findings with cholestatic disease?

A
  • Increased peripheral vasodilation
  • Increased CO
  • Increased portal venous pressure
  • Decreased portal venous blood flow
46
Q

What is hepatitis?

A

A group of liver disorders of varying etiologies that result in hepatic inflammation and necrosis for > 6 months

47
Q

What does hepatitis include?

A
  • HBV
  • HDV
  • HCV
  • Auto-immune hepatitis
  • Drug associated hepatitis
48
Q

How is hepatitis graded?

A

Based on degree of inflammation, necrosis, progression of disease and degree of fibrosis

49
Q

What 5 viruses can cause hepatitis?

A

Hep A, B, C, D, E

50
Q

What is the most common blood borne infection in the US?

A

Hep C

51
Q

How is Hep E transmitted and where is it common?

A
  • Enteric transmission

- Asia, Africa, Central America

52
Q

What are the signs and symptoms of HA influenza?

A
  • Anorexia
  • Nausea/vomiting
  • Low grade fever
  • Dark urine
  • Clay colored stools
  • Jaundice
  • Acute hepatic failure
53
Q

What is the treatment for Hepatitis B?

A
  • Drugs include interferon

- Treatment is based on age, severity of disease, potential side effects and complications vs likelihood of response

54
Q

What is the drug treatment for Hep C?

A

Interferon and Ribavirin

55
Q

What are the signs and symptoms of auto-immune hepatitis?

A
  • Hepatocellular necrosis and inflammation
  • Circulating autoantibodies
  • Hypergammaglobulinemia
56
Q

What is the treatment for auto-immune hepatitis?

A

Corticosteroids and AZT

57
Q

What are some pre-operative considerations for acute/chronic viral hepatitis?

A
  • Aspiration precautions must be implemented
  • Preoperative evaluatoin should focus on signs and symptoms of encepalopathy, bleeding, jaundice, ascites, and hemodynamics
58
Q

What labs should you look at for patients with acute/chronic hepatitis?

A
  • Electrolytes
  • BUN/Creatinine
  • Glucose
  • H&H
  • Liver enzymes
  • Bilirubin
  • Coagulation studies
  • ABG
  • Albumin
59
Q

What are the characteristics of non-alcoholic fatty liver disease?

A
  • Most common cause of chronic liver disease
  • Fat accumulation in the liver exceeding 5%
  • Risk factors include NIDDM and obesity
  • Asymptomatic but elevated liver enzymes found on physical exam
  • Produces some degree of hepatocyte necrosis which promotes the accumulation of inflammatory cells in liver
  • Leads to cirrhosis
  • Weight loss (even 5 lbs) can reverse the elevated liver enzymes
60
Q

What is required to determine between the types of liver disase?

A

A liver biopsy

61
Q

What are the signs and symptoms of alcoholic liver disease?

A
  • Malaise
  • Nausea
  • Anorexia
  • Weakness
  • Abdominal discomfort
  • Hepatomegaly
  • Jaundice
62
Q

How long after cessation of ETOH can a patient develop DTs?

A

Within 6-8 hours

63
Q

When do alcohol hallucinations and grand mal seizures occur after ETOH withdrawal?

A

Within 24 hours

64
Q

When do DTs usually appear after alcohol withdrawal and what are they preceded by?

A

Usually appear within 72 hours and are preceded by tremulousness, hallucinations or seizures.

65
Q

What is the treatment for DTs?

A

Benzodiazepines

66
Q

What are signs and symptoms of cirrhosis?

A
  • Anorexia
  • weakness
  • nausea vomitting
  • abd pain
  • hepatomegaly
  • ascites
  • Edema
  • jaundice
  • spider veins
  • metabolic/hepatic encephalopathy
  • Hyperdynamic circulation: high CO, low PVR
  • Coagulation disorders
  • Endocrine disorders
  • Gastroesophageal varices
  • Intrapulmonary shunting
  • V/Q mismatch
  • Arterial hypoxemia due to intrapulmonary dilations
  • Portal hypertension
67
Q

What part of the clotting process do you have abnormalities in with liver disease?

A

All 3 phases:

  • Hemostasis
  • Coagulation
  • Fibrinolysis
68
Q

What clotting factors are reduced in liver disease?

A

II, V, VII, IX, X

69
Q

What coagulation lab values are altered in liver disease?

A
  • Clotting factors reduced
  • PT and INR elevated
  • Thrombocytopenia
  • Abnormal fibrinogen
70
Q

How are platelets made?

A

Platelets are derived from the megakaryocytes in the bone marrow in response to thrombopoietin which is synthesized in the liver.

71
Q

What findings related to platelets might you find in liver disease?

A
  • Abnormal platelet function
  • Decreased platelet function
  • Increased bleeding time
72
Q

What clotting factors rely on vitamin K?

A

II, VII, IX, X, and protein S and protein C

73
Q

What patients can develop vitamin K deficiency?

A
  • Pts on parenteral nutrition
  • Biliary obstruction
  • Pancreatic insufficiency
  • Malabsorption
  • GI obstruction
  • Rapid GI transit
74
Q

What lab results can be an effect of vitamin K deficiency?

A

-Prolonged PT and PTT

Health Assessment Exam 2 (6 decks)

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