Neuromuscular disorder of esophagus leading to failure of LES to relax when swallowing, reduced peristalsis, esophageal dilation Triad is dysphagia, weight loss, regurgitation Risk of aspiration

A narrowing of the lower esophagus caused by a ring of mucosal tissue or muscular tissue Causes dysphagia, food obstruction, vomiting Aspiration risk

GI/Liver Flashcards by Julie Luu

What are some components of a GI history?

Does the patient have :

Nutritional deficiency
Weight loss greater than 10% in last 6 months
Nausea/Vomiting
Occult blood loss
Overt GI bleeding
Abdominal pain
Abdominal distention
Abdominal masses
Dysphagia
Gastric hyperacidity with or without reflux
Epigastric pain

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What is NPO status?

What is the guideline?

•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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Which patients are at high risk for Aspiration?

Patients considered an aspiration risk:

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

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What are some medications used for aspiration prophylaxis?

ASA does not promote the routine use of these medications to decrease aspiration in patients with no apparent risk factors

H2 Antagonists

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

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

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

Omeprazole- Prilosec

Proton pump inhibitor

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What is Mendelson Syndrome?

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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What is Achalasia?

Neuromuscular disorder of esophagus leading to failure of LES to relax when swallowing, reduced peristalsis, esophageal dilation
Triad is dysphagia, weight loss, regurgitation
Risk of aspiration

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What is Barrett’s Esophagus?

What are the treatments?

What are the signs and symptoms?

Metaplastic disorder of the esophagus secondary to reflux
Precursor to esophageal cancer

Treatment

H2 Blockers
Proton Pump Inhibitors
Nissen fundoplication

Signs & Symptoms

Dysphagia
Reflux esophagitis
Retrosternal pain or heartburn
LES dystonia
Weight loss

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Whats Schatzki RIng?

A narrowing of the lower esophagus caused by a ring of mucosal tissue or muscular tissue
Causes dysphagia, food obstruction, vomiting
Aspiration risk

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What is Hiatal Hernia?

What are the signs and symptoms?

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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What is GERD?

S/S?

Tx?

•Retrograde movement of gastric contents through the lower esophageal sphincter into esophagus

Signs

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

Treatment:

Metoclopramide, H2 blockers, PPIs
Aspiration risk
High incidence of bronchospasm

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What is Gastroparesis?

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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Describe Peptic Ulcer Disease

Treatment?

SIgns?

Ulcerations in the GI mucosa most commonly the duodenal bulb or antrum of stomach
H. Pylori –usual cause
Men and Women age 45-60
Causes: Chronic use of NSAIDS, ETOH, Steroids

Treatment

H2 antagonists
Proton pump inhibitors
Antimicrobial therapy
Antacids

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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What is Malaborption Syndromes?

S/S?

Clinically significance deficits in mineral, vitamins and electrolytes
Small bowel perforation or obstruction
Small Intestine
Celiac Sprue
Fat Malabsorption
Protein Malabsorption

Signs & Symptoms

Unexplained wt. loss
Steatorrhea
Diarrhea
Anemia
Fatigue
Deficiency in Vitamin K
Bleeding dyscrasia
Edema/ascites

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Discribe the difference between the 2 inflammatory bowel disease

Crohn’s Disease

•Inflammation and ulceration to the distal ileum and large colon

Deficiency in absorption of magnesium, calcium, vit D, B12, Phosphorus, Folic acid, Zinc, Iron potassium
Protein loss, decreased plasma albumin
Anemia

•Recurrent right lower quadrant pain, diarrhea, palpable mass, fever, anorexia/wt. loss

Ulcerative Colitis

•Inflammation and loss of colonic mucosa from rectum to distal colon; becomes hemorrhagic, edematous, ulcerated

Intermittent bloody diarrhea
Fever/ malaise
Anorexia/wt. loss
Abdominal pain
Associated with risk of colon cancer

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Where are carinoid tumors?

What can it produce?

What are signs and symptoms of Carcinoid syndrome?

Site of origin in the GI tract
Can produce carcinoid syndrome or crisis
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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What is Nutritional Deficiency?

What is used as a predictor?

Malnutrition is associated with
prolonged hospital stay
wound infection
abscess
respiratory failure
death
Serum Albumin level of
Less than 3.5 in the general surgical population is accurate predictor of malnutrition
Less than 2.1 major predictor of morbidity in veterans undergoing non-cardiac surgery

•Weight loss of greater than 10% in last 6 months

What does the GI physical consist of?

General inspection
Weight, vital signs
Abdominal examination
Auscultate bowel sounds
Palpate abdomen
Note guarding and pain
Note organomegaly
Percuss

What are some useful labs for a GI patient?

Hematocrit
Serum electrolytes
BUN
Serum albumin

What are some preop considerations for a GI Pt?

Aspiration risk
- Prophylaxis and airway management considerations; bronchospasm
Bleeding causing anemia
Nutritional deficits and/or electrolyte disturbances
Pain control
Medications: stress-dose steroids,
If carcinoid, cardiac workup needed? Hemodynamically stable?

What are some functions of the liver?

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

What are some components of a liver history?

Easy bruising?
Anorexia or weight changes
N&V or pain with fatty meals
Pruritus or fatigue
Abdominal distention/ascites
GI Bleeding
Scleral icterus, jaundice
Hepatomegaly or splenomegaly
Palmer erythema
Gynecomastia
Spider angiomata, petechiae, and ecchymosis
Dark urine and/or pale stools
History of jaundice
Prior blood transfusions
Recreational drugs/Alcohol
Current medications including herbals
Family history of jaundice and liver disease
History of blood transfusions
Travel history
Occupational history

What medications increases liver enzyme levels?

Antibiotics
Antiepileptic drugs
Inhibitors of hydroxymethylglutaryl-coenzyme
Nonsteroidal anti-inflammatory drugs
Sulfonylureas for hyperglycemia
Herbals
Cocaine, ecstasy, angel dust, glues/solvents

What is included in a liver physical?

General inspection (wt., vital signs, mental status)
Exam patient’s hands, looking for:
Koilonychia
Leukonychia
Nail clubbing
Palmar erythema
Asterixis
Dupuytren’s contracture
Check sclera for jaundice or pallor
Exam chest for gynaecomastia or spider nevi- signs liver dz
Skin color (jaundice), scratches (itching)
Skin turgor
Dependent edema
Auscultate breath sounds
Pleural effusions
Abdominal examination
Auscultate bowel sounds
Palpate abdomen
Note guarding and pain
Note organomegaly
Percuss

What labs would you want to assess?

and what would you want to consider?

Albumin (normal 3.5-5.0 g/dl)
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
Consider a toxicology screen and blood alcohol levels
Liver patients often require increased sedatives due to induced enzymes
Preoperative degree of liver dysfunction is a major determinant of post-operative outcome
Anemia is a common finding
CBC, PT/PTT, INR platelet count

What are some Normal LFTs?

Describe the coagulation disorder in liver failure

* 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

What are platlets? What platelet disorder may you find with liver failure?

* Platelets are derived from the megakaryocytes in the bone marrow in response to thrombopoietin which is synthesized in the liver. * This process is abnormal in liver disease and you may find * Abnormal platelet function * Decreased platelet function * Increased bleeding time

Why is Vit K important? What are are the results of a Vit K deficiency?

* 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 * Vitamin K deficiency develops in patients on parenteral nutrition, biliary obstruction, pancreatic insuff, malabsorption, GI obstruction and rapid GI transit * Effects of Vitamin K deficiency include prolonged PT, PTT

What kind of Preoperative testing would you want with Liver Failure and why?

Pre-operative EKG is warranted CV * Increased levels of endogenous vasodilators such as vasoactive intestinal peptide * High cardiac output * Decreased systemic vascular resistance * Hyperdynamic circulatory state * Arteriovenous shunting * Portal hypertension CXR

What is the Child-Turcotte-Pugh Classification for Severity of Cirrhosis?

Whats the Meld score?

What are some Liver Dz?

* Cholestatic Disease * Chronic hepatitis * Acute hepatitis * Non-alcoholic fatty liver disease * Alcoholic liver disease * Cirrhosis

Describe Cholestatic Dz What are some treatments? What are some expected findings?

* 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 * **Treatment** is to correct with parental Vitamin K * FFP is necessary if emergent surgery or presence of hepatic injury **Expected findings** * Increased peripheral vasodilation * Increased CO * Increased portal venous pressure * Decreased portal venous blood flow

What is hepatitis? Treatment?

* 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

What are some preop considerations for Hepatitis? Labs?

* Aspiration precautions * Preoperative evaluation should focus on signs and symptoms of encephalopathy, bleeding, jaundice, ascites, and hemodynamics **Labs:** •Electrolytes, BUN, creatinine, serum glucose, H/H, liver enzymes, bilirubin, coagulation studies, albumin, and abg

Describe Non-Alcoholic Fatty Liver Dz

* 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 (AST & ALT) 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

Described Alcoholic Liver Disease How do diagnosis? S/S?

* 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 * Steatosis (fatty liver) * Alcoholic hepatitis (precursor Cirrhosis) * Cirrhosis **S&S** * malaise * nausea * anorexia * weakness * abdominal discomfort * hepatomegaly jaundice

Describe Alcoholism and Delirium Tremens

* Heavy ETOH use is associated with acute hepatitis and abrupt cessation is associated with DTs * With ETOH withdrawal: * 6-8 hours may become tremulous * 6-24 hours hallucinations and seizures * Within 72 hours, DTs usually appear (can last up to 5 days) **•DTs are hallucinations, profound confusion, tachycardia, hypertension, hyperthermia, agitation, sweating** * Treatment is with **benzodiazepines** * Consider other co-morbidities

What is Cirrhosis due to? S/S?

•Commonly due to hepatitis C and alcoholism **S & S:** * Gastroesophageal variceal * Intrapulmonary shunting * Ventilation/perfusion mismatch * Arterial hypoxemia due to Intra-pulmonary vascular dilations (IPVD) * Ascites and edema * Coagulation disorders w/ bleeding * Endocrine disorders * Encephalopathy * Portal hypertension