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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
What is carcinoid syndrome?
- 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
26
What are the signs and symptoms of carcinoid syndrome?
- Cutaneous flushing - Diarrhea - Palpitations - Bronchospasm - Dyspnea - Hypotension - Hypertension - Orthostasis - Pre-op test are guided by physical findings
27
What are some general pre-operative considerations for the GI patient?
- Airway management and prevention of aspiration - Fluid and electrolyte balance - Skin - Peripheral circulation - Heart rate - Blood pressure - Urine output - Kidney function - Orthostasis
28
What are some useful lab values to get on the GI patient?
- Hematocrit - Serum electrolytes - BUN - Serum albumin
29
What monitoring is needed for GI patients?
- Maybe they need invasive lines like CVP or PAP monitorime | - A-line
30
What are some negative consequences of malnutrition?
- Prolonged hospital stay - Wound infection - Abscess - Respiratory failure - Death
31
How can malnutrition be predicted?
- 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
What are some functions of the liver?
- 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
What are risk factors and symptoms associated with chronic liver disease?
- 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
What physical exam findings are indicative of liver disease?
- Easy bruising - Anorexia - Weight loss or gain - Nausea and vomiting - Pain - Pruritis - GI bleeding
35
What are two ways to grade liver dysfunction to predict surgical morbidity and mortality? What factors do these look at?
-MELD Score -Child-Turcotte-Pugh Score Look at: -Encephalopathy -Ascites -Bilirubin -Albumin -PT (INR) -Primary biliary cirrhosis
36
What are some lab tests that can be used to assess liver function?
- 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
What are you looking for in the preoperative physical assessment of a liver patient?
- Jaundice - Ascites - Hepatitis - Blood transfusion - Dependent edema - Asterixis (hand tremor)
38
What are some cardiovascular findings you may see in the liver patient?
- 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
What are some respiratory findings you may see in the liver patient?
- Ascites impairs the movement of the diaphragm resulting in decreased FRC - Right to left shunting secondary to arteriovenous shunting
40
What are some considerations regarding fluid status for the liver patient?
- Ascites and edema offer evidence of derangement in fluid status - Correction of volume status with attention to centralfilling pressures
41
What are some considerations regarding the CNS for the liver patient?
-Encephalopathy is the most dramatic manifestation of CNS involvement during hepatic failure
42
What are some examples of liver diseases?
- Cholestatic disease - Chronic hepatitis - Acute hepatitis - Non-alcoholic fatty liver disease - Alcoholic liver disease - Cirrhosis
43
What are the characteristics of cholestatic disease?
- 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
What is the treatments for cholestatic disease?
- Treatment is to correct with parental Vitamin K | - FFP is necessary if emergent surgery or presence of hepatic injury
45
What are some expected findings with cholestatic disease?
- Increased peripheral vasodilation - Increased CO - Increased portal venous pressure - Decreased portal venous blood flow
46
What is hepatitis?
A group of liver disorders of varying etiologies that result in hepatic inflammation and necrosis for > 6 months
47
What does hepatitis include?
- HBV - HDV - HCV - Auto-immune hepatitis - Drug associated hepatitis
48
How is hepatitis graded?
Based on degree of inflammation, necrosis, progression of disease and degree of fibrosis
49
What 5 viruses can cause hepatitis?
Hep A, B, C, D, E
50
What is the most common blood borne infection in the US?
Hep C
51
How is Hep E transmitted and where is it common?
- Enteric transmission | - Asia, Africa, Central America
52
What are the signs and symptoms of HA influenza?
- Anorexia - Nausea/vomiting - Low grade fever - Dark urine - Clay colored stools - Jaundice - Acute hepatic failure
53
What is the treatment for Hepatitis B?
- Drugs include interferon | - Treatment is based on age, severity of disease, potential side effects and complications vs likelihood of response
54
What is the drug treatment for Hep C?
Interferon and Ribavirin
55
What are the signs and symptoms of auto-immune hepatitis?
- Hepatocellular necrosis and inflammation - Circulating autoantibodies - Hypergammaglobulinemia
56
What is the treatment for auto-immune hepatitis?
Corticosteroids and AZT
57
What are some pre-operative considerations for acute/chronic viral hepatitis?
- Aspiration precautions must be implemented - Preoperative evaluatoin should focus on signs and symptoms of encepalopathy, bleeding, jaundice, ascites, and hemodynamics
58
What labs should you look at for patients with acute/chronic hepatitis?
- Electrolytes - BUN/Creatinine - Glucose - H&H - Liver enzymes - Bilirubin - Coagulation studies - ABG - Albumin
59
What are the characteristics of non-alcoholic fatty liver disease?
- 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
What is required to determine between the types of liver disase?
A liver biopsy
61
What are the signs and symptoms of alcoholic liver disease?
- Malaise - Nausea - Anorexia - Weakness - Abdominal discomfort - Hepatomegaly - Jaundice
62
How long after cessation of ETOH can a patient develop DTs?
Within 6-8 hours
63
When do alcohol hallucinations and grand mal seizures occur after ETOH withdrawal?
Within 24 hours
64
When do DTs usually appear after alcohol withdrawal and what are they preceded by?
Usually appear within 72 hours and are preceded by tremulousness, hallucinations or seizures.
65
What is the treatment for DTs?
Benzodiazepines
66
What are signs and symptoms of cirrhosis?
- 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
What part of the clotting process do you have abnormalities in with liver disease?
All 3 phases: - Hemostasis - Coagulation - Fibrinolysis
68
What clotting factors are reduced in liver disease?
II, V, VII, IX, X
69
What coagulation lab values are altered in liver disease?
- Clotting factors reduced - PT and INR elevated - Thrombocytopenia - Abnormal fibrinogen
70
How are platelets made?
Platelets are derived from the megakaryocytes in the bone marrow in response to thrombopoietin which is synthesized in the liver.
71
What findings related to platelets might you find in liver disease?
- Abnormal platelet function - Decreased platelet function - Increased bleeding time
72
What clotting factors rely on vitamin K?
II, VII, IX, X, and protein S and protein C
73
What patients can develop vitamin K deficiency?
- Pts on parenteral nutrition - Biliary obstruction - Pancreatic insufficiency - Malabsorption - GI obstruction - Rapid GI transit
74
What lab results can be an effect of vitamin K deficiency?
-Prolonged PT and PTT

Health Assessment Exam 2 (6 decks)

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